MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

koakes@mdedge.com

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

koakes@mdedge.com

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

koakes@mdedge.com

MILAN – A checkpoint inhibitor given with or without targeted therapy resulted in robust response rates in patients with advanced basal cell carcinoma, according to an investigator in a recent proof-of-concept study.

The side effect profile for the progressive death 1 (PD-1) inhibitor pembrolizumab (Keytruda), plus or minus the hedgehog pathway inhibitor vismodegib (Erivedge), was “not out of range” with what’s been observed in other cancer types, said Anne Lynn S. Chang, MD, a medical dermatologist at Stanford (Calif.) University.

Taken together, these safety and efficacy results suggest pembrolizumab could prove useful for patients with advanced basal cell carcinomas, Dr. Chang said in an oral presentation at the World Congress of Dermatology.

Unexpectedly, dual therapy with pembrolizumab and vismodegib was not clearly superior to pembrolizumab alone, though the two arms are not directly comparable in this nonrandomized, investigator-initiated study, according to Dr. Chang.

“That was a surprise for us, but this is a subjective and a small study,” she told attendees at the conference.

There is currently a multi-institutional clinical trial underway to evaluate another PD-1 inhibitor, cemiplimab, in patients with advanced basal cell carcinoma previously treated with a hedgehog pathway inhibitor, she said.

While a large fraction of basal cell carcinomas are cured by resection, those that are locally advanced or metastatic to lymph nodes or distant organs are challenging to manage. Hedgehog pathway inhibitors, which include vismodegib and sonidegib, are the only Food and Drug Administration–approved drug class in this setting, but more than half of patients do not have a response to treatment, and another 20% or so will initially respond but develop resistance, Dr. Chang said.

Other treatments that have been tried in advanced basal cell carcinomas include taxanes, platinum-based agents, 5-fluorouracil, and everolimus, but their efficacy is unclear, according to Dr. Chang, because of a lack of systematic studies.

Investigators thought PD-1 inhibitors might be promising in basal cell carcinoma for a few reasons, Dr. Chang said. In particular, PD-1 inhibitor treatment response has been linked to mutational burden and PD–ligand 1 expression, and advanced basal cell carcinomas have the largest mutational burden of all human cancers, a large proportion of which express PD-L1.

There are multiple case reports in the literature suggesting that advanced basal cell carcinoma is responsive to PD-1 inhibitors, she added.

In the study, nine patients received 200 mg infusion of pembrolizumab every 3 weeks, and seven received the pembrolizumab infusions plus oral vismodegib 150 mg per day.

The pembrolizumab monotherapy group included patients who had tumor progression on vismodegib, did not tolerate vismodegib, or had contraindications to vismodegib. The pembrolizumab-vismodegib regimen was used in patients who had prior stable or partial responses to hedgehog pathway inhibitors.

The overall response rate was 38%, or 6 of 16 patients, with a 70% probability of 1-year progression-free survival and 94% probability of 1-year overall survival, Dr. Chang reported.

The results did not make the case that pembrolizumab and vismodegib was superior to pembrolizumab alone, though as Dr. Chang noted, the numbers of patients were small. Response rates were 29% (two of seven patients) in the combination arm and 44% (four of nine patients) in the monotherapy arm.

There were 24 immune-related adverse events in the trial; the most serious was hyponatremia, which was reversible, according to Dr. Chang. The overall rates of grade 3-4 adverse events were 22% for pembrolizumab monotherapy and 17% for dual therapy.

A report on the study has also been published in the Journal of the American Academy of Dermatology.

Funding for the study was provided by Merck. Dr. Chang reported serving as a clinical investigator and advisory board member for studies sponsored by Genentech-Roche, Merck, Novartis, and Regeneron.
 

MILAN – A checkpoint inhibitor given with or without targeted therapy resulted in robust response rates in patients with advanced basal cell carcinoma, according to an investigator in a recent proof-of-concept study.

The side effect profile for the progressive death 1 (PD-1) inhibitor pembrolizumab (Keytruda), plus or minus the hedgehog pathway inhibitor vismodegib (Erivedge), was “not out of range” with what’s been observed in other cancer types, said Anne Lynn S. Chang, MD, a medical dermatologist at Stanford (Calif.) University.

Taken together, these safety and efficacy results suggest pembrolizumab could prove useful for patients with advanced basal cell carcinomas, Dr. Chang said in an oral presentation at the World Congress of Dermatology.

Unexpectedly, dual therapy with pembrolizumab and vismodegib was not clearly superior to pembrolizumab alone, though the two arms are not directly comparable in this nonrandomized, investigator-initiated study, according to Dr. Chang.

“That was a surprise for us, but this is a subjective and a small study,” she told attendees at the conference.

There is currently a multi-institutional clinical trial underway to evaluate another PD-1 inhibitor, cemiplimab, in patients with advanced basal cell carcinoma previously treated with a hedgehog pathway inhibitor, she said.

While a large fraction of basal cell carcinomas are cured by resection, those that are locally advanced or metastatic to lymph nodes or distant organs are challenging to manage. Hedgehog pathway inhibitors, which include vismodegib and sonidegib, are the only Food and Drug Administration–approved drug class in this setting, but more than half of patients do not have a response to treatment, and another 20% or so will initially respond but develop resistance, Dr. Chang said.

Other treatments that have been tried in advanced basal cell carcinomas include taxanes, platinum-based agents, 5-fluorouracil, and everolimus, but their efficacy is unclear, according to Dr. Chang, because of a lack of systematic studies.

Investigators thought PD-1 inhibitors might be promising in basal cell carcinoma for a few reasons, Dr. Chang said. In particular, PD-1 inhibitor treatment response has been linked to mutational burden and PD–ligand 1 expression, and advanced basal cell carcinomas have the largest mutational burden of all human cancers, a large proportion of which express PD-L1.

There are multiple case reports in the literature suggesting that advanced basal cell carcinoma is responsive to PD-1 inhibitors, she added.

In the study, nine patients received 200 mg infusion of pembrolizumab every 3 weeks, and seven received the pembrolizumab infusions plus oral vismodegib 150 mg per day.

The pembrolizumab monotherapy group included patients who had tumor progression on vismodegib, did not tolerate vismodegib, or had contraindications to vismodegib. The pembrolizumab-vismodegib regimen was used in patients who had prior stable or partial responses to hedgehog pathway inhibitors.

The overall response rate was 38%, or 6 of 16 patients, with a 70% probability of 1-year progression-free survival and 94% probability of 1-year overall survival, Dr. Chang reported.

The results did not make the case that pembrolizumab and vismodegib was superior to pembrolizumab alone, though as Dr. Chang noted, the numbers of patients were small. Response rates were 29% (two of seven patients) in the combination arm and 44% (four of nine patients) in the monotherapy arm.

There were 24 immune-related adverse events in the trial; the most serious was hyponatremia, which was reversible, according to Dr. Chang. The overall rates of grade 3-4 adverse events were 22% for pembrolizumab monotherapy and 17% for dual therapy.

A report on the study has also been published in the Journal of the American Academy of Dermatology.

Funding for the study was provided by Merck. Dr. Chang reported serving as a clinical investigator and advisory board member for studies sponsored by Genentech-Roche, Merck, Novartis, and Regeneron.
 

MILAN – A checkpoint inhibitor given with or without targeted therapy resulted in robust response rates in patients with advanced basal cell carcinoma, according to an investigator in a recent proof-of-concept study.

The side effect profile for the progressive death 1 (PD-1) inhibitor pembrolizumab (Keytruda), plus or minus the hedgehog pathway inhibitor vismodegib (Erivedge), was “not out of range” with what’s been observed in other cancer types, said Anne Lynn S. Chang, MD, a medical dermatologist at Stanford (Calif.) University.

Taken together, these safety and efficacy results suggest pembrolizumab could prove useful for patients with advanced basal cell carcinomas, Dr. Chang said in an oral presentation at the World Congress of Dermatology.

Unexpectedly, dual therapy with pembrolizumab and vismodegib was not clearly superior to pembrolizumab alone, though the two arms are not directly comparable in this nonrandomized, investigator-initiated study, according to Dr. Chang.

“That was a surprise for us, but this is a subjective and a small study,” she told attendees at the conference.

There is currently a multi-institutional clinical trial underway to evaluate another PD-1 inhibitor, cemiplimab, in patients with advanced basal cell carcinoma previously treated with a hedgehog pathway inhibitor, she said.

While a large fraction of basal cell carcinomas are cured by resection, those that are locally advanced or metastatic to lymph nodes or distant organs are challenging to manage. Hedgehog pathway inhibitors, which include vismodegib and sonidegib, are the only Food and Drug Administration–approved drug class in this setting, but more than half of patients do not have a response to treatment, and another 20% or so will initially respond but develop resistance, Dr. Chang said.

Other treatments that have been tried in advanced basal cell carcinomas include taxanes, platinum-based agents, 5-fluorouracil, and everolimus, but their efficacy is unclear, according to Dr. Chang, because of a lack of systematic studies.

Investigators thought PD-1 inhibitors might be promising in basal cell carcinoma for a few reasons, Dr. Chang said. In particular, PD-1 inhibitor treatment response has been linked to mutational burden and PD–ligand 1 expression, and advanced basal cell carcinomas have the largest mutational burden of all human cancers, a large proportion of which express PD-L1.

There are multiple case reports in the literature suggesting that advanced basal cell carcinoma is responsive to PD-1 inhibitors, she added.

In the study, nine patients received 200 mg infusion of pembrolizumab every 3 weeks, and seven received the pembrolizumab infusions plus oral vismodegib 150 mg per day.

The pembrolizumab monotherapy group included patients who had tumor progression on vismodegib, did not tolerate vismodegib, or had contraindications to vismodegib. The pembrolizumab-vismodegib regimen was used in patients who had prior stable or partial responses to hedgehog pathway inhibitors.

The overall response rate was 38%, or 6 of 16 patients, with a 70% probability of 1-year progression-free survival and 94% probability of 1-year overall survival, Dr. Chang reported.

The results did not make the case that pembrolizumab and vismodegib was superior to pembrolizumab alone, though as Dr. Chang noted, the numbers of patients were small. Response rates were 29% (two of seven patients) in the combination arm and 44% (four of nine patients) in the monotherapy arm.

There were 24 immune-related adverse events in the trial; the most serious was hyponatremia, which was reversible, according to Dr. Chang. The overall rates of grade 3-4 adverse events were 22% for pembrolizumab monotherapy and 17% for dual therapy.

A report on the study has also been published in the Journal of the American Academy of Dermatology.

Funding for the study was provided by Merck. Dr. Chang reported serving as a clinical investigator and advisory board member for studies sponsored by Genentech-Roche, Merck, Novartis, and Regeneron.
 

Forty percent of Americans say that they would be more likely to spend an hour a day improving their health if they got paid to do it, according to a survey by UnitedHealthcare.

More than half (54%) of the 1,006 respondents said that they didn’t need a financial incentive to get that much exercise, but 21% said that $1-$3 a day would be necessary and 19% said that they would need $4-$5 per day, the company said in its 2019 Wellness Checkup Survey.

Women were more likely than men to say that they needed an incentive (42% vs. 36%). Among age-related subgroups, there was a clear progression from youngest to oldest: The youngest age group (18-34 years, 47%) and youngest generation (Millennials, 46%) in the study were the most likely to require an incentive, while the oldest age group (65 years and older, 30%) and generation (Baby Boomers, 31%) were the least likely, UnitedHealthcare said.

A majority (57%) of respondents said that it was important – either very important (19%) or somewhat important (38%) – for a fitness routine to have a social component, either in-person or virtual. Almost two-thirds of respondents expressed support for wearable fitness-tracking devices: 42% would use one if it was provided by their employer, and 22% said that they already had one, the survey results show.

“This year employers are expected to invest an average of more than $3.6 million on their respective well-being programs, and over 60% of employees are interested in engaging in these initiatives. [This] survey provides insights that we hope can be helpful to enhance the design and implementation of well-being programs, which may help improve employees’ health, reduce absenteeism, and curb care costs,” Rebecca Madsen, UnitedHealthcare’s chief consumer officer, said in the company’s written statement.

The survey was conducted April 11-15, 2019, and the margin of error was plus or minus 3.1%.

rfranki@mdedge.com

Forty percent of Americans say that they would be more likely to spend an hour a day improving their health if they got paid to do it, according to a survey by UnitedHealthcare.

More than half (54%) of the 1,006 respondents said that they didn’t need a financial incentive to get that much exercise, but 21% said that $1-$3 a day would be necessary and 19% said that they would need $4-$5 per day, the company said in its 2019 Wellness Checkup Survey.

Women were more likely than men to say that they needed an incentive (42% vs. 36%). Among age-related subgroups, there was a clear progression from youngest to oldest: The youngest age group (18-34 years, 47%) and youngest generation (Millennials, 46%) in the study were the most likely to require an incentive, while the oldest age group (65 years and older, 30%) and generation (Baby Boomers, 31%) were the least likely, UnitedHealthcare said.

A majority (57%) of respondents said that it was important – either very important (19%) or somewhat important (38%) – for a fitness routine to have a social component, either in-person or virtual. Almost two-thirds of respondents expressed support for wearable fitness-tracking devices: 42% would use one if it was provided by their employer, and 22% said that they already had one, the survey results show.

“This year employers are expected to invest an average of more than $3.6 million on their respective well-being programs, and over 60% of employees are interested in engaging in these initiatives. [This] survey provides insights that we hope can be helpful to enhance the design and implementation of well-being programs, which may help improve employees’ health, reduce absenteeism, and curb care costs,” Rebecca Madsen, UnitedHealthcare’s chief consumer officer, said in the company’s written statement.

The survey was conducted April 11-15, 2019, and the margin of error was plus or minus 3.1%.

rfranki@mdedge.com

Forty percent of Americans say that they would be more likely to spend an hour a day improving their health if they got paid to do it, according to a survey by UnitedHealthcare.

More than half (54%) of the 1,006 respondents said that they didn’t need a financial incentive to get that much exercise, but 21% said that $1-$3 a day would be necessary and 19% said that they would need $4-$5 per day, the company said in its 2019 Wellness Checkup Survey.

Women were more likely than men to say that they needed an incentive (42% vs. 36%). Among age-related subgroups, there was a clear progression from youngest to oldest: The youngest age group (18-34 years, 47%) and youngest generation (Millennials, 46%) in the study were the most likely to require an incentive, while the oldest age group (65 years and older, 30%) and generation (Baby Boomers, 31%) were the least likely, UnitedHealthcare said.

A majority (57%) of respondents said that it was important – either very important (19%) or somewhat important (38%) – for a fitness routine to have a social component, either in-person or virtual. Almost two-thirds of respondents expressed support for wearable fitness-tracking devices: 42% would use one if it was provided by their employer, and 22% said that they already had one, the survey results show.

“This year employers are expected to invest an average of more than $3.6 million on their respective well-being programs, and over 60% of employees are interested in engaging in these initiatives. [This] survey provides insights that we hope can be helpful to enhance the design and implementation of well-being programs, which may help improve employees’ health, reduce absenteeism, and curb care costs,” Rebecca Madsen, UnitedHealthcare’s chief consumer officer, said in the company’s written statement.

The survey was conducted April 11-15, 2019, and the margin of error was plus or minus 3.1%.

rfranki@mdedge.com

Using eosinophil levels to guide steroid treatment in patients with chronic obstructive pulmonary disease (COPD) was found to be noninferior to standard treatment in terms of the number of days out of hospital and alive, new research has found.

Writing in the Lancet Respiratory Medicine, researchers reported the outcomes of a multicenter, controlled, open-label trial comparing eosinophil-guided and standard therapy with systemic corticosteroids in 318 patients with COPD.

Pradeesh Sivapalan, MD, of the respiratory medicine section of Herlev and Gentofte Hospital at the University of Copenhagen, and coauthors wrote that eosinophilic inflammation had been seen in 20%-40% of patients with acute exacerbations of COPD. Patients with higher eosinophilic blood counts were at increased risk of acute exacerbations but were also more likely to benefit from corticosteroid treatment.

In the eosinophil-guided therapy arm of the study, 159 patients received 80 mg of intravenous methylprednisolone on day 1, then from the second day were treated with 37.5 mg of prednisolone oral tablet daily ­– up to 4 days – only on days when their blood eosinophil count was at least 0.3 x 10^⁹ cells/L. In the control arm, 159 patients also received 80 mg of intravenous methylprednisolone on day 1, followed by 37.5 mg of prednisolone tablets daily for 4 days.

After 14 days, there were no significant differences between the two groups for mean days alive and out of hospital.

There were 12 more cases of readmission with COPD, including three fatalities, in the eosinophil-guided group within the first month. However the authors said these differences were not statistically significant, but “because the study was not powered to detect differences in this absolute risk range, we cannot rule out that this was an actual harm effect from the interventional strategy.”

The eosinophil-guided therapy group did show more than a 50% reduction in the median duration of systemic corticosteroid therapy, which was 2 days in the eosinophil-guided group, compared with 5 days in the control group (P less than .0001), and the differences between the two groups remained significant at days 30 and 90.

“The tested strategy was successful in reducing the exposure to systemic corticosteroids, but we cannot exclude the possibility that a more aggressive algorithm, such as a single dose of systemic corticosteroid, might have been more effective,” the authors wrote.

At the 90-day follow-up, there were no differences in the number of infections requiring antibiotic treatment, nor in dyspepsia, ulcer complications, or initiation of new proton-pump inhibitor treatment.

The study was supported by the Danish Regions Medical Fund and the Danish Council for Independent Research. Two authors declared personal fees from pharmaceutical companies outside the submitted work. No other conflicts were declared.

SOURCE: Sivapalan P et al. Lancet Respir Med. 2019, May 20. doi: 10.1016/S2213-2600(19)30176-6.

Using eosinophil levels to guide steroid treatment in patients with chronic obstructive pulmonary disease (COPD) was found to be noninferior to standard treatment in terms of the number of days out of hospital and alive, new research has found.

Writing in the Lancet Respiratory Medicine, researchers reported the outcomes of a multicenter, controlled, open-label trial comparing eosinophil-guided and standard therapy with systemic corticosteroids in 318 patients with COPD.

Pradeesh Sivapalan, MD, of the respiratory medicine section of Herlev and Gentofte Hospital at the University of Copenhagen, and coauthors wrote that eosinophilic inflammation had been seen in 20%-40% of patients with acute exacerbations of COPD. Patients with higher eosinophilic blood counts were at increased risk of acute exacerbations but were also more likely to benefit from corticosteroid treatment.

In the eosinophil-guided therapy arm of the study, 159 patients received 80 mg of intravenous methylprednisolone on day 1, then from the second day were treated with 37.5 mg of prednisolone oral tablet daily ­– up to 4 days – only on days when their blood eosinophil count was at least 0.3 x 10^⁹ cells/L. In the control arm, 159 patients also received 80 mg of intravenous methylprednisolone on day 1, followed by 37.5 mg of prednisolone tablets daily for 4 days.

After 14 days, there were no significant differences between the two groups for mean days alive and out of hospital.

There were 12 more cases of readmission with COPD, including three fatalities, in the eosinophil-guided group within the first month. However the authors said these differences were not statistically significant, but “because the study was not powered to detect differences in this absolute risk range, we cannot rule out that this was an actual harm effect from the interventional strategy.”

The eosinophil-guided therapy group did show more than a 50% reduction in the median duration of systemic corticosteroid therapy, which was 2 days in the eosinophil-guided group, compared with 5 days in the control group (P less than .0001), and the differences between the two groups remained significant at days 30 and 90.

“The tested strategy was successful in reducing the exposure to systemic corticosteroids, but we cannot exclude the possibility that a more aggressive algorithm, such as a single dose of systemic corticosteroid, might have been more effective,” the authors wrote.

At the 90-day follow-up, there were no differences in the number of infections requiring antibiotic treatment, nor in dyspepsia, ulcer complications, or initiation of new proton-pump inhibitor treatment.

The study was supported by the Danish Regions Medical Fund and the Danish Council for Independent Research. Two authors declared personal fees from pharmaceutical companies outside the submitted work. No other conflicts were declared.

SOURCE: Sivapalan P et al. Lancet Respir Med. 2019, May 20. doi: 10.1016/S2213-2600(19)30176-6.

Using eosinophil levels to guide steroid treatment in patients with chronic obstructive pulmonary disease (COPD) was found to be noninferior to standard treatment in terms of the number of days out of hospital and alive, new research has found.

Writing in the Lancet Respiratory Medicine, researchers reported the outcomes of a multicenter, controlled, open-label trial comparing eosinophil-guided and standard therapy with systemic corticosteroids in 318 patients with COPD.

Pradeesh Sivapalan, MD, of the respiratory medicine section of Herlev and Gentofte Hospital at the University of Copenhagen, and coauthors wrote that eosinophilic inflammation had been seen in 20%-40% of patients with acute exacerbations of COPD. Patients with higher eosinophilic blood counts were at increased risk of acute exacerbations but were also more likely to benefit from corticosteroid treatment.

In the eosinophil-guided therapy arm of the study, 159 patients received 80 mg of intravenous methylprednisolone on day 1, then from the second day were treated with 37.5 mg of prednisolone oral tablet daily ­– up to 4 days – only on days when their blood eosinophil count was at least 0.3 x 10^⁹ cells/L. In the control arm, 159 patients also received 80 mg of intravenous methylprednisolone on day 1, followed by 37.5 mg of prednisolone tablets daily for 4 days.

After 14 days, there were no significant differences between the two groups for mean days alive and out of hospital.

There were 12 more cases of readmission with COPD, including three fatalities, in the eosinophil-guided group within the first month. However the authors said these differences were not statistically significant, but “because the study was not powered to detect differences in this absolute risk range, we cannot rule out that this was an actual harm effect from the interventional strategy.”

The eosinophil-guided therapy group did show more than a 50% reduction in the median duration of systemic corticosteroid therapy, which was 2 days in the eosinophil-guided group, compared with 5 days in the control group (P less than .0001), and the differences between the two groups remained significant at days 30 and 90.

“The tested strategy was successful in reducing the exposure to systemic corticosteroids, but we cannot exclude the possibility that a more aggressive algorithm, such as a single dose of systemic corticosteroid, might have been more effective,” the authors wrote.

At the 90-day follow-up, there were no differences in the number of infections requiring antibiotic treatment, nor in dyspepsia, ulcer complications, or initiation of new proton-pump inhibitor treatment.

The study was supported by the Danish Regions Medical Fund and the Danish Council for Independent Research. Two authors declared personal fees from pharmaceutical companies outside the submitted work. No other conflicts were declared.

SOURCE: Sivapalan P et al. Lancet Respir Med. 2019, May 20. doi: 10.1016/S2213-2600(19)30176-6.

The Firearm Safety Among Children and Teens (FACTS) Consortium issued a research agenda with the goal of preventing pediatric firearm injuries and death.

Kateywhat/ThinkStock

The 26 research agenda items from FACTS, which span across the broad topic areas of epidemiology, surveillance, and risk and protective factors; primary, secondary, and cross-cutting protective factors; policy-related issues; and data-enhancement priorities, were published in JAMA Pediatrics.

“Firearms are the second leading cause of death among children and adolescents aged 1 to 18 years in the United States and responsible for more than 2,570 deaths and nearly 12,000 nonfatal injuries requiring emergency department treatment in 2017,” said Rebecca Cunningham, MD, of the University of Michigan, Ann Arbor, and colleagues who are members of the FACTS Consortium.

“Pediatric firearm injuries result from a range of causes, including the unintentional discharge of a firearm, self-inflicted wounds, or the escalation of interpersonal violence,” they continued. “Nearly 265 million firearms are in civilian hands in the United States, and a 44% increase in pediatric firearm mortality rate has been documented during the past 5 years.”

The FACTS Consortium defined an agenda “to serve as a guide for future research efforts to decrease pediatric death and injury.”

Some of the research agenda items include the following:

• Understanding epidemiologic trends and how demographic factors are associated with fatal and nonfatal outcomes.
• The long-term cost associated with pediatric firearm outcomes.
• The effectiveness of health care–focused primary prevention strategies for children, adolescents, and their families to reduce firearm outcomes.
• Examination of health care–based interventions for children and adolescents who have experienced or witnessed a firearm injury to prevent (or reduce) subsequent firearm outcomes including firearm injury recidivism and mental health, socioemotional, and educational outcomes.

“It is an excellent list, and I think it was very thoughtful to come out with a research agenda for firearm safety for kids,” Marlene Melzer-Lange, MD, chair of the American Academy of Pediatrics subcommittee on violence prevention, said in an interview. “The thing that’s been lacking nationally has been funding for firearm injury prevention, both for children and adults, and to have something focused specifically on children – because children have the biggest chance of living the longest – is really important.”

She described the research agenda as being “comprehensive” and didn’t see anything that stood out as missing from the list, although the big issue that remains is getting funding for the research now that an agenda has been outlined.

And getting that is not going to be easy.

“I think it’s going to take some political will of the people and particularly of our legislators ... to allow the [Centers for Disease Control and Prevention] to provide funding” said Dr. Melzer-Lange, an attending emergency department physician at Children’s Hospital of Wisconsin, Milwaukee, adding that AAP has long been asking for such funding. “It’s going [to come down to] the legislators [having] enough guts to actually put the funding in and not be afraid of external groups that might ask them not to do that.”

She remains optimistic and hopeful that the legislators are going to look at it and will eventually say that this is an crisis and will take more action beyond just talking about it.

Dr. Melzer-Lange also emphasized that this is about firearm safety and not firearm control, especially for children and teenagers.

All authors reported receiving grants from National Institutes of Health/National Institute of Child Health and Human Development.

gtwachtman@mdedge.com

SOURCE: Cunningham RM et al. JAMA Pediatrics. 2019. doi: 10.1001/jamapediatrics.2019.1494.

The Firearm Safety Among Children and Teens (FACTS) Consortium issued a research agenda with the goal of preventing pediatric firearm injuries and death.

Kateywhat/ThinkStock

The 26 research agenda items from FACTS, which span across the broad topic areas of epidemiology, surveillance, and risk and protective factors; primary, secondary, and cross-cutting protective factors; policy-related issues; and data-enhancement priorities, were published in JAMA Pediatrics.

“Firearms are the second leading cause of death among children and adolescents aged 1 to 18 years in the United States and responsible for more than 2,570 deaths and nearly 12,000 nonfatal injuries requiring emergency department treatment in 2017,” said Rebecca Cunningham, MD, of the University of Michigan, Ann Arbor, and colleagues who are members of the FACTS Consortium.

“Pediatric firearm injuries result from a range of causes, including the unintentional discharge of a firearm, self-inflicted wounds, or the escalation of interpersonal violence,” they continued. “Nearly 265 million firearms are in civilian hands in the United States, and a 44% increase in pediatric firearm mortality rate has been documented during the past 5 years.”

The FACTS Consortium defined an agenda “to serve as a guide for future research efforts to decrease pediatric death and injury.”

Some of the research agenda items include the following:

• Understanding epidemiologic trends and how demographic factors are associated with fatal and nonfatal outcomes.
• The long-term cost associated with pediatric firearm outcomes.
• The effectiveness of health care–focused primary prevention strategies for children, adolescents, and their families to reduce firearm outcomes.
• Examination of health care–based interventions for children and adolescents who have experienced or witnessed a firearm injury to prevent (or reduce) subsequent firearm outcomes including firearm injury recidivism and mental health, socioemotional, and educational outcomes.

“It is an excellent list, and I think it was very thoughtful to come out with a research agenda for firearm safety for kids,” Marlene Melzer-Lange, MD, chair of the American Academy of Pediatrics subcommittee on violence prevention, said in an interview. “The thing that’s been lacking nationally has been funding for firearm injury prevention, both for children and adults, and to have something focused specifically on children – because children have the biggest chance of living the longest – is really important.”

She described the research agenda as being “comprehensive” and didn’t see anything that stood out as missing from the list, although the big issue that remains is getting funding for the research now that an agenda has been outlined.

And getting that is not going to be easy.

“I think it’s going to take some political will of the people and particularly of our legislators ... to allow the [Centers for Disease Control and Prevention] to provide funding” said Dr. Melzer-Lange, an attending emergency department physician at Children’s Hospital of Wisconsin, Milwaukee, adding that AAP has long been asking for such funding. “It’s going [to come down to] the legislators [having] enough guts to actually put the funding in and not be afraid of external groups that might ask them not to do that.”

She remains optimistic and hopeful that the legislators are going to look at it and will eventually say that this is an crisis and will take more action beyond just talking about it.

Dr. Melzer-Lange also emphasized that this is about firearm safety and not firearm control, especially for children and teenagers.

All authors reported receiving grants from National Institutes of Health/National Institute of Child Health and Human Development.

gtwachtman@mdedge.com

SOURCE: Cunningham RM et al. JAMA Pediatrics. 2019. doi: 10.1001/jamapediatrics.2019.1494.

The Firearm Safety Among Children and Teens (FACTS) Consortium issued a research agenda with the goal of preventing pediatric firearm injuries and death.

Kateywhat/ThinkStock

The 26 research agenda items from FACTS, which span across the broad topic areas of epidemiology, surveillance, and risk and protective factors; primary, secondary, and cross-cutting protective factors; policy-related issues; and data-enhancement priorities, were published in JAMA Pediatrics.

“Firearms are the second leading cause of death among children and adolescents aged 1 to 18 years in the United States and responsible for more than 2,570 deaths and nearly 12,000 nonfatal injuries requiring emergency department treatment in 2017,” said Rebecca Cunningham, MD, of the University of Michigan, Ann Arbor, and colleagues who are members of the FACTS Consortium.

“Pediatric firearm injuries result from a range of causes, including the unintentional discharge of a firearm, self-inflicted wounds, or the escalation of interpersonal violence,” they continued. “Nearly 265 million firearms are in civilian hands in the United States, and a 44% increase in pediatric firearm mortality rate has been documented during the past 5 years.”

The FACTS Consortium defined an agenda “to serve as a guide for future research efforts to decrease pediatric death and injury.”

Some of the research agenda items include the following:

• Understanding epidemiologic trends and how demographic factors are associated with fatal and nonfatal outcomes.
• The long-term cost associated with pediatric firearm outcomes.
• The effectiveness of health care–focused primary prevention strategies for children, adolescents, and their families to reduce firearm outcomes.
• Examination of health care–based interventions for children and adolescents who have experienced or witnessed a firearm injury to prevent (or reduce) subsequent firearm outcomes including firearm injury recidivism and mental health, socioemotional, and educational outcomes.

“It is an excellent list, and I think it was very thoughtful to come out with a research agenda for firearm safety for kids,” Marlene Melzer-Lange, MD, chair of the American Academy of Pediatrics subcommittee on violence prevention, said in an interview. “The thing that’s been lacking nationally has been funding for firearm injury prevention, both for children and adults, and to have something focused specifically on children – because children have the biggest chance of living the longest – is really important.”

She described the research agenda as being “comprehensive” and didn’t see anything that stood out as missing from the list, although the big issue that remains is getting funding for the research now that an agenda has been outlined.

And getting that is not going to be easy.

“I think it’s going to take some political will of the people and particularly of our legislators ... to allow the [Centers for Disease Control and Prevention] to provide funding” said Dr. Melzer-Lange, an attending emergency department physician at Children’s Hospital of Wisconsin, Milwaukee, adding that AAP has long been asking for such funding. “It’s going [to come down to] the legislators [having] enough guts to actually put the funding in and not be afraid of external groups that might ask them not to do that.”

She remains optimistic and hopeful that the legislators are going to look at it and will eventually say that this is an crisis and will take more action beyond just talking about it.

Dr. Melzer-Lange also emphasized that this is about firearm safety and not firearm control, especially for children and teenagers.

All authors reported receiving grants from National Institutes of Health/National Institute of Child Health and Human Development.

gtwachtman@mdedge.com

SOURCE: Cunningham RM et al. JAMA Pediatrics. 2019. doi: 10.1001/jamapediatrics.2019.1494.

SAN ANTONIO – Key determinants of no-show rates to a sleep clinic include being a new patient and lacking health insurance coverage, results from a single-center study showed.

Doug Brunk/MDedge News

“There are lots of people with sleep problems,” one of the study’s authors, Alvan Nzewuihe, MD, said in an interview at the annual meeting of the Associated Professional Sleep Societies. “However, we have to identify these patients to be able to help them. If they don’t come to the sleep clinic [for assessment], we are going nowhere.”

In an effort to better understand determinants of no-show rates among sleep clinics, Dr. Nzewuihe and colleagues performed a 10-month, retrospective chart review of 2,532 patients scheduled at Saint Louis University’s SLUCare Sleep Disorders Center during the months of July and October 2017 and April 2018. A no-show was determined if the patient failed to show up at their scheduled appointment on time or if they canceled their appointment. The researchers used multivariable logistic regression to determine which factors were independently associated with no-show rates.

Dr. Nzewuihe, a sleep medicine physician at the university, reported that the overall no-show rate during the study period was 21.2% and did not change with age, sex, or appointment factors such as time of day, day of week, or season of the year. Significant determinants of no-show rates included being a new patient (39.1% vs. 28.8% among established patients; P less than .0001) and having no health insurance (47.5% vs. public 28.3% vs private 24.2%; P less than .0001). Multivariate logistic regression confirmed the associations. New patients were 1.96 times more likely to not show up to the sleep clinic, compared with established patients, while patients with no health insurance coverage were 1.55 times more likely to not show up, compared with those with public health insurance.

The researchers wrote in their poster abstract, “Patients who are new to the clinic or have no insurance coverage have a higher odds of not showing up to their appointment and delaying their care. Efforts to prioritize high-risk patients of nonadherence will help contribute to better care and outcomes. Further studies are needed to develop methods to decrease no-show rates once high-risk appointments have been identified.”

Dr. Nzewuihe acknowledged certain limitations of the study, including its retrospective design and the fact that other possible contributing factors were not evaluated such as literacy level, employment status, and length of time between appointment booking and appointment date. The study’s first author was Julie Sahrmann, DO. The researchers reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Sahrmann J et al. Sleep 2019, Abstract 0965.

SAN ANTONIO – Key determinants of no-show rates to a sleep clinic include being a new patient and lacking health insurance coverage, results from a single-center study showed.

Doug Brunk/MDedge News

“There are lots of people with sleep problems,” one of the study’s authors, Alvan Nzewuihe, MD, said in an interview at the annual meeting of the Associated Professional Sleep Societies. “However, we have to identify these patients to be able to help them. If they don’t come to the sleep clinic [for assessment], we are going nowhere.”

In an effort to better understand determinants of no-show rates among sleep clinics, Dr. Nzewuihe and colleagues performed a 10-month, retrospective chart review of 2,532 patients scheduled at Saint Louis University’s SLUCare Sleep Disorders Center during the months of July and October 2017 and April 2018. A no-show was determined if the patient failed to show up at their scheduled appointment on time or if they canceled their appointment. The researchers used multivariable logistic regression to determine which factors were independently associated with no-show rates.

Dr. Nzewuihe, a sleep medicine physician at the university, reported that the overall no-show rate during the study period was 21.2% and did not change with age, sex, or appointment factors such as time of day, day of week, or season of the year. Significant determinants of no-show rates included being a new patient (39.1% vs. 28.8% among established patients; P less than .0001) and having no health insurance (47.5% vs. public 28.3% vs private 24.2%; P less than .0001). Multivariate logistic regression confirmed the associations. New patients were 1.96 times more likely to not show up to the sleep clinic, compared with established patients, while patients with no health insurance coverage were 1.55 times more likely to not show up, compared with those with public health insurance.

The researchers wrote in their poster abstract, “Patients who are new to the clinic or have no insurance coverage have a higher odds of not showing up to their appointment and delaying their care. Efforts to prioritize high-risk patients of nonadherence will help contribute to better care and outcomes. Further studies are needed to develop methods to decrease no-show rates once high-risk appointments have been identified.”

Dr. Nzewuihe acknowledged certain limitations of the study, including its retrospective design and the fact that other possible contributing factors were not evaluated such as literacy level, employment status, and length of time between appointment booking and appointment date. The study’s first author was Julie Sahrmann, DO. The researchers reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Sahrmann J et al. Sleep 2019, Abstract 0965.

SAN ANTONIO – Key determinants of no-show rates to a sleep clinic include being a new patient and lacking health insurance coverage, results from a single-center study showed.

Doug Brunk/MDedge News

“There are lots of people with sleep problems,” one of the study’s authors, Alvan Nzewuihe, MD, said in an interview at the annual meeting of the Associated Professional Sleep Societies. “However, we have to identify these patients to be able to help them. If they don’t come to the sleep clinic [for assessment], we are going nowhere.”

In an effort to better understand determinants of no-show rates among sleep clinics, Dr. Nzewuihe and colleagues performed a 10-month, retrospective chart review of 2,532 patients scheduled at Saint Louis University’s SLUCare Sleep Disorders Center during the months of July and October 2017 and April 2018. A no-show was determined if the patient failed to show up at their scheduled appointment on time or if they canceled their appointment. The researchers used multivariable logistic regression to determine which factors were independently associated with no-show rates.

Dr. Nzewuihe, a sleep medicine physician at the university, reported that the overall no-show rate during the study period was 21.2% and did not change with age, sex, or appointment factors such as time of day, day of week, or season of the year. Significant determinants of no-show rates included being a new patient (39.1% vs. 28.8% among established patients; P less than .0001) and having no health insurance (47.5% vs. public 28.3% vs private 24.2%; P less than .0001). Multivariate logistic regression confirmed the associations. New patients were 1.96 times more likely to not show up to the sleep clinic, compared with established patients, while patients with no health insurance coverage were 1.55 times more likely to not show up, compared with those with public health insurance.

The researchers wrote in their poster abstract, “Patients who are new to the clinic or have no insurance coverage have a higher odds of not showing up to their appointment and delaying their care. Efforts to prioritize high-risk patients of nonadherence will help contribute to better care and outcomes. Further studies are needed to develop methods to decrease no-show rates once high-risk appointments have been identified.”

Dr. Nzewuihe acknowledged certain limitations of the study, including its retrospective design and the fact that other possible contributing factors were not evaluated such as literacy level, employment status, and length of time between appointment booking and appointment date. The study’s first author was Julie Sahrmann, DO. The researchers reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Sahrmann J et al. Sleep 2019, Abstract 0965.

SEATTLE – The one constant in multiple sclerosis (MS) is its lack of constancy. “As our lives are dynamic and change over time, MS is also dynamic and changes over time.” This is especially the case in women, noted Mitzi Joi Williams, MD.

bowdenimages/iStock/Getty Images

About three in four people with MS are female – about 750,000 in the United States. And the risk and incidence may be highest in African American women.

In a presentation about the unique needs of women with MS, Dr. Williams, an assistant professor of internal medicine at the Morehouse School of Medicine in Atlanta, offered these tips at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Pay attention to sexual dysfunction

Patients with MS often are ashamed to talk about sexual dysfunction, Dr. Williams said, but it is on many minds. “If I have a program on intimacy in MS, people are out the door.”

She urged colleagues to understand that MS can affect sexuality through three routes: primary, secondary, and tertiary dysfunction.

In primary sexual dysfunction, brain and spinal lesions directly related to MS can cause problems such as lack of sensation or abnormal sensations, decreased libido, vaginal dryness, and difficult orgasm.

Secondary sexual dysfunction refers to problems caused by symptoms of MS such as fatigue, which can worsen as the day progresses and affect nighttime intimacy, she said. Bladder dysfunction is another sensitive area in sexuality, with patients – especially women – “concerned that they will lose control of their bladder or they have already lost control.”

Cognitive dysfunction also can disrupt sexual function. “It is important to focus, and certain things cannot happen if you do not. If you are not able to focus and concentrate, it can affect interest,” Dr. Williams said.

Additionally, medications can improve some symptoms while making others worse. For example, a drug may relieve spasticity but boost fatigue. “We have to walk this tightrope,” she said. “But if we are not asking our patients, they may not volunteer this information.”

Finally, she said, MS can spark tertiary sexual dysfunction – poor body image, depression, anxiety, and disruptive changes in familial roles. For example, one partner may become a caregiver, and “it is hard to go from caregiving to sexy time.”

“It is something we have to acknowledge and find ways to deal with,” Dr. Williams said.

To address these issues, she pointed to strategies for symptomatic relief and disease-modifying therapy (DMT) and pinpointed several treatment options.

• Fatigue – stimulants, diet, exercise.
• Spasticity – muscle relaxants, exercise.
• Bladder dysfunction – fluid restriction, medication.
• Paresthesia – antidepressants, anticonvulsants.
• Numbness – vibrators, devices to increase stimulation.

Sexual therapy, couples therapy, and pelvic floor physical therapy also can be helpful.

Be aware of special needs during prepregnancy and pregnancy

“MS itself does not have a lot of effects on fertility, pregnancy, or pregnancy outcomes,” Dr. Williams said. However, “medications cause concern about how we manage pregnancy and fertility.”

In vitro fertilization may increase the risk of relapse, she added, and patients on dimethyl fumarate who experience vomiting or diarrhea may not be able to properly absorb oral contraceptives.

Women with MS may not need to go off DMT when they are trying to conceive, she said. “If patients have very aggressive disease, they may need to be on DMT through conception, through the first trimester, and even the entire pregnancy to prevent long-term disability.”

What about pregnancy itself? “An MS diagnosis alone does not mean that a pregnancy is high risk,” she said. “There are not necessarily additional tests and ultrasounds that are recommended for our patients based on MS diagnosis alone.”

Treatment discontinuation may be warranted during pregnancy, when MS generally improves. However, some MS symptoms – fatigue, bladder dysfunction, and balance – may increase. Corticosteroids can be appropriate if relapses occur during pregnancy.

Menopause and MS symptoms may overlap

Symptoms such as hot flashes, mood changes, sleep disturbance, bladder dysfunction, and decreased energy may be signs of MS, or they could indicate menopause, Dr. Williams said. “Sometimes patients come in and they are getting worse, and we look into it and discover they are premenopausal.”

A decline in estrogen during menopause may worsen MS symptoms, she added, and hormone therapy may be appropriate. A phase 2 study found a benefit in menopausal patients with MS for estriol in conjunction with a DMT, but more studies are needed.

Dr. Williams reported no relevant financial disclosures.

SEATTLE – The one constant in multiple sclerosis (MS) is its lack of constancy. “As our lives are dynamic and change over time, MS is also dynamic and changes over time.” This is especially the case in women, noted Mitzi Joi Williams, MD.

bowdenimages/iStock/Getty Images

About three in four people with MS are female – about 750,000 in the United States. And the risk and incidence may be highest in African American women.

In a presentation about the unique needs of women with MS, Dr. Williams, an assistant professor of internal medicine at the Morehouse School of Medicine in Atlanta, offered these tips at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Pay attention to sexual dysfunction

Patients with MS often are ashamed to talk about sexual dysfunction, Dr. Williams said, but it is on many minds. “If I have a program on intimacy in MS, people are out the door.”

She urged colleagues to understand that MS can affect sexuality through three routes: primary, secondary, and tertiary dysfunction.

In primary sexual dysfunction, brain and spinal lesions directly related to MS can cause problems such as lack of sensation or abnormal sensations, decreased libido, vaginal dryness, and difficult orgasm.

Secondary sexual dysfunction refers to problems caused by symptoms of MS such as fatigue, which can worsen as the day progresses and affect nighttime intimacy, she said. Bladder dysfunction is another sensitive area in sexuality, with patients – especially women – “concerned that they will lose control of their bladder or they have already lost control.”

Cognitive dysfunction also can disrupt sexual function. “It is important to focus, and certain things cannot happen if you do not. If you are not able to focus and concentrate, it can affect interest,” Dr. Williams said.

Additionally, medications can improve some symptoms while making others worse. For example, a drug may relieve spasticity but boost fatigue. “We have to walk this tightrope,” she said. “But if we are not asking our patients, they may not volunteer this information.”

Finally, she said, MS can spark tertiary sexual dysfunction – poor body image, depression, anxiety, and disruptive changes in familial roles. For example, one partner may become a caregiver, and “it is hard to go from caregiving to sexy time.”

“It is something we have to acknowledge and find ways to deal with,” Dr. Williams said.

To address these issues, she pointed to strategies for symptomatic relief and disease-modifying therapy (DMT) and pinpointed several treatment options.

• Fatigue – stimulants, diet, exercise.
• Spasticity – muscle relaxants, exercise.
• Bladder dysfunction – fluid restriction, medication.
• Paresthesia – antidepressants, anticonvulsants.
• Numbness – vibrators, devices to increase stimulation.

Sexual therapy, couples therapy, and pelvic floor physical therapy also can be helpful.

Be aware of special needs during prepregnancy and pregnancy

“MS itself does not have a lot of effects on fertility, pregnancy, or pregnancy outcomes,” Dr. Williams said. However, “medications cause concern about how we manage pregnancy and fertility.”

In vitro fertilization may increase the risk of relapse, she added, and patients on dimethyl fumarate who experience vomiting or diarrhea may not be able to properly absorb oral contraceptives.

Women with MS may not need to go off DMT when they are trying to conceive, she said. “If patients have very aggressive disease, they may need to be on DMT through conception, through the first trimester, and even the entire pregnancy to prevent long-term disability.”

What about pregnancy itself? “An MS diagnosis alone does not mean that a pregnancy is high risk,” she said. “There are not necessarily additional tests and ultrasounds that are recommended for our patients based on MS diagnosis alone.”

Treatment discontinuation may be warranted during pregnancy, when MS generally improves. However, some MS symptoms – fatigue, bladder dysfunction, and balance – may increase. Corticosteroids can be appropriate if relapses occur during pregnancy.

Menopause and MS symptoms may overlap

Symptoms such as hot flashes, mood changes, sleep disturbance, bladder dysfunction, and decreased energy may be signs of MS, or they could indicate menopause, Dr. Williams said. “Sometimes patients come in and they are getting worse, and we look into it and discover they are premenopausal.”

A decline in estrogen during menopause may worsen MS symptoms, she added, and hormone therapy may be appropriate. A phase 2 study found a benefit in menopausal patients with MS for estriol in conjunction with a DMT, but more studies are needed.

Dr. Williams reported no relevant financial disclosures.

SEATTLE – The one constant in multiple sclerosis (MS) is its lack of constancy. “As our lives are dynamic and change over time, MS is also dynamic and changes over time.” This is especially the case in women, noted Mitzi Joi Williams, MD.

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About three in four people with MS are female – about 750,000 in the United States. And the risk and incidence may be highest in African American women.

In a presentation about the unique needs of women with MS, Dr. Williams, an assistant professor of internal medicine at the Morehouse School of Medicine in Atlanta, offered these tips at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Pay attention to sexual dysfunction

Patients with MS often are ashamed to talk about sexual dysