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Code Status Documentation
In the hospital, cardiopulmonary resuscitation (CPR) is the default treatment for a patient who suffers a cardiac arrest. Clinician assessment of patient preferences regarding resuscitation, with appropriate documentation in the medical record, is therefore essential for patients who do not wish to be resuscitated.[1] In addition, given frequent patient handoffs between physicians, consistent documentation of patient preferences is critical.[2] Unfortunately, multiple deficiencies in the quality of code status documentation have been identified in prior work.[3, 4] In this issue of the Journal of Hospital Medicine, Weinerman and colleagues[5] build on this literature by not only evaluating the completeness of code status documentation in multiple documentation sites, but also its consistency.
In this Canadian multihospital study, the authors found that only 38 of the 187 patients (20%) admitted to 1 of 4 medicine services had complete and consistent documentation of code status. Even more worrisome is that two‐thirds of the patients had inconsistent code status documentation. Although most of these inconsistencies involved missing information in 1 of the 5 sites of documentation (progress note, physician order, electronic resident sign‐out lists, nursing‐care plan, and do‐not‐resuscitate [DNR] face sheet), 31% were deemed clinically significant (eg, DNR in 1 source and full code in another). Such inconsistent documentation represents a serious threat to patient safety, and highlights the need for interventions aimed at improving the quality and reliability of code status documentation.
The authors identified 71 cases where code status documentation in progress notes was missing or inconsistent with documentation in other sites. Sixty of these notes lacked mention of a preference for full code status, 10 lacked documentation of DNR status, and 1 note incorrectly documented full code rather than DNR status. Interpretation of these findings requires consensus on whether the progress note is an appropriate location for code status documentation. With the evolution of the electronic medical record, the role of the progress note has changed, and unfortunately, these notes have become a lengthy chronicle of a patient's hospital course that includes all clinical data, medical problems, and an array of bottom‐of‐the‐list items such as code status. Information is easily added, but rarely removed, and what remains often goes unedited even for high‐stakes issues such as code status. Given the potential for copying and pasting of progress notes day after day, it is critical that clinicians periodically review the code status documented in the patient's notes and update this information as those preferences change. One solution that may minimize the potential for inaccurate documentation in progress notes is for institutions to utilize a separate note for code status documentation that the clinician fills out following any code status discussion. Having this note clearly labeled (eg, Code Status Note) and in a universal place within the electronic record may provide a reliable and efficient way for both physicians and nurses to identify a patient's preferences, while minimizing the inclusion of repetitive information in daily notes. Furthermore, if entered into a discrete field within the electronic record, this information could then autopopulate other sites (eg, sign‐out, nursing forms), thereby maintaining consistency. Use of note templates can provide a way to then help standardize the quality of information that is included in this type of code status note.
An alternate solution that may minimize the potential for inaccurate implementation of code status preferences is to focus on the fact that they are orders. As this study highlights, there is a need to improve both the completeness and consistency of code status documentation and, to this end, orders such as the Medical Orders for Life‐Sustaining Treatment (MOLST) or Physician Orders for Life‐Sustaining Treatment (POLST) may help.[6] Not only do these orders expand upon resuscitation preferences to include broader preferences for treatment in the context of serious illness, but they are also meant to serve as a standard way to document patient care preferences across healthcare settings. Although the MOLST and POLST primarily aim to translate patient preferences into medical orders to be followed outside of the hospital, their implementation into the electronic medical record may provide a more consistent way to document patient preferences in the hospital as well.
Although many studies have identified the need to improve the quality of code status discussions,[7, 8, 9, 10] the work by Weinerman and colleagues reminds us that attention to documentation is also critical. Ensuring that the electronic medical record contains documentation of the patient's resuscitation preferences and overall goals of care, and that this information can be found easily and reliably by physicians and nurses, should drive future quality improvement and research in this area.
Disclosure
Nothing to report.
- , , , et al. Physician understanding of patient resuscitation preferences: insights and clinical implications. J Am Geriatr Soc. 2000;48(5 suppl):S44–S51.
- , , , et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87(4):411–418.
- , , , . Documentation quality of inpatient code status discussions. J Pain Symptom Manage. 2014;48(4):632–638.
- , , , et al. Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study. J Hosp Med. 2008;3(6):437–445.
- , , , , , . Frequency and clinical relevance of inconsistent code status documentation. J Hosp Med. 2015;10(8):491–496.
- , , . Use of the Physician Orders for Life‐Sustaining Treatment Program in the clinical setting: a systematic review of the literature. J Am Geriatr Soc. 2015;63(2):341–350.
- The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;274(20):1591–1598.
- , , . How do medical residents discuss resuscitation with patients? J Gen Intern Med. 1995;10(8):436–442.
- , , , , . Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med. 2011;26(4):359–366.
- , , , . Code status discussions: agreement between internal medicine residents and hospitalized patients. Teach Learn Med. 2010;22(4):251–256.
In the hospital, cardiopulmonary resuscitation (CPR) is the default treatment for a patient who suffers a cardiac arrest. Clinician assessment of patient preferences regarding resuscitation, with appropriate documentation in the medical record, is therefore essential for patients who do not wish to be resuscitated.[1] In addition, given frequent patient handoffs between physicians, consistent documentation of patient preferences is critical.[2] Unfortunately, multiple deficiencies in the quality of code status documentation have been identified in prior work.[3, 4] In this issue of the Journal of Hospital Medicine, Weinerman and colleagues[5] build on this literature by not only evaluating the completeness of code status documentation in multiple documentation sites, but also its consistency.
In this Canadian multihospital study, the authors found that only 38 of the 187 patients (20%) admitted to 1 of 4 medicine services had complete and consistent documentation of code status. Even more worrisome is that two‐thirds of the patients had inconsistent code status documentation. Although most of these inconsistencies involved missing information in 1 of the 5 sites of documentation (progress note, physician order, electronic resident sign‐out lists, nursing‐care plan, and do‐not‐resuscitate [DNR] face sheet), 31% were deemed clinically significant (eg, DNR in 1 source and full code in another). Such inconsistent documentation represents a serious threat to patient safety, and highlights the need for interventions aimed at improving the quality and reliability of code status documentation.
The authors identified 71 cases where code status documentation in progress notes was missing or inconsistent with documentation in other sites. Sixty of these notes lacked mention of a preference for full code status, 10 lacked documentation of DNR status, and 1 note incorrectly documented full code rather than DNR status. Interpretation of these findings requires consensus on whether the progress note is an appropriate location for code status documentation. With the evolution of the electronic medical record, the role of the progress note has changed, and unfortunately, these notes have become a lengthy chronicle of a patient's hospital course that includes all clinical data, medical problems, and an array of bottom‐of‐the‐list items such as code status. Information is easily added, but rarely removed, and what remains often goes unedited even for high‐stakes issues such as code status. Given the potential for copying and pasting of progress notes day after day, it is critical that clinicians periodically review the code status documented in the patient's notes and update this information as those preferences change. One solution that may minimize the potential for inaccurate documentation in progress notes is for institutions to utilize a separate note for code status documentation that the clinician fills out following any code status discussion. Having this note clearly labeled (eg, Code Status Note) and in a universal place within the electronic record may provide a reliable and efficient way for both physicians and nurses to identify a patient's preferences, while minimizing the inclusion of repetitive information in daily notes. Furthermore, if entered into a discrete field within the electronic record, this information could then autopopulate other sites (eg, sign‐out, nursing forms), thereby maintaining consistency. Use of note templates can provide a way to then help standardize the quality of information that is included in this type of code status note.
An alternate solution that may minimize the potential for inaccurate implementation of code status preferences is to focus on the fact that they are orders. As this study highlights, there is a need to improve both the completeness and consistency of code status documentation and, to this end, orders such as the Medical Orders for Life‐Sustaining Treatment (MOLST) or Physician Orders for Life‐Sustaining Treatment (POLST) may help.[6] Not only do these orders expand upon resuscitation preferences to include broader preferences for treatment in the context of serious illness, but they are also meant to serve as a standard way to document patient care preferences across healthcare settings. Although the MOLST and POLST primarily aim to translate patient preferences into medical orders to be followed outside of the hospital, their implementation into the electronic medical record may provide a more consistent way to document patient preferences in the hospital as well.
Although many studies have identified the need to improve the quality of code status discussions,[7, 8, 9, 10] the work by Weinerman and colleagues reminds us that attention to documentation is also critical. Ensuring that the electronic medical record contains documentation of the patient's resuscitation preferences and overall goals of care, and that this information can be found easily and reliably by physicians and nurses, should drive future quality improvement and research in this area.
Disclosure
Nothing to report.
In the hospital, cardiopulmonary resuscitation (CPR) is the default treatment for a patient who suffers a cardiac arrest. Clinician assessment of patient preferences regarding resuscitation, with appropriate documentation in the medical record, is therefore essential for patients who do not wish to be resuscitated.[1] In addition, given frequent patient handoffs between physicians, consistent documentation of patient preferences is critical.[2] Unfortunately, multiple deficiencies in the quality of code status documentation have been identified in prior work.[3, 4] In this issue of the Journal of Hospital Medicine, Weinerman and colleagues[5] build on this literature by not only evaluating the completeness of code status documentation in multiple documentation sites, but also its consistency.
In this Canadian multihospital study, the authors found that only 38 of the 187 patients (20%) admitted to 1 of 4 medicine services had complete and consistent documentation of code status. Even more worrisome is that two‐thirds of the patients had inconsistent code status documentation. Although most of these inconsistencies involved missing information in 1 of the 5 sites of documentation (progress note, physician order, electronic resident sign‐out lists, nursing‐care plan, and do‐not‐resuscitate [DNR] face sheet), 31% were deemed clinically significant (eg, DNR in 1 source and full code in another). Such inconsistent documentation represents a serious threat to patient safety, and highlights the need for interventions aimed at improving the quality and reliability of code status documentation.
The authors identified 71 cases where code status documentation in progress notes was missing or inconsistent with documentation in other sites. Sixty of these notes lacked mention of a preference for full code status, 10 lacked documentation of DNR status, and 1 note incorrectly documented full code rather than DNR status. Interpretation of these findings requires consensus on whether the progress note is an appropriate location for code status documentation. With the evolution of the electronic medical record, the role of the progress note has changed, and unfortunately, these notes have become a lengthy chronicle of a patient's hospital course that includes all clinical data, medical problems, and an array of bottom‐of‐the‐list items such as code status. Information is easily added, but rarely removed, and what remains often goes unedited even for high‐stakes issues such as code status. Given the potential for copying and pasting of progress notes day after day, it is critical that clinicians periodically review the code status documented in the patient's notes and update this information as those preferences change. One solution that may minimize the potential for inaccurate documentation in progress notes is for institutions to utilize a separate note for code status documentation that the clinician fills out following any code status discussion. Having this note clearly labeled (eg, Code Status Note) and in a universal place within the electronic record may provide a reliable and efficient way for both physicians and nurses to identify a patient's preferences, while minimizing the inclusion of repetitive information in daily notes. Furthermore, if entered into a discrete field within the electronic record, this information could then autopopulate other sites (eg, sign‐out, nursing forms), thereby maintaining consistency. Use of note templates can provide a way to then help standardize the quality of information that is included in this type of code status note.
An alternate solution that may minimize the potential for inaccurate implementation of code status preferences is to focus on the fact that they are orders. As this study highlights, there is a need to improve both the completeness and consistency of code status documentation and, to this end, orders such as the Medical Orders for Life‐Sustaining Treatment (MOLST) or Physician Orders for Life‐Sustaining Treatment (POLST) may help.[6] Not only do these orders expand upon resuscitation preferences to include broader preferences for treatment in the context of serious illness, but they are also meant to serve as a standard way to document patient care preferences across healthcare settings. Although the MOLST and POLST primarily aim to translate patient preferences into medical orders to be followed outside of the hospital, their implementation into the electronic medical record may provide a more consistent way to document patient preferences in the hospital as well.
Although many studies have identified the need to improve the quality of code status discussions,[7, 8, 9, 10] the work by Weinerman and colleagues reminds us that attention to documentation is also critical. Ensuring that the electronic medical record contains documentation of the patient's resuscitation preferences and overall goals of care, and that this information can be found easily and reliably by physicians and nurses, should drive future quality improvement and research in this area.
Disclosure
Nothing to report.
- , , , et al. Physician understanding of patient resuscitation preferences: insights and clinical implications. J Am Geriatr Soc. 2000;48(5 suppl):S44–S51.
- , , , et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87(4):411–418.
- , , , . Documentation quality of inpatient code status discussions. J Pain Symptom Manage. 2014;48(4):632–638.
- , , , et al. Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study. J Hosp Med. 2008;3(6):437–445.
- , , , , , . Frequency and clinical relevance of inconsistent code status documentation. J Hosp Med. 2015;10(8):491–496.
- , , . Use of the Physician Orders for Life‐Sustaining Treatment Program in the clinical setting: a systematic review of the literature. J Am Geriatr Soc. 2015;63(2):341–350.
- The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;274(20):1591–1598.
- , , . How do medical residents discuss resuscitation with patients? J Gen Intern Med. 1995;10(8):436–442.
- , , , , . Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med. 2011;26(4):359–366.
- , , , . Code status discussions: agreement between internal medicine residents and hospitalized patients. Teach Learn Med. 2010;22(4):251–256.
- , , , et al. Physician understanding of patient resuscitation preferences: insights and clinical implications. J Am Geriatr Soc. 2000;48(5 suppl):S44–S51.
- , , , et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87(4):411–418.
- , , , . Documentation quality of inpatient code status discussions. J Pain Symptom Manage. 2014;48(4):632–638.
- , , , et al. Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study. J Hosp Med. 2008;3(6):437–445.
- , , , , , . Frequency and clinical relevance of inconsistent code status documentation. J Hosp Med. 2015;10(8):491–496.
- , , . Use of the Physician Orders for Life‐Sustaining Treatment Program in the clinical setting: a systematic review of the literature. J Am Geriatr Soc. 2015;63(2):341–350.
- The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;274(20):1591–1598.
- , , . How do medical residents discuss resuscitation with patients? J Gen Intern Med. 1995;10(8):436–442.
- , , , , . Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med. 2011;26(4):359–366.
- , , , . Code status discussions: agreement between internal medicine residents and hospitalized patients. Teach Learn Med. 2010;22(4):251–256.
HHS secretary tells how to combat drug abuse
More people are dying of drug overdoses in the United States than in car crashes, Nicholas Garlow writes in a blog entry for the U.S. Department of Health & Human Services.
Sylvia Mathews Burwell, secretary of the HHS, announced ways to combat opioid abuse during a speech at the 4th annual National Rx Drug Abuse Summit in Atlanta.
The strategies Ms. Burwell cited are:
• Provide the training, tools, and educational resources that health care professionals need to make more informed prescribing decisions.
• Increase the use of naloxone, a drug that can reverse opioid overdose*.
• Use medication-assisted treatment to help lift people from opioid addiction.
Drug overdose is the leading cause of injury death in the country. In fact, the number of drug overdoses resulting in deaths has increased fivefold since 1980, Mr. Garlow writes.
*Correction, 4/16/2015: An earlier version of this article misstated naloxone's indication.
More people are dying of drug overdoses in the United States than in car crashes, Nicholas Garlow writes in a blog entry for the U.S. Department of Health & Human Services.
Sylvia Mathews Burwell, secretary of the HHS, announced ways to combat opioid abuse during a speech at the 4th annual National Rx Drug Abuse Summit in Atlanta.
The strategies Ms. Burwell cited are:
• Provide the training, tools, and educational resources that health care professionals need to make more informed prescribing decisions.
• Increase the use of naloxone, a drug that can reverse opioid overdose*.
• Use medication-assisted treatment to help lift people from opioid addiction.
Drug overdose is the leading cause of injury death in the country. In fact, the number of drug overdoses resulting in deaths has increased fivefold since 1980, Mr. Garlow writes.
*Correction, 4/16/2015: An earlier version of this article misstated naloxone's indication.
More people are dying of drug overdoses in the United States than in car crashes, Nicholas Garlow writes in a blog entry for the U.S. Department of Health & Human Services.
Sylvia Mathews Burwell, secretary of the HHS, announced ways to combat opioid abuse during a speech at the 4th annual National Rx Drug Abuse Summit in Atlanta.
The strategies Ms. Burwell cited are:
• Provide the training, tools, and educational resources that health care professionals need to make more informed prescribing decisions.
• Increase the use of naloxone, a drug that can reverse opioid overdose*.
• Use medication-assisted treatment to help lift people from opioid addiction.
Drug overdose is the leading cause of injury death in the country. In fact, the number of drug overdoses resulting in deaths has increased fivefold since 1980, Mr. Garlow writes.
*Correction, 4/16/2015: An earlier version of this article misstated naloxone's indication.
Ablation during mitral valve surgery offers up mixed results
SAN DIEGO – Surgical ablation of atrial fibrillation at the time of mitral valve surgery provides significantly greater rhythm control than mitral valve surgery alone, a study showed.
Freedom from atrial fibrillation (AF) at both 6 months and 1 year was 63% in patients undergoing mitral valve surgery (MVS) plus ablation and 29% in those undergoing MVS alone, a statistically significant difference.
However, patients who had ablation plus MVS were 2.5 times more likely to have a permanent pacemaker implanted than were those who had MVS alone, at 21.5% and 8.1%, respectively, also a significant difference.
Ablation did not increase mortality or major adverse cardiac or cerebrovascular events, Dr. A. Marc Gillinov said at the annual meeting of the American College of Cardiology.
Preoperative AF is present in up to 50% of patients undergoing mitral valve operations and is associated with an increased risk of death and stroke.
The study enrolled 260 relatively elderly patients (mean age 69 years) with AF that was persistent (non–self-terminating for at least 7 days) or long-standing persistent (continuous for at least a year), in addition to mitral valve disease. A total of 133 patients were randomly assigned to MVS plus ablation and 127 to MVS alone. The ablation group was further randomized to pulmonary vein isolation or a biatrial maze procedure; all underwent closure of the left atrial appendage.
There was no significant difference in freedom from AF at 6 months and 1 year between patients who had pulmonary vein isolation or a biatrial maze procedure, at 61% and 66%, respectively, said Dr. Gillinov, a cardiac surgeon at Cleveland Clinic.
One-year mortality was similar among all patients undergoing MVS plus ablation vs. MVS alone, at 6.8% and 8.7%.
The two groups also had similar Short Form-12 questionnaire scores for physical function and mental function, although AF occurring at least once daily was significantly less common with ablation, at 19.8%, compared with 45.2% in the MVS-alone patients, he said.
The heart rhythm endpoint was “stringent,” with 3-day Holter monitors obtained at both 6 and 12 months and repeat ablation procedures and death considered treatment failures, Dr. Gillinov said.
He acknowledged that 20% of patients did not have data for the primary endpoint and that the endpoint was not a clinical one, but said a trial with mortality or stroke as the endpoint would require more than 1,000 patients and many years follow-up.
Regarding whether ablation should now be performed routinely, “the glass is half full or half empty,” remarked discussant Dr. Bernard Gersh of Mayo Clinic in Rochester, Minn. “On one hand, you have shown less atrial fibrillation [with ablation], but no effect on quality of life, and the price to be paid was a higher rate of pacemaker implantation,” he said.
The pacemaker implantation rate was higher than expected – 17% in-hospital – and does represent a potential cost, but he would routinely do a maze procedure, Dr. Gillinov said.
Discussant Dr. Alice Jacobs of the Cardiovascular Center at Boston Medical Center, said she expected Dr. Gillinov to say the procedure should not be used in everyone given the lack of benefit in stroke, probably because they tied off the left atrium appendage, and the increase in pacemaker implantations.
About half of the pacemaker implantations were due to atrioventricular block, possibly a consequence of the valve surgery, and one-third to sinus-node dysfunction, which is common in elderly patients, Dr. Gillinov explained.
The study was funded by the National Institutes of Health and the Canadian Institutes of Health Research. Dr. Gillinov reported serving as a consultant/speaker for AtriCure, Medtronic, On-X, Edwards, and Tendyne; research funding from St. Jude Medical; an equity interest in Clear Catheter; and that his institution receives royalties from AtriCure for a left atrial appendage occlusion device.
SAN DIEGO – Surgical ablation of atrial fibrillation at the time of mitral valve surgery provides significantly greater rhythm control than mitral valve surgery alone, a study showed.
Freedom from atrial fibrillation (AF) at both 6 months and 1 year was 63% in patients undergoing mitral valve surgery (MVS) plus ablation and 29% in those undergoing MVS alone, a statistically significant difference.
However, patients who had ablation plus MVS were 2.5 times more likely to have a permanent pacemaker implanted than were those who had MVS alone, at 21.5% and 8.1%, respectively, also a significant difference.
Ablation did not increase mortality or major adverse cardiac or cerebrovascular events, Dr. A. Marc Gillinov said at the annual meeting of the American College of Cardiology.
Preoperative AF is present in up to 50% of patients undergoing mitral valve operations and is associated with an increased risk of death and stroke.
The study enrolled 260 relatively elderly patients (mean age 69 years) with AF that was persistent (non–self-terminating for at least 7 days) or long-standing persistent (continuous for at least a year), in addition to mitral valve disease. A total of 133 patients were randomly assigned to MVS plus ablation and 127 to MVS alone. The ablation group was further randomized to pulmonary vein isolation or a biatrial maze procedure; all underwent closure of the left atrial appendage.
There was no significant difference in freedom from AF at 6 months and 1 year between patients who had pulmonary vein isolation or a biatrial maze procedure, at 61% and 66%, respectively, said Dr. Gillinov, a cardiac surgeon at Cleveland Clinic.
One-year mortality was similar among all patients undergoing MVS plus ablation vs. MVS alone, at 6.8% and 8.7%.
The two groups also had similar Short Form-12 questionnaire scores for physical function and mental function, although AF occurring at least once daily was significantly less common with ablation, at 19.8%, compared with 45.2% in the MVS-alone patients, he said.
The heart rhythm endpoint was “stringent,” with 3-day Holter monitors obtained at both 6 and 12 months and repeat ablation procedures and death considered treatment failures, Dr. Gillinov said.
He acknowledged that 20% of patients did not have data for the primary endpoint and that the endpoint was not a clinical one, but said a trial with mortality or stroke as the endpoint would require more than 1,000 patients and many years follow-up.
Regarding whether ablation should now be performed routinely, “the glass is half full or half empty,” remarked discussant Dr. Bernard Gersh of Mayo Clinic in Rochester, Minn. “On one hand, you have shown less atrial fibrillation [with ablation], but no effect on quality of life, and the price to be paid was a higher rate of pacemaker implantation,” he said.
The pacemaker implantation rate was higher than expected – 17% in-hospital – and does represent a potential cost, but he would routinely do a maze procedure, Dr. Gillinov said.
Discussant Dr. Alice Jacobs of the Cardiovascular Center at Boston Medical Center, said she expected Dr. Gillinov to say the procedure should not be used in everyone given the lack of benefit in stroke, probably because they tied off the left atrium appendage, and the increase in pacemaker implantations.
About half of the pacemaker implantations were due to atrioventricular block, possibly a consequence of the valve surgery, and one-third to sinus-node dysfunction, which is common in elderly patients, Dr. Gillinov explained.
The study was funded by the National Institutes of Health and the Canadian Institutes of Health Research. Dr. Gillinov reported serving as a consultant/speaker for AtriCure, Medtronic, On-X, Edwards, and Tendyne; research funding from St. Jude Medical; an equity interest in Clear Catheter; and that his institution receives royalties from AtriCure for a left atrial appendage occlusion device.
SAN DIEGO – Surgical ablation of atrial fibrillation at the time of mitral valve surgery provides significantly greater rhythm control than mitral valve surgery alone, a study showed.
Freedom from atrial fibrillation (AF) at both 6 months and 1 year was 63% in patients undergoing mitral valve surgery (MVS) plus ablation and 29% in those undergoing MVS alone, a statistically significant difference.
However, patients who had ablation plus MVS were 2.5 times more likely to have a permanent pacemaker implanted than were those who had MVS alone, at 21.5% and 8.1%, respectively, also a significant difference.
Ablation did not increase mortality or major adverse cardiac or cerebrovascular events, Dr. A. Marc Gillinov said at the annual meeting of the American College of Cardiology.
Preoperative AF is present in up to 50% of patients undergoing mitral valve operations and is associated with an increased risk of death and stroke.
The study enrolled 260 relatively elderly patients (mean age 69 years) with AF that was persistent (non–self-terminating for at least 7 days) or long-standing persistent (continuous for at least a year), in addition to mitral valve disease. A total of 133 patients were randomly assigned to MVS plus ablation and 127 to MVS alone. The ablation group was further randomized to pulmonary vein isolation or a biatrial maze procedure; all underwent closure of the left atrial appendage.
There was no significant difference in freedom from AF at 6 months and 1 year between patients who had pulmonary vein isolation or a biatrial maze procedure, at 61% and 66%, respectively, said Dr. Gillinov, a cardiac surgeon at Cleveland Clinic.
One-year mortality was similar among all patients undergoing MVS plus ablation vs. MVS alone, at 6.8% and 8.7%.
The two groups also had similar Short Form-12 questionnaire scores for physical function and mental function, although AF occurring at least once daily was significantly less common with ablation, at 19.8%, compared with 45.2% in the MVS-alone patients, he said.
The heart rhythm endpoint was “stringent,” with 3-day Holter monitors obtained at both 6 and 12 months and repeat ablation procedures and death considered treatment failures, Dr. Gillinov said.
He acknowledged that 20% of patients did not have data for the primary endpoint and that the endpoint was not a clinical one, but said a trial with mortality or stroke as the endpoint would require more than 1,000 patients and many years follow-up.
Regarding whether ablation should now be performed routinely, “the glass is half full or half empty,” remarked discussant Dr. Bernard Gersh of Mayo Clinic in Rochester, Minn. “On one hand, you have shown less atrial fibrillation [with ablation], but no effect on quality of life, and the price to be paid was a higher rate of pacemaker implantation,” he said.
The pacemaker implantation rate was higher than expected – 17% in-hospital – and does represent a potential cost, but he would routinely do a maze procedure, Dr. Gillinov said.
Discussant Dr. Alice Jacobs of the Cardiovascular Center at Boston Medical Center, said she expected Dr. Gillinov to say the procedure should not be used in everyone given the lack of benefit in stroke, probably because they tied off the left atrium appendage, and the increase in pacemaker implantations.
About half of the pacemaker implantations were due to atrioventricular block, possibly a consequence of the valve surgery, and one-third to sinus-node dysfunction, which is common in elderly patients, Dr. Gillinov explained.
The study was funded by the National Institutes of Health and the Canadian Institutes of Health Research. Dr. Gillinov reported serving as a consultant/speaker for AtriCure, Medtronic, On-X, Edwards, and Tendyne; research funding from St. Jude Medical; an equity interest in Clear Catheter; and that his institution receives royalties from AtriCure for a left atrial appendage occlusion device.
AT ACC 15
Key clinical point: Surgical ablation of atrial fibrillation during mitral valve surgery decreases AF at 6 months and 1 year, but increases pacemaker implantations.
Major finding: Freedom from AF at both 6 months and 1 year was 63% with mitral valve surgery plus ablation and 29% for MVS alone.
Data source: Prospective, randomized study in 260 patients with persistent or longstanding persistent AF who required mitral valve surgery.
Disclosures: The study was funded by the National Institutes of Health and the Canadian Institutes of Health Research. Dr. Gillinov reported serving as a consultant/speaker for AtriCure, Medtronic, On-X, Edwards, and Tendyne; research funding from St. Jude Medical; an equity interest in Clear Catheter; and that his institution receives royalties from AtriCure for a left atrial appendage occlusion device.
Three factors boost dabigatran adherence
Patient adherence to dabigatran therapy varied enormously in a nationwide study of pharmacy data, and three factors were identified that markedly enhanced adherence, according to a report published online April 14 in JAMA.
After research suggested that adherence to dabigatran was suboptimal among patients taking the drug for nonvalvular atrial fibrillation, investigators explored variations in adherence across thousands of sites using a Veterans Health Administration pharmacy database. They found that among 4,863 patients filling dabigatran prescriptions at 67 pharmacies during a 2-year period, adherence ranged from a low of 42% to a high of 93%, said Dr. Supriya Shore, a cardiology fellow at Emory University, Atlanta, and her associates.
The single most important factor that influenced dabigatran adherence was appropriate patient selection before dispensing the drug. This was defined as the pharmacist assessing the indication for treatment and ruling out contraindications after the physician ordered the prescription, as well as checking the patient’s adherence to other medications. Pharmacist monitoring of dabigatran use and adverse events, either alone or in collaboration with the treating clinician, also boosted adherence.
In addition, pharmacists working with clinicians to identify and address nonadherence also enhanced patient adherence. Prescribing physicians may not be able to routinely monitor adherence because of their large workload and limited time during clinic visits. Having a pharmacist do so mitigated patients’ tendency to stop taking the drug when minor adverse effects developed, the investigators reported (JAMA 2015 April 14 [doi:101001/jama.2015.2761]).
“These findings suggest that such site-level practices provide modifiable targets to improve patient adherence to dabigatran, as opposed to patient characteristics that frequently cannot be modified,” Dr. Shore and her associates wrote.
This study was funded in part by VA Health Services Research & Development, an American Heart Association National Scientist Development Grant, and a Gilead Sciences Cardiovascular Research Scholars Program award. Dr. Shore reported having no financial disclosures; one of her associates reported serving as a consultant to Precision Health Economics, Medtronic, and St. Jude Medical.
Patient adherence to dabigatran therapy varied enormously in a nationwide study of pharmacy data, and three factors were identified that markedly enhanced adherence, according to a report published online April 14 in JAMA.
After research suggested that adherence to dabigatran was suboptimal among patients taking the drug for nonvalvular atrial fibrillation, investigators explored variations in adherence across thousands of sites using a Veterans Health Administration pharmacy database. They found that among 4,863 patients filling dabigatran prescriptions at 67 pharmacies during a 2-year period, adherence ranged from a low of 42% to a high of 93%, said Dr. Supriya Shore, a cardiology fellow at Emory University, Atlanta, and her associates.
The single most important factor that influenced dabigatran adherence was appropriate patient selection before dispensing the drug. This was defined as the pharmacist assessing the indication for treatment and ruling out contraindications after the physician ordered the prescription, as well as checking the patient’s adherence to other medications. Pharmacist monitoring of dabigatran use and adverse events, either alone or in collaboration with the treating clinician, also boosted adherence.
In addition, pharmacists working with clinicians to identify and address nonadherence also enhanced patient adherence. Prescribing physicians may not be able to routinely monitor adherence because of their large workload and limited time during clinic visits. Having a pharmacist do so mitigated patients’ tendency to stop taking the drug when minor adverse effects developed, the investigators reported (JAMA 2015 April 14 [doi:101001/jama.2015.2761]).
“These findings suggest that such site-level practices provide modifiable targets to improve patient adherence to dabigatran, as opposed to patient characteristics that frequently cannot be modified,” Dr. Shore and her associates wrote.
This study was funded in part by VA Health Services Research & Development, an American Heart Association National Scientist Development Grant, and a Gilead Sciences Cardiovascular Research Scholars Program award. Dr. Shore reported having no financial disclosures; one of her associates reported serving as a consultant to Precision Health Economics, Medtronic, and St. Jude Medical.
Patient adherence to dabigatran therapy varied enormously in a nationwide study of pharmacy data, and three factors were identified that markedly enhanced adherence, according to a report published online April 14 in JAMA.
After research suggested that adherence to dabigatran was suboptimal among patients taking the drug for nonvalvular atrial fibrillation, investigators explored variations in adherence across thousands of sites using a Veterans Health Administration pharmacy database. They found that among 4,863 patients filling dabigatran prescriptions at 67 pharmacies during a 2-year period, adherence ranged from a low of 42% to a high of 93%, said Dr. Supriya Shore, a cardiology fellow at Emory University, Atlanta, and her associates.
The single most important factor that influenced dabigatran adherence was appropriate patient selection before dispensing the drug. This was defined as the pharmacist assessing the indication for treatment and ruling out contraindications after the physician ordered the prescription, as well as checking the patient’s adherence to other medications. Pharmacist monitoring of dabigatran use and adverse events, either alone or in collaboration with the treating clinician, also boosted adherence.
In addition, pharmacists working with clinicians to identify and address nonadherence also enhanced patient adherence. Prescribing physicians may not be able to routinely monitor adherence because of their large workload and limited time during clinic visits. Having a pharmacist do so mitigated patients’ tendency to stop taking the drug when minor adverse effects developed, the investigators reported (JAMA 2015 April 14 [doi:101001/jama.2015.2761]).
“These findings suggest that such site-level practices provide modifiable targets to improve patient adherence to dabigatran, as opposed to patient characteristics that frequently cannot be modified,” Dr. Shore and her associates wrote.
This study was funded in part by VA Health Services Research & Development, an American Heart Association National Scientist Development Grant, and a Gilead Sciences Cardiovascular Research Scholars Program award. Dr. Shore reported having no financial disclosures; one of her associates reported serving as a consultant to Precision Health Economics, Medtronic, and St. Jude Medical.
FROM JAMA
Key clinical point: Three modifiable factors improved AF patients’ adherence to dabigatran therapy.
Major finding: Among 4,863 patients filling dabigatran prescriptions at 67 pharmacies across the country during a 2-year period, adherence ranged from 42% to 93%.
Data source: A retrospective quantitative analysis and a cross-sectional qualitative analysis of data concerning 4,863 patients who filled dabigatran prescriptions at 67 sites.
Disclosures: This study was funded in part by VA Health Services Research & Development, an American Heart Association National Scientist Development Grant, and a Gilead Sciences Cardiovascular Research Scholars Program award. Dr. Shore reported having no financial disclosures; one of her associates reported serving as a consultant to Precision Health Economics, Medtronic, and St. Jude Medical.
Make the Diagnosis - April 2015
Diagnosis: Lichen Planus
Lichen planus is a common inflammatory condition involving the skin, nails, mucous membranes, and hair follicles. It has no racial predilection, and often affects men and women aged 20-60 years. It is less common in children, who account for only 4% of cases. The lesions are often atypical.
Clinically, patients often present with erythematous to violaceous small, flat-topped, polygonal papules that may coalesce into plaques. Lesions are generally pruritic, and may be tender or painful. Older lesions may be hyperpigmented. White streaks known as Wickham striae can cross the surface of lesions. These striae also can be present orally, such as in the patient described here. Oral lesions also may be atrophic or erosive.
Common body locations with involvement are the inner wrists, legs, torso, or genitals (glans penis). The face is rarely involved. Nail changes, such as longitudinal ridging and splitting, onycholysis, red lunula, yellow nail syndrome, and pterygium formation, can occur.
Lichen planus often spontaneously resolves on its own, with 2/3 of patients resolving in a year. Mucous membrane disease tends to be more chronic. The etiology of lichen planus is unknown. It may have an autoimmune mechanism in which T cells induce keratinocytes to undergo apoptosis. Between 4% and 60% of lichen planus patients also have hepatitis C infections. The differential diagnosis for cutaneous lesions include lichenoid drug eruption, guttate psoriasis, syphilis, and pityriasis lichenoides et varioliformis acuta. Oral lesions may resemble candidiasis, leukoplakia, malignancies, and bullous disease.
Topical and intralesional steroids are often effective for localized disease. Systemic corticosteroids can be useful when lesions are widespread. Phototherapy, isotretinoin, acitretin, hydroxychloroquine, and oral immunosuppressive agents (such as cyclosporine and mycophenolate mofetil) all have been described in the treatment of lichen planus.
Diagnosis: Lichen Planus
Lichen planus is a common inflammatory condition involving the skin, nails, mucous membranes, and hair follicles. It has no racial predilection, and often affects men and women aged 20-60 years. It is less common in children, who account for only 4% of cases. The lesions are often atypical.
Clinically, patients often present with erythematous to violaceous small, flat-topped, polygonal papules that may coalesce into plaques. Lesions are generally pruritic, and may be tender or painful. Older lesions may be hyperpigmented. White streaks known as Wickham striae can cross the surface of lesions. These striae also can be present orally, such as in the patient described here. Oral lesions also may be atrophic or erosive.
Common body locations with involvement are the inner wrists, legs, torso, or genitals (glans penis). The face is rarely involved. Nail changes, such as longitudinal ridging and splitting, onycholysis, red lunula, yellow nail syndrome, and pterygium formation, can occur.
Lichen planus often spontaneously resolves on its own, with 2/3 of patients resolving in a year. Mucous membrane disease tends to be more chronic. The etiology of lichen planus is unknown. It may have an autoimmune mechanism in which T cells induce keratinocytes to undergo apoptosis. Between 4% and 60% of lichen planus patients also have hepatitis C infections. The differential diagnosis for cutaneous lesions include lichenoid drug eruption, guttate psoriasis, syphilis, and pityriasis lichenoides et varioliformis acuta. Oral lesions may resemble candidiasis, leukoplakia, malignancies, and bullous disease.
Topical and intralesional steroids are often effective for localized disease. Systemic corticosteroids can be useful when lesions are widespread. Phototherapy, isotretinoin, acitretin, hydroxychloroquine, and oral immunosuppressive agents (such as cyclosporine and mycophenolate mofetil) all have been described in the treatment of lichen planus.
Diagnosis: Lichen Planus
Lichen planus is a common inflammatory condition involving the skin, nails, mucous membranes, and hair follicles. It has no racial predilection, and often affects men and women aged 20-60 years. It is less common in children, who account for only 4% of cases. The lesions are often atypical.
Clinically, patients often present with erythematous to violaceous small, flat-topped, polygonal papules that may coalesce into plaques. Lesions are generally pruritic, and may be tender or painful. Older lesions may be hyperpigmented. White streaks known as Wickham striae can cross the surface of lesions. These striae also can be present orally, such as in the patient described here. Oral lesions also may be atrophic or erosive.
Common body locations with involvement are the inner wrists, legs, torso, or genitals (glans penis). The face is rarely involved. Nail changes, such as longitudinal ridging and splitting, onycholysis, red lunula, yellow nail syndrome, and pterygium formation, can occur.
Lichen planus often spontaneously resolves on its own, with 2/3 of patients resolving in a year. Mucous membrane disease tends to be more chronic. The etiology of lichen planus is unknown. It may have an autoimmune mechanism in which T cells induce keratinocytes to undergo apoptosis. Between 4% and 60% of lichen planus patients also have hepatitis C infections. The differential diagnosis for cutaneous lesions include lichenoid drug eruption, guttate psoriasis, syphilis, and pityriasis lichenoides et varioliformis acuta. Oral lesions may resemble candidiasis, leukoplakia, malignancies, and bullous disease.
Topical and intralesional steroids are often effective for localized disease. Systemic corticosteroids can be useful when lesions are widespread. Phototherapy, isotretinoin, acitretin, hydroxychloroquine, and oral immunosuppressive agents (such as cyclosporine and mycophenolate mofetil) all have been described in the treatment of lichen planus.
This case and photo were submitted by Dr. Damon McClain, a dermatologist in Camp Lejeune, N.C. A 34-year-old male presented with a 1-month history of an itchy rash on his penis and feet. Upon physical examination, these lesions were seen orally. Blood work, including hepatitis serologies, was negative. His skin lesions improved with topical steroids.
Gene appears key to HSC regulation
in the bone marrow
The gene Ash1l plays a key role in regulating the maintenance and self-renewal of hematopoietic stem cells (HSCs), according to a study published in The Journal of Clinical Investigation.
The research provides new insight into how the body creates and maintains a healthy blood supply and immune system. It also opens new lines of inquiry about Ash1l’s potential role in cancers—like leukemia—that involve other members of the same gene family.
“If we find that Ash1l plays a role [in leukemia], that would open up avenues to try to block or slow down its activity pharmacologically,” said study author Ivan Maillard, MD, of the University of Michigan Medical School in Ann Arbor.
The Ash1l gene regulates the expression of multiple downstream homeotic genes, which help ensure the correct anatomical structure of a developing organism. And Ash1l is part of a family of genes that includes MLL1.
The researchers found that both Ash1l and MLL1 contribute to blood renewal. They observed mild defects in mice missing one gene or the other, but lacking both genes led to catastrophic deficiencies.
“We now have clear evidence that these genes cooperate to develop a healthy blood system,” Dr Maillard said.
He and his colleagues also found that Ash1l-deficient mice had normal numbers of HSCs during early development but a lack of HSCs in maturity—an indication the cells were not able to properly maintain themselves in the bone marrow.
Ash1l-deficient HSCs were unable to establish normal blood renewal after an HSC transplant. Moreover, Ash1l-deficient stem cells competed poorly with normal HSCs in the bone marrow and could easily be dislodged.
“By continuing to investigate the basic, underlying mechanisms [of blood renewal], we are helping to untangle the complex machinery . . . that may lay the foundation for new human treatments 5, 10, or 20 years from now,” Dr Maillard said. 
in the bone marrow
The gene Ash1l plays a key role in regulating the maintenance and self-renewal of hematopoietic stem cells (HSCs), according to a study published in The Journal of Clinical Investigation.
The research provides new insight into how the body creates and maintains a healthy blood supply and immune system. It also opens new lines of inquiry about Ash1l’s potential role in cancers—like leukemia—that involve other members of the same gene family.
“If we find that Ash1l plays a role [in leukemia], that would open up avenues to try to block or slow down its activity pharmacologically,” said study author Ivan Maillard, MD, of the University of Michigan Medical School in Ann Arbor.
The Ash1l gene regulates the expression of multiple downstream homeotic genes, which help ensure the correct anatomical structure of a developing organism. And Ash1l is part of a family of genes that includes MLL1.
The researchers found that both Ash1l and MLL1 contribute to blood renewal. They observed mild defects in mice missing one gene or the other, but lacking both genes led to catastrophic deficiencies.
“We now have clear evidence that these genes cooperate to develop a healthy blood system,” Dr Maillard said.
He and his colleagues also found that Ash1l-deficient mice had normal numbers of HSCs during early development but a lack of HSCs in maturity—an indication the cells were not able to properly maintain themselves in the bone marrow.
Ash1l-deficient HSCs were unable to establish normal blood renewal after an HSC transplant. Moreover, Ash1l-deficient stem cells competed poorly with normal HSCs in the bone marrow and could easily be dislodged.
“By continuing to investigate the basic, underlying mechanisms [of blood renewal], we are helping to untangle the complex machinery . . . that may lay the foundation for new human treatments 5, 10, or 20 years from now,” Dr Maillard said.
in the bone marrow
The gene Ash1l plays a key role in regulating the maintenance and self-renewal of hematopoietic stem cells (HSCs), according to a study published in The Journal of Clinical Investigation.
The research provides new insight into how the body creates and maintains a healthy blood supply and immune system. It also opens new lines of inquiry about Ash1l’s potential role in cancers—like leukemia—that involve other members of the same gene family.
“If we find that Ash1l plays a role [in leukemia], that would open up avenues to try to block or slow down its activity pharmacologically,” said study author Ivan Maillard, MD, of the University of Michigan Medical School in Ann Arbor.
The Ash1l gene regulates the expression of multiple downstream homeotic genes, which help ensure the correct anatomical structure of a developing organism. And Ash1l is part of a family of genes that includes MLL1.
The researchers found that both Ash1l and MLL1 contribute to blood renewal. They observed mild defects in mice missing one gene or the other, but lacking both genes led to catastrophic deficiencies.
“We now have clear evidence that these genes cooperate to develop a healthy blood system,” Dr Maillard said.
He and his colleagues also found that Ash1l-deficient mice had normal numbers of HSCs during early development but a lack of HSCs in maturity—an indication the cells were not able to properly maintain themselves in the bone marrow.
Ash1l-deficient HSCs were unable to establish normal blood renewal after an HSC transplant. Moreover, Ash1l-deficient stem cells competed poorly with normal HSCs in the bone marrow and could easily be dislodged.
“By continuing to investigate the basic, underlying mechanisms [of blood renewal], we are helping to untangle the complex machinery . . . that may lay the foundation for new human treatments 5, 10, or 20 years from now,” Dr Maillard said.
How telomere length affects cancer mortality
with telomeres in green
Image by Claus Azzalin
New research suggests telomere length is associated with cancer mortality—but not in the way researchers expected.
The study showed that short telomeres in peripheral blood leukocytes were associated with high mortality from all causes.
But genetically determined short telomeres were associated with low cancer mortality.
Line Rode, MD, PhD, of Herlev Hospital in Denmark, and colleagues reported these findings in JNCI: Journal of the National Cancer Institute.
Some previous studies have suggested an association between short telomeres and high mortality, including cancer mortality, while others have not. A possible explanation for the conflicting evidence may be that the association was correlational, but other factors that were not adjusted for (such as age and lifestyle) were the real causes.
Genetic variation in genes associated with telomere length (TERC, TERT, and OBFC1) is independent of age and lifestyle factors. So researchers speculated that a genetic analysis called a Mendelian randomization could eliminate some of the confounding and allow them to confirm the association between telomere length and cancer mortality.
To perform this analysis, the team used data from 2 prospective cohort studies. The Copenhagen City Heart Study and the Copenhagen General Population Study included 64,637 individuals who were followed from 1991 to 2011.
Participants completed a questionnaire, underwent a physical examination, and had blood drawn for biochemistry, genotyping, and telomere length assays.
For each subject, the researchers had information on physical characteristics such as body mass index (BMI), blood pressure, and cholesterol measurements, as well as smoking status, alcohol consumption, physical activity, and socioeconomic variables.
In addition to measuring telomere length for each subject, the researchers used 3 single nucleotide polymorphisms of TERC, TERT, and OBFC1 to construct a score for the presence of telomere-shortening alleles.
A total of 7607 individuals died during the study period, 2420 of cancer. Overall, decreasing telomere length was associated with age, variables such as BMI and smoking, and death from all causes, including cancer.
In contrast, a higher genetic score for telomere shortening was associated with decreased cancer mortality but not with any other causes of death.
The researchers said this suggests the slightly shorter telomeres in cancer patients with the higher genetic score for telomere shortening might be beneficial because uncontrolled cancer cell replication is reduced.
And long telomeres may confer a survival advantage for cancer cells, as they allow for multiple cell divisions that lead to high cancer mortality.
with telomeres in green
Image by Claus Azzalin
New research suggests telomere length is associated with cancer mortality—but not in the way researchers expected.
The study showed that short telomeres in peripheral blood leukocytes were associated with high mortality from all causes.
But genetically determined short telomeres were associated with low cancer mortality.
Line Rode, MD, PhD, of Herlev Hospital in Denmark, and colleagues reported these findings in JNCI: Journal of the National Cancer Institute.
Some previous studies have suggested an association between short telomeres and high mortality, including cancer mortality, while others have not. A possible explanation for the conflicting evidence may be that the association was correlational, but other factors that were not adjusted for (such as age and lifestyle) were the real causes.
Genetic variation in genes associated with telomere length (TERC, TERT, and OBFC1) is independent of age and lifestyle factors. So researchers speculated that a genetic analysis called a Mendelian randomization could eliminate some of the confounding and allow them to confirm the association between telomere length and cancer mortality.
To perform this analysis, the team used data from 2 prospective cohort studies. The Copenhagen City Heart Study and the Copenhagen General Population Study included 64,637 individuals who were followed from 1991 to 2011.
Participants completed a questionnaire, underwent a physical examination, and had blood drawn for biochemistry, genotyping, and telomere length assays.
For each subject, the researchers had information on physical characteristics such as body mass index (BMI), blood pressure, and cholesterol measurements, as well as smoking status, alcohol consumption, physical activity, and socioeconomic variables.
In addition to measuring telomere length for each subject, the researchers used 3 single nucleotide polymorphisms of TERC, TERT, and OBFC1 to construct a score for the presence of telomere-shortening alleles.
A total of 7607 individuals died during the study period, 2420 of cancer. Overall, decreasing telomere length was associated with age, variables such as BMI and smoking, and death from all causes, including cancer.
In contrast, a higher genetic score for telomere shortening was associated with decreased cancer mortality but not with any other causes of death.
The researchers said this suggests the slightly shorter telomeres in cancer patients with the higher genetic score for telomere shortening might be beneficial because uncontrolled cancer cell replication is reduced.
And long telomeres may confer a survival advantage for cancer cells, as they allow for multiple cell divisions that lead to high cancer mortality.
with telomeres in green
Image by Claus Azzalin
New research suggests telomere length is associated with cancer mortality—but not in the way researchers expected.
The study showed that short telomeres in peripheral blood leukocytes were associated with high mortality from all causes.
But genetically determined short telomeres were associated with low cancer mortality.
Line Rode, MD, PhD, of Herlev Hospital in Denmark, and colleagues reported these findings in JNCI: Journal of the National Cancer Institute.
Some previous studies have suggested an association between short telomeres and high mortality, including cancer mortality, while others have not. A possible explanation for the conflicting evidence may be that the association was correlational, but other factors that were not adjusted for (such as age and lifestyle) were the real causes.
Genetic variation in genes associated with telomere length (TERC, TERT, and OBFC1) is independent of age and lifestyle factors. So researchers speculated that a genetic analysis called a Mendelian randomization could eliminate some of the confounding and allow them to confirm the association between telomere length and cancer mortality.
To perform this analysis, the team used data from 2 prospective cohort studies. The Copenhagen City Heart Study and the Copenhagen General Population Study included 64,637 individuals who were followed from 1991 to 2011.
Participants completed a questionnaire, underwent a physical examination, and had blood drawn for biochemistry, genotyping, and telomere length assays.
For each subject, the researchers had information on physical characteristics such as body mass index (BMI), blood pressure, and cholesterol measurements, as well as smoking status, alcohol consumption, physical activity, and socioeconomic variables.
In addition to measuring telomere length for each subject, the researchers used 3 single nucleotide polymorphisms of TERC, TERT, and OBFC1 to construct a score for the presence of telomere-shortening alleles.
A total of 7607 individuals died during the study period, 2420 of cancer. Overall, decreasing telomere length was associated with age, variables such as BMI and smoking, and death from all causes, including cancer.
In contrast, a higher genetic score for telomere shortening was associated with decreased cancer mortality but not with any other causes of death.
The researchers said this suggests the slightly shorter telomeres in cancer patients with the higher genetic score for telomere shortening might be beneficial because uncontrolled cancer cell replication is reduced.
And long telomeres may confer a survival advantage for cancer cells, as they allow for multiple cell divisions that lead to high cancer mortality.
Oral anticoagulants overprescribed in AF
Results of a large study indicate that patients with atrial fibrillation (AF) and a low risk of thromboembolism are sometimes prescribed oral
anticoagulants even though guidelines recommend against it.
“The irony is that there is a general push to get providers to prescribe these drugs, and they are also generally underprescribed among many AF
patients who actually need them,” said study author Gregory Marcus, MD, of the University of California San Francisco.
“Our study suggests people are trying to do the right thing but, due to a lack of understanding of some of the critical nuances, go too far in that direction in low-risk patients.”
Dr Marcus and his colleagues described this study in JAMA Internal Medicine.
The team noted that previous AF guidelines recommend against the use of oral anticoagulants in patients younger than 60 years of age without heart disease or other known risk factors for thromboembolism, and updated guidelines do not recommend the use of oral anticoagulants in patients without any established risk factor for stroke.
The researchers wanted to determine the frequency with which oral anticoagulant prescriptions are made outside of guideline recommendations. So they assessed 10,995 AF patients ages 60 and under from the overall Practice Innovation and Clinical Excellence (PINNACLE) Registry of the National Cardiovascular Data Registry who were treated in the US between 2008 and 2012.
About 23% (n=2561) of patients with a CHADS2 score of 0 and about 27% (n=1787) of patients with a CHA2DS2-VASc score of 0 were prescribed oral anticoagulant therapy contrary to guideline recommendations.
In a multivariable analysis of patients with a CHADS2 score of 0, several factors were associated with a higher likelihood of being prescribed oral anticoagulants. These included older age (relative risk [RR]=1.48 per 10 years; P<0.001), male sex (RR=1.34; P<0.001), higher body mass index (RR=1.18 per 5kg/m2; P<0.001), and having Medicare rather than private insurance (RR=1.32; P<0.001).
On the other hand, being treated in the South rather than the Northeast was associated with a lower likelihood of being prescribed oral anticoagulants (RR=0.69; P=0.04).
The researchers observed similar results in a multivariable analysis of patients with a CHA2DS2-VASc score of 0. Being treated in the South rather than the Northeast was associated with a lower likelihood of being prescribed oral anticoagulants (RR=0.67; P=0.03).
And older age (RR=1.44 per 10 years; P<0.001), higher body mass index (RR=1.19 per 5 kg/m2; P<0.001), having Medicare rather than private insurance (RR=1.29; P<0.001), and having no insurance rather than private insurance (RR=1.19; P=0.02) were all associated with a higher likelihood of being prescribed oral anticoagulants.
The researchers said these results suggest providers may not be fully aware of the potential risks of these drugs or the particularly low risk of thromboembolism in certain populations.
“Practitioners who prescribe blood thinners need to be diligent about weighing the risks and benefits of these medications,” said study author Jonathan C. Hsu, MD, of the University of California San Diego.
“In those patients with no risk factors for stroke, the risk of bleeding likely outweighs the benefit of stroke reduction. The fact that blood thinners were prescribed to so many patients with no risk factors for stroke is a wake-up call that we need to do better for our patients.”
Results of a large study indicate that patients with atrial fibrillation (AF) and a low risk of thromboembolism are sometimes prescribed oral
anticoagulants even though guidelines recommend against it.
“The irony is that there is a general push to get providers to prescribe these drugs, and they are also generally underprescribed among many AF
patients who actually need them,” said study author Gregory Marcus, MD, of the University of California San Francisco.
“Our study suggests people are trying to do the right thing but, due to a lack of understanding of some of the critical nuances, go too far in that direction in low-risk patients.”
Dr Marcus and his colleagues described this study in JAMA Internal Medicine.
The team noted that previous AF guidelines recommend against the use of oral anticoagulants in patients younger than 60 years of age without heart disease or other known risk factors for thromboembolism, and updated guidelines do not recommend the use of oral anticoagulants in patients without any established risk factor for stroke.
The researchers wanted to determine the frequency with which oral anticoagulant prescriptions are made outside of guideline recommendations. So they assessed 10,995 AF patients ages 60 and under from the overall Practice Innovation and Clinical Excellence (PINNACLE) Registry of the National Cardiovascular Data Registry who were treated in the US between 2008 and 2012.
About 23% (n=2561) of patients with a CHADS2 score of 0 and about 27% (n=1787) of patients with a CHA2DS2-VASc score of 0 were prescribed oral anticoagulant therapy contrary to guideline recommendations.
In a multivariable analysis of patients with a CHADS2 score of 0, several factors were associated with a higher likelihood of being prescribed oral anticoagulants. These included older age (relative risk [RR]=1.48 per 10 years; P<0.001), male sex (RR=1.34; P<0.001), higher body mass index (RR=1.18 per 5kg/m2; P<0.001), and having Medicare rather than private insurance (RR=1.32; P<0.001).
On the other hand, being treated in the South rather than the Northeast was associated with a lower likelihood of being prescribed oral anticoagulants (RR=0.69; P=0.04).
The researchers observed similar results in a multivariable analysis of patients with a CHA2DS2-VASc score of 0. Being treated in the South rather than the Northeast was associated with a lower likelihood of being prescribed oral anticoagulants (RR=0.67; P=0.03).
And older age (RR=1.44 per 10 years; P<0.001), higher body mass index (RR=1.19 per 5 kg/m2; P<0.001), having Medicare rather than private insurance (RR=1.29; P<0.001), and having no insurance rather than private insurance (RR=1.19; P=0.02) were all associated with a higher likelihood of being prescribed oral anticoagulants.
The researchers said these results suggest providers may not be fully aware of the potential risks of these drugs or the particularly low risk of thromboembolism in certain populations.
“Practitioners who prescribe blood thinners need to be diligent about weighing the risks and benefits of these medications,” said study author Jonathan C. Hsu, MD, of the University of California San Diego.
“In those patients with no risk factors for stroke, the risk of bleeding likely outweighs the benefit of stroke reduction. The fact that blood thinners were prescribed to so many patients with no risk factors for stroke is a wake-up call that we need to do better for our patients.”
Results of a large study indicate that patients with atrial fibrillation (AF) and a low risk of thromboembolism are sometimes prescribed oral
anticoagulants even though guidelines recommend against it.
“The irony is that there is a general push to get providers to prescribe these drugs, and they are also generally underprescribed among many AF
patients who actually need them,” said study author Gregory Marcus, MD, of the University of California San Francisco.
“Our study suggests people are trying to do the right thing but, due to a lack of understanding of some of the critical nuances, go too far in that direction in low-risk patients.”
Dr Marcus and his colleagues described this study in JAMA Internal Medicine.
The team noted that previous AF guidelines recommend against the use of oral anticoagulants in patients younger than 60 years of age without heart disease or other known risk factors for thromboembolism, and updated guidelines do not recommend the use of oral anticoagulants in patients without any established risk factor for stroke.
The researchers wanted to determine the frequency with which oral anticoagulant prescriptions are made outside of guideline recommendations. So they assessed 10,995 AF patients ages 60 and under from the overall Practice Innovation and Clinical Excellence (PINNACLE) Registry of the National Cardiovascular Data Registry who were treated in the US between 2008 and 2012.
About 23% (n=2561) of patients with a CHADS2 score of 0 and about 27% (n=1787) of patients with a CHA2DS2-VASc score of 0 were prescribed oral anticoagulant therapy contrary to guideline recommendations.
In a multivariable analysis of patients with a CHADS2 score of 0, several factors were associated with a higher likelihood of being prescribed oral anticoagulants. These included older age (relative risk [RR]=1.48 per 10 years; P<0.001), male sex (RR=1.34; P<0.001), higher body mass index (RR=1.18 per 5kg/m2; P<0.001), and having Medicare rather than private insurance (RR=1.32; P<0.001).
On the other hand, being treated in the South rather than the Northeast was associated with a lower likelihood of being prescribed oral anticoagulants (RR=0.69; P=0.04).
The researchers observed similar results in a multivariable analysis of patients with a CHA2DS2-VASc score of 0. Being treated in the South rather than the Northeast was associated with a lower likelihood of being prescribed oral anticoagulants (RR=0.67; P=0.03).
And older age (RR=1.44 per 10 years; P<0.001), higher body mass index (RR=1.19 per 5 kg/m2; P<0.001), having Medicare rather than private insurance (RR=1.29; P<0.001), and having no insurance rather than private insurance (RR=1.19; P=0.02) were all associated with a higher likelihood of being prescribed oral anticoagulants.
The researchers said these results suggest providers may not be fully aware of the potential risks of these drugs or the particularly low risk of thromboembolism in certain populations.
“Practitioners who prescribe blood thinners need to be diligent about weighing the risks and benefits of these medications,” said study author Jonathan C. Hsu, MD, of the University of California San Diego.
“In those patients with no risk factors for stroke, the risk of bleeding likely outweighs the benefit of stroke reduction. The fact that blood thinners were prescribed to so many patients with no risk factors for stroke is a wake-up call that we need to do better for our patients.”
Gene therapy superior to partially matched HSCT for SCID-X1
Photo by Chad McNeeley
Children with X-linked severe combined immunodeficiency (SCID-X1) who undergo gene therapy have fewer infections and hospitalizations than those who receive a hematopoietic stem cell transplant (HSCT) from a partially matched donor, according to a study published in Blood.
“Over the last decade, gene therapy has emerged as a viable alternative to a partial matched stem cell transplant for infants with SCID-X1,” said study author Fabien Touzot, MD, PhD, of Necker Children’s Hospital in Paris, France.
“To ensure that we are providing the best alternative therapy possible, we wanted to compare outcomes among infants treated with gene therapy and infants receiving partial matched transplants.”
Dr Touzot and his colleagues studied the medical records of 27 children who received either a partially matched HSCT (n=13) or gene therapy (n=14) for SCID-X1 at Necker Children’s Hospital between 1999 and 2013.
The children receiving half-matched transplants and the children receiving gene therapy had been followed for a median of 6 years and 12 years, respectively.
The researchers compared T-cell development among the patients, as well as key clinical outcomes such as infections and hospitalization.
The 14 children in the gene therapy group developed healthy immune cells faster than the 13 children in the half-matched transplant group. In fact, in the first 6 months after therapy, T-cell counts had reached normal values in 78% of the gene therapy patients, compared to 26% of the HSCT patients.
The more rapid growth of the immune system in gene therapy patients was also associated with faster resolution of disseminated BDG infections. These infections resolved in a median of 11 months in the gene therapy group, compared to 25.5 months in the half-matched transplant group.
Gene therapy patients also had fewer infection-related hospitalizations—3 hospitalizations in 3 patients, compared to 15 hospitalizations in 5 patients from the half-matched HSCT group.
“Our analysis suggests that gene therapy can put these incredibly sick children on the road to defending themselves against infection faster than a half-matched transplant,” Dr Touzot said. “These results suggest that, for patients without a fully matched stem cell donor, gene therapy is the next-best approach.”
Photo by Chad McNeeley
Children with X-linked severe combined immunodeficiency (SCID-X1) who undergo gene therapy have fewer infections and hospitalizations than those who receive a hematopoietic stem cell transplant (HSCT) from a partially matched donor, according to a study published in Blood.
“Over the last decade, gene therapy has emerged as a viable alternative to a partial matched stem cell transplant for infants with SCID-X1,” said study author Fabien Touzot, MD, PhD, of Necker Children’s Hospital in Paris, France.
“To ensure that we are providing the best alternative therapy possible, we wanted to compare outcomes among infants treated with gene therapy and infants receiving partial matched transplants.”
Dr Touzot and his colleagues studied the medical records of 27 children who received either a partially matched HSCT (n=13) or gene therapy (n=14) for SCID-X1 at Necker Children’s Hospital between 1999 and 2013.
The children receiving half-matched transplants and the children receiving gene therapy had been followed for a median of 6 years and 12 years, respectively.
The researchers compared T-cell development among the patients, as well as key clinical outcomes such as infections and hospitalization.
The 14 children in the gene therapy group developed healthy immune cells faster than the 13 children in the half-matched transplant group. In fact, in the first 6 months after therapy, T-cell counts had reached normal values in 78% of the gene therapy patients, compared to 26% of the HSCT patients.
The more rapid growth of the immune system in gene therapy patients was also associated with faster resolution of disseminated BDG infections. These infections resolved in a median of 11 months in the gene therapy group, compared to 25.5 months in the half-matched transplant group.
Gene therapy patients also had fewer infection-related hospitalizations—3 hospitalizations in 3 patients, compared to 15 hospitalizations in 5 patients from the half-matched HSCT group.
“Our analysis suggests that gene therapy can put these incredibly sick children on the road to defending themselves against infection faster than a half-matched transplant,” Dr Touzot said. “These results suggest that, for patients without a fully matched stem cell donor, gene therapy is the next-best approach.”
Photo by Chad McNeeley
Children with X-linked severe combined immunodeficiency (SCID-X1) who undergo gene therapy have fewer infections and hospitalizations than those who receive a hematopoietic stem cell transplant (HSCT) from a partially matched donor, according to a study published in Blood.
“Over the last decade, gene therapy has emerged as a viable alternative to a partial matched stem cell transplant for infants with SCID-X1,” said study author Fabien Touzot, MD, PhD, of Necker Children’s Hospital in Paris, France.
“To ensure that we are providing the best alternative therapy possible, we wanted to compare outcomes among infants treated with gene therapy and infants receiving partial matched transplants.”
Dr Touzot and his colleagues studied the medical records of 27 children who received either a partially matched HSCT (n=13) or gene therapy (n=14) for SCID-X1 at Necker Children’s Hospital between 1999 and 2013.
The children receiving half-matched transplants and the children receiving gene therapy had been followed for a median of 6 years and 12 years, respectively.
The researchers compared T-cell development among the patients, as well as key clinical outcomes such as infections and hospitalization.
The 14 children in the gene therapy group developed healthy immune cells faster than the 13 children in the half-matched transplant group. In fact, in the first 6 months after therapy, T-cell counts had reached normal values in 78% of the gene therapy patients, compared to 26% of the HSCT patients.
The more rapid growth of the immune system in gene therapy patients was also associated with faster resolution of disseminated BDG infections. These infections resolved in a median of 11 months in the gene therapy group, compared to 25.5 months in the half-matched transplant group.
Gene therapy patients also had fewer infection-related hospitalizations—3 hospitalizations in 3 patients, compared to 15 hospitalizations in 5 patients from the half-matched HSCT group.
“Our analysis suggests that gene therapy can put these incredibly sick children on the road to defending themselves against infection faster than a half-matched transplant,” Dr Touzot said. “These results suggest that, for patients without a fully matched stem cell donor, gene therapy is the next-best approach.”
Yoga for Dermatologic Conditions
Regardless of its spiritual origins, yoga has become a popular way of reaching mind and body well-being with nearly 30 million people practicing regularly worldwide.1 Yoga, which is the combination of physical postures, controlled breathing, and meditation or mindfulness, has long been used in complementary and alternative medicine around the world and recently has gained popularity as a therapeutic practice, with nearly 14 million Americans reporting that yoga was recommended to them by a physician or therapist.2,3 Studies suggest that people who participate in even brief yoga programs may see improvements in anxiety, somatic stress and discomfort, health-related quality of life, and self-rated sleep quality, all benefits that can help medical conditions, especially those that are dermatologic in nature.4,5
Stress and Dermatologic Conditions
The interaction between the mind, skin, and body is well known. Research in psychoneuroimmunology, the interaction between psychological processes and the nervous and immune systems, has examined the role of neuropeptides, hormones, and neurotransmitters in psychodermatological disorders. The correlation between neuroimmunological pathways and skin inflammation is now well recognized, specifically the interactions between the brain and skin underlying many dermatological diseases (eg, acne, alopecia areata, various types of eczema and dermatitis, oral and genital herpes, hyperhidrosis, pruritus, psoriasis, rosacea, urticaria, warts, breaking or ridging of the nails).6-9
Two biological systems are known to be affected by the systemic stress response: (1) the hypothalamic-pituitary-adrenal axis, which regulates the release of adrenocorticotropin, ß-endorphin, and cortisol, and (2) the sympathoadrenal medullary system, which regulates the release of catecholamines (eg, epinephrine, norepinephrine).7 Cortisol and catecholamines have been shown to have potent effects on the immune system as well as the inflammatory response.9 Additionally, it has been shown that cutaneous sensory nerve terminals release neuropeptides, including calcitonin gene-related peptide and substance P, both of which have different effects on the local inflammatory response.10,11
Psychological stress is well known to trigger many dermatologic conditions, but it also may lead to abnormal skin barrier function.12 The mechanism in which skin barrier function is affected appears to involve a stress-induced increase of endogenous glucocorticoids, which may consequently disrupt skin barrier function and recovery rates, stratum corneum cohesion, and epidermal antimicrobial function.13,14
Atopic dermatitis, for example, is classified as a psychophysiological disorder. Although it is not caused by stress, atopic dermatitis has been described to be precipitated or exacerbated by stress in patients.15 In fact, it was found that stressful life events preceded the onset of itching in more than 70% of patients with atopic dermatitis,16 which is especially relevant, as there is no cure and patients often experience a lifelong struggle with the condition. Additionally, stress mediates the degranulation of mast cells via corticotropin-releasing hormone and neuropeptides, and the upregulation of mast cell corticotropin-releasing hormone receptors supporting its putative role in the pathogenesis of urticaria.9,17 Furthermore, the increase in cortisol also has been described in the exacerbation of acne during times of stress.18
Psychological factors affect the management of skin conditions in more than one-third of reported dermatology patients; therefore, it is important to consider these factors in the treatment of chronic dermatological conditions, especially when they are inquired by the patient.19,20
Yoga Benefits in the Literature
The therapeutic potential of yoga has been explored in a growing number of randomized controlled trials to date.21 A recently published bibliometric analysis provided a comprehensive review of the characteristics of the randomized yoga trials available in the literature.22 The review included 366 full-text articles, with the 2 earliest studies published in 1975 and nearly 90% published within the last decade. In addition to healthy patients, it was found these randomized controlled yoga trials most commonly enrolled patients with breast cancer, depression, asthma, and type 2 diabetes mellitus.22 Another study examined psychological (eg, self-rated stress and stress behavior, anger, exhaustion, quality of life) and physiological (eg, blood pressure, heart rate, urinary catecholamines, salivary cortisol) measurements obtained before and after a 10-session yoga program that participants completed over a 4-month period, with results showing significant improvements (P<.05) on almost all stress-related subjective and physiological variables. Results were comparable with cognitive behavioral therapy.23
Not only has it been shown that yoga helps patients on a psychological level, but a recent study reported that 90-minute sessions of mindfulness meditation and gentle Hatha yoga over an 8-week period led to observable benefits on a cellular level, as telomere length was maintained in distressed breast cancer survivors compared to decreases in telomere length in the control group with patients who solely participated in a stress management seminar.24 To date, there are no known studies examining the effects of yoga on patients with skin cancer. However, a few studies have specifically examined the effect of yoga in managing non–cancer-related dermatologic issues. Specifically, one small study of psoriasis patients found that those who listened to mindfulness meditation tapes while undergoing standard phototherapy (psoralen plus UVA) healed faster than those who underwent phototherapy treatment alone.25
Because some dermatologic problems have comorbidities and increased risk factors of other medical problems, such as psoriasis with psoriatic arthritis and metabolic diseases (eg, abdominal obesity, diabetes, nonalcoholic fatty liver disease, dyslipidemia, metabolic syndrome, chronic kidney disease), it is even more pertinent to recommend approaches for healthy mind and body well-being as a supplement to medical care.26
Final Thoughts
With accurate diagnosis by a dermatologist, appropriate conventional treatments can improve dermatologic problems. These treatments alone can reduce patients’ stress and improve skin, hair, and nail conditions; however, if it is clear that stress is interfering with a patient’s overall well-being and ability to cope with his/her dermatologic condition, concurrent stress management interventions may be warranted. In some instances, recommending yoga sessions, mindful meditation, or breathing exercises may help, while in others referral to a mental health professional may be necessary.
Beyond the direct physiological effects of stress, it also is worth mentioning that patients who deal with stress also tend to scratch, pick, or irritate their skin more and often lack the motivation to adhere to skin care regimens or treatments, again supporting the idea that our approach in managing these patients must be multifaceted. As dermatologists in training, residents should be cognizant of the potential psychological sequelae of some dermatologic problems and be aware of the possible use of supplemental interventions by our patients.
1. Dangerfield A. Yoga wars. BBC News. http://news.bbc.co.uk/1/hi/7844691.stm. Published January 23, 2009. Accessed March 25, 2015.
2. Yoga Journal releases 2012 yoga in America market study [press release]. San Francisco, CA: Yoga Journal; December 6, 2012.
3. De Michaelis E. A History of Modern Yoga: Patanjali and Western Esotericism. London, United Kingdom: A&C Black; 2005.
4. Telles S, Singh N, Yadav A, et al. Effect of yoga on different aspects of mental health. Indian J Physiol Pharmacol. 2012;56:245-254.
5. Rodriguez-Vallecillo E, Woodbury-Fariña MA. Dermatological manifestations of stress in normal and psychiatric populations. Psychiatr Clin North Am. 2014;37:625-651.
6. Stander S, Raap U, Weisshaar E, et al. Pathogenesis of pruritus. J Dtsch Dermatol Ges. 2011;9:456-463.
7. Arck PC, Slominski A, Theoharides TC, et al. Neuroimmunology of stress: skin takes center stage. J Invest Dermatol. 2006;126:1697-1704.
8. Recognizing the mind-skin connection. Harvard Health Publications Web site. http://www.health.harvard.edu/newsletter_article/Recognizing_the_mind-skin_connection. Published November 1, 2006. Accessed March 31, 2015.
9. Tausk F, Elenkov I, Moynihan J. Psychoneuroimmunology. Dermatol Ther. 2008;21:22-31.
10. Pavlovic S, Liezmann C, Blois SM, et al. Substance P is a key mediator of stress-induced protection from allergic sensitization via modified antigen presentation. J Immunol. 2011;186:848-855.
11. Toyoda M, Nakamura M, Makino T, et al. Nerve growth factor and substance P are useful plasma markers of disease activity in atopic dermatitis. Br J Dermatol. 2002;147:71-79.
12. Koo JYM, Lee CS. General approach to evaluating psychodermatological disorders. In: Koo JYM, Lee CS, eds. Psychocutaneous Medicine. New York, NY: Marcel Dekker; 2003:1-29.
13. Garg A, Chren MM, Sands LP, et al. Psychological stress perturbs epidermal permeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol. 2001;137:53-59.
14. Elias PM, Sun R, Eder AR, et al. Treating atopic dermatitis at the source: corrective barrier repair therapy based upon new pathogenic insights. Expert Rev Dermatol. 2013;8:27-36.
15. Morren MA, Przybilla B, Bamelis M, et al. Atopic dermatitis: triggering factors. J Am Acad Dermatol. 1994;31:467-473.
16. Faulstich ME, Williamson DA. An overview of atopic dermatitis: toward a bio-behavioural integration. J Psychosom Res. 1985;29:647-654.
17. Theoharides TC, Donelan JM, Papadopoulou N, et al. Mast cells as targets of corticotropin-releasing factor and related peptides. Trends Pharmacol Sci. 2004;25:563-568.
18. Suh DH, Kwon HH. What’s new in the physiopathology of acne [published online ahead of print Jan 24, 2015]? Br J Dermatol. doi:10.1111/bjd.13634.
19. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol. 2006;54:420-426.
20. Ponarovsky B, Amital D, Lazarov A, et al. Anxiety and depression in patients with allergic and non-allergic cutaneous disorders. Int J Dermatol. 2011;50:1217-1222.
21. Khalsa SB. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian J Physiol Pharmacol. 2004;48:269-285.
22. Cramer H, Lauche R, Dobos G. Characteristics of randomized controlled trials of yoga: a bibliometric analysis. BMC Complement Altern Med. 2014;14:328.
23. Granath J, Ingvarsson S, von Thiele U, et al. Stress management: a randomized study of cognitive behavioural therapy and yoga. Cogn Behav Ther. 2006;35:3-10.
24. Carlson LE, Beattie TL, Giese-Davis J, et al. Mindfulness-based cancer recovery and supportive-expressive therapy maintain telomere length relative to controls in distressed breast cancer survivors. Cancer. 2015;121:476-484.
25. Kabat-Zinn J, Wheeler E, Light T, et al. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosom Med. 1998;60:625-632.
26. Gisondi P, Galvan A, Idolazzi L, et al. Management of moderate to severe psoriasis in patients with metabolic comorbidities. Front Med (Lausanne). 2015;2:1.
Regardless of its spiritual origins, yoga has become a popular way of reaching mind and body well-being with nearly 30 million people practicing regularly worldwide.1 Yoga, which is the combination of physical postures, controlled breathing, and meditation or mindfulness, has long been used in complementary and alternative medicine around the world and recently has gained popularity as a therapeutic practice, with nearly 14 million Americans reporting that yoga was recommended to them by a physician or therapist.2,3 Studies suggest that people who participate in even brief yoga programs may see improvements in anxiety, somatic stress and discomfort, health-related quality of life, and self-rated sleep quality, all benefits that can help medical conditions, especially those that are dermatologic in nature.4,5
Stress and Dermatologic Conditions
The interaction between the mind, skin, and body is well known. Research in psychoneuroimmunology, the interaction between psychological processes and the nervous and immune systems, has examined the role of neuropeptides, hormones, and neurotransmitters in psychodermatological disorders. The correlation between neuroimmunological pathways and skin inflammation is now well recognized, specifically the interactions between the brain and skin underlying many dermatological diseases (eg, acne, alopecia areata, various types of eczema and dermatitis, oral and genital herpes, hyperhidrosis, pruritus, psoriasis, rosacea, urticaria, warts, breaking or ridging of the nails).6-9
Two biological systems are known to be affected by the systemic stress response: (1) the hypothalamic-pituitary-adrenal axis, which regulates the release of adrenocorticotropin, ß-endorphin, and cortisol, and (2) the sympathoadrenal medullary system, which regulates the release of catecholamines (eg, epinephrine, norepinephrine).7 Cortisol and catecholamines have been shown to have potent effects on the immune system as well as the inflammatory response.9 Additionally, it has been shown that cutaneous sensory nerve terminals release neuropeptides, including calcitonin gene-related peptide and substance P, both of which have different effects on the local inflammatory response.10,11
Psychological stress is well known to trigger many dermatologic conditions, but it also may lead to abnormal skin barrier function.12 The mechanism in which skin barrier function is affected appears to involve a stress-induced increase of endogenous glucocorticoids, which may consequently disrupt skin barrier function and recovery rates, stratum corneum cohesion, and epidermal antimicrobial function.13,14
Atopic dermatitis, for example, is classified as a psychophysiological disorder. Although it is not caused by stress, atopic dermatitis has been described to be precipitated or exacerbated by stress in patients.15 In fact, it was found that stressful life events preceded the onset of itching in more than 70% of patients with atopic dermatitis,16 which is especially relevant, as there is no cure and patients often experience a lifelong struggle with the condition. Additionally, stress mediates the degranulation of mast cells via corticotropin-releasing hormone and neuropeptides, and the upregulation of mast cell corticotropin-releasing hormone receptors supporting its putative role in the pathogenesis of urticaria.9,17 Furthermore, the increase in cortisol also has been described in the exacerbation of acne during times of stress.18
Psychological factors affect the management of skin conditions in more than one-third of reported dermatology patients; therefore, it is important to consider these factors in the treatment of chronic dermatological conditions, especially when they are inquired by the patient.19,20
Yoga Benefits in the Literature
The therapeutic potential of yoga has been explored in a growing number of randomized controlled trials to date.21 A recently published bibliometric analysis provided a comprehensive review of the characteristics of the randomized yoga trials available in the literature.22 The review included 366 full-text articles, with the 2 earliest studies published in 1975 and nearly 90% published within the last decade. In addition to healthy patients, it was found these randomized controlled yoga trials most commonly enrolled patients with breast cancer, depression, asthma, and type 2 diabetes mellitus.22 Another study examined psychological (eg, self-rated stress and stress behavior, anger, exhaustion, quality of life) and physiological (eg, blood pressure, heart rate, urinary catecholamines, salivary cortisol) measurements obtained before and after a 10-session yoga program that participants completed over a 4-month period, with results showing significant improvements (P<.05) on almost all stress-related subjective and physiological variables. Results were comparable with cognitive behavioral therapy.23
Not only has it been shown that yoga helps patients on a psychological level, but a recent study reported that 90-minute sessions of mindfulness meditation and gentle Hatha yoga over an 8-week period led to observable benefits on a cellular level, as telomere length was maintained in distressed breast cancer survivors compared to decreases in telomere length in the control group with patients who solely participated in a stress management seminar.24 To date, there are no known studies examining the effects of yoga on patients with skin cancer. However, a few studies have specifically examined the effect of yoga in managing non–cancer-related dermatologic issues. Specifically, one small study of psoriasis patients found that those who listened to mindfulness meditation tapes while undergoing standard phototherapy (psoralen plus UVA) healed faster than those who underwent phototherapy treatment alone.25
Because some dermatologic problems have comorbidities and increased risk factors of other medical problems, such as psoriasis with psoriatic arthritis and metabolic diseases (eg, abdominal obesity, diabetes, nonalcoholic fatty liver disease, dyslipidemia, metabolic syndrome, chronic kidney disease), it is even more pertinent to recommend approaches for healthy mind and body well-being as a supplement to medical care.26
Final Thoughts
With accurate diagnosis by a dermatologist, appropriate conventional treatments can improve dermatologic problems. These treatments alone can reduce patients’ stress and improve skin, hair, and nail conditions; however, if it is clear that stress is interfering with a patient’s overall well-being and ability to cope with his/her dermatologic condition, concurrent stress management interventions may be warranted. In some instances, recommending yoga sessions, mindful meditation, or breathing exercises may help, while in others referral to a mental health professional may be necessary.
Beyond the direct physiological effects of stress, it also is worth mentioning that patients who deal with stress also tend to scratch, pick, or irritate their skin more and often lack the motivation to adhere to skin care regimens or treatments, again supporting the idea that our approach in managing these patients must be multifaceted. As dermatologists in training, residents should be cognizant of the potential psychological sequelae of some dermatologic problems and be aware of the possible use of supplemental interventions by our patients.
Regardless of its spiritual origins, yoga has become a popular way of reaching mind and body well-being with nearly 30 million people practicing regularly worldwide.1 Yoga, which is the combination of physical postures, controlled breathing, and meditation or mindfulness, has long been used in complementary and alternative medicine around the world and recently has gained popularity as a therapeutic practice, with nearly 14 million Americans reporting that yoga was recommended to them by a physician or therapist.2,3 Studies suggest that people who participate in even brief yoga programs may see improvements in anxiety, somatic stress and discomfort, health-related quality of life, and self-rated sleep quality, all benefits that can help medical conditions, especially those that are dermatologic in nature.4,5
Stress and Dermatologic Conditions
The interaction between the mind, skin, and body is well known. Research in psychoneuroimmunology, the interaction between psychological processes and the nervous and immune systems, has examined the role of neuropeptides, hormones, and neurotransmitters in psychodermatological disorders. The correlation between neuroimmunological pathways and skin inflammation is now well recognized, specifically the interactions between the brain and skin underlying many dermatological diseases (eg, acne, alopecia areata, various types of eczema and dermatitis, oral and genital herpes, hyperhidrosis, pruritus, psoriasis, rosacea, urticaria, warts, breaking or ridging of the nails).6-9
Two biological systems are known to be affected by the systemic stress response: (1) the hypothalamic-pituitary-adrenal axis, which regulates the release of adrenocorticotropin, ß-endorphin, and cortisol, and (2) the sympathoadrenal medullary system, which regulates the release of catecholamines (eg, epinephrine, norepinephrine).7 Cortisol and catecholamines have been shown to have potent effects on the immune system as well as the inflammatory response.9 Additionally, it has been shown that cutaneous sensory nerve terminals release neuropeptides, including calcitonin gene-related peptide and substance P, both of which have different effects on the local inflammatory response.10,11
Psychological stress is well known to trigger many dermatologic conditions, but it also may lead to abnormal skin barrier function.12 The mechanism in which skin barrier function is affected appears to involve a stress-induced increase of endogenous glucocorticoids, which may consequently disrupt skin barrier function and recovery rates, stratum corneum cohesion, and epidermal antimicrobial function.13,14
Atopic dermatitis, for example, is classified as a psychophysiological disorder. Although it is not caused by stress, atopic dermatitis has been described to be precipitated or exacerbated by stress in patients.15 In fact, it was found that stressful life events preceded the onset of itching in more than 70% of patients with atopic dermatitis,16 which is especially relevant, as there is no cure and patients often experience a lifelong struggle with the condition. Additionally, stress mediates the degranulation of mast cells via corticotropin-releasing hormone and neuropeptides, and the upregulation of mast cell corticotropin-releasing hormone receptors supporting its putative role in the pathogenesis of urticaria.9,17 Furthermore, the increase in cortisol also has been described in the exacerbation of acne during times of stress.18
Psychological factors affect the management of skin conditions in more than one-third of reported dermatology patients; therefore, it is important to consider these factors in the treatment of chronic dermatological conditions, especially when they are inquired by the patient.19,20
Yoga Benefits in the Literature
The therapeutic potential of yoga has been explored in a growing number of randomized controlled trials to date.21 A recently published bibliometric analysis provided a comprehensive review of the characteristics of the randomized yoga trials available in the literature.22 The review included 366 full-text articles, with the 2 earliest studies published in 1975 and nearly 90% published within the last decade. In addition to healthy patients, it was found these randomized controlled yoga trials most commonly enrolled patients with breast cancer, depression, asthma, and type 2 diabetes mellitus.22 Another study examined psychological (eg, self-rated stress and stress behavior, anger, exhaustion, quality of life) and physiological (eg, blood pressure, heart rate, urinary catecholamines, salivary cortisol) measurements obtained before and after a 10-session yoga program that participants completed over a 4-month period, with results showing significant improvements (P<.05) on almost all stress-related subjective and physiological variables. Results were comparable with cognitive behavioral therapy.23
Not only has it been shown that yoga helps patients on a psychological level, but a recent study reported that 90-minute sessions of mindfulness meditation and gentle Hatha yoga over an 8-week period led to observable benefits on a cellular level, as telomere length was maintained in distressed breast cancer survivors compared to decreases in telomere length in the control group with patients who solely participated in a stress management seminar.24 To date, there are no known studies examining the effects of yoga on patients with skin cancer. However, a few studies have specifically examined the effect of yoga in managing non–cancer-related dermatologic issues. Specifically, one small study of psoriasis patients found that those who listened to mindfulness meditation tapes while undergoing standard phototherapy (psoralen plus UVA) healed faster than those who underwent phototherapy treatment alone.25
Because some dermatologic problems have comorbidities and increased risk factors of other medical problems, such as psoriasis with psoriatic arthritis and metabolic diseases (eg, abdominal obesity, diabetes, nonalcoholic fatty liver disease, dyslipidemia, metabolic syndrome, chronic kidney disease), it is even more pertinent to recommend approaches for healthy mind and body well-being as a supplement to medical care.26
Final Thoughts
With accurate diagnosis by a dermatologist, appropriate conventional treatments can improve dermatologic problems. These treatments alone can reduce patients’ stress and improve skin, hair, and nail conditions; however, if it is clear that stress is interfering with a patient’s overall well-being and ability to cope with his/her dermatologic condition, concurrent stress management interventions may be warranted. In some instances, recommending yoga sessions, mindful meditation, or breathing exercises may help, while in others referral to a mental health professional may be necessary.
Beyond the direct physiological effects of stress, it also is worth mentioning that patients who deal with stress also tend to scratch, pick, or irritate their skin more and often lack the motivation to adhere to skin care regimens or treatments, again supporting the idea that our approach in managing these patients must be multifaceted. As dermatologists in training, residents should be cognizant of the potential psychological sequelae of some dermatologic problems and be aware of the possible use of supplemental interventions by our patients.
1. Dangerfield A. Yoga wars. BBC News. http://news.bbc.co.uk/1/hi/7844691.stm. Published January 23, 2009. Accessed March 25, 2015.
2. Yoga Journal releases 2012 yoga in America market study [press release]. San Francisco, CA: Yoga Journal; December 6, 2012.
3. De Michaelis E. A History of Modern Yoga: Patanjali and Western Esotericism. London, United Kingdom: A&C Black; 2005.
4. Telles S, Singh N, Yadav A, et al. Effect of yoga on different aspects of mental health. Indian J Physiol Pharmacol. 2012;56:245-254.
5. Rodriguez-Vallecillo E, Woodbury-Fariña MA. Dermatological manifestations of stress in normal and psychiatric populations. Psychiatr Clin North Am. 2014;37:625-651.
6. Stander S, Raap U, Weisshaar E, et al. Pathogenesis of pruritus. J Dtsch Dermatol Ges. 2011;9:456-463.
7. Arck PC, Slominski A, Theoharides TC, et al. Neuroimmunology of stress: skin takes center stage. J Invest Dermatol. 2006;126:1697-1704.
8. Recognizing the mind-skin connection. Harvard Health Publications Web site. http://www.health.harvard.edu/newsletter_article/Recognizing_the_mind-skin_connection. Published November 1, 2006. Accessed March 31, 2015.
9. Tausk F, Elenkov I, Moynihan J. Psychoneuroimmunology. Dermatol Ther. 2008;21:22-31.
10. Pavlovic S, Liezmann C, Blois SM, et al. Substance P is a key mediator of stress-induced protection from allergic sensitization via modified antigen presentation. J Immunol. 2011;186:848-855.
11. Toyoda M, Nakamura M, Makino T, et al. Nerve growth factor and substance P are useful plasma markers of disease activity in atopic dermatitis. Br J Dermatol. 2002;147:71-79.
12. Koo JYM, Lee CS. General approach to evaluating psychodermatological disorders. In: Koo JYM, Lee CS, eds. Psychocutaneous Medicine. New York, NY: Marcel Dekker; 2003:1-29.
13. Garg A, Chren MM, Sands LP, et al. Psychological stress perturbs epidermal permeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol. 2001;137:53-59.
14. Elias PM, Sun R, Eder AR, et al. Treating atopic dermatitis at the source: corrective barrier repair therapy based upon new pathogenic insights. Expert Rev Dermatol. 2013;8:27-36.
15. Morren MA, Przybilla B, Bamelis M, et al. Atopic dermatitis: triggering factors. J Am Acad Dermatol. 1994;31:467-473.
16. Faulstich ME, Williamson DA. An overview of atopic dermatitis: toward a bio-behavioural integration. J Psychosom Res. 1985;29:647-654.
17. Theoharides TC, Donelan JM, Papadopoulou N, et al. Mast cells as targets of corticotropin-releasing factor and related peptides. Trends Pharmacol Sci. 2004;25:563-568.
18. Suh DH, Kwon HH. What’s new in the physiopathology of acne [published online ahead of print Jan 24, 2015]? Br J Dermatol. doi:10.1111/bjd.13634.
19. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol. 2006;54:420-426.
20. Ponarovsky B, Amital D, Lazarov A, et al. Anxiety and depression in patients with allergic and non-allergic cutaneous disorders. Int J Dermatol. 2011;50:1217-1222.
21. Khalsa SB. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian J Physiol Pharmacol. 2004;48:269-285.
22. Cramer H, Lauche R, Dobos G. Characteristics of randomized controlled trials of yoga: a bibliometric analysis. BMC Complement Altern Med. 2014;14:328.
23. Granath J, Ingvarsson S, von Thiele U, et al. Stress management: a randomized study of cognitive behavioural therapy and yoga. Cogn Behav Ther. 2006;35:3-10.
24. Carlson LE, Beattie TL, Giese-Davis J, et al. Mindfulness-based cancer recovery and supportive-expressive therapy maintain telomere length relative to controls in distressed breast cancer survivors. Cancer. 2015;121:476-484.
25. Kabat-Zinn J, Wheeler E, Light T, et al. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosom Med. 1998;60:625-632.
26. Gisondi P, Galvan A, Idolazzi L, et al. Management of moderate to severe psoriasis in patients with metabolic comorbidities. Front Med (Lausanne). 2015;2:1.
1. Dangerfield A. Yoga wars. BBC News. http://news.bbc.co.uk/1/hi/7844691.stm. Published January 23, 2009. Accessed March 25, 2015.
2. Yoga Journal releases 2012 yoga in America market study [press release]. San Francisco, CA: Yoga Journal; December 6, 2012.
3. De Michaelis E. A History of Modern Yoga: Patanjali and Western Esotericism. London, United Kingdom: A&C Black; 2005.
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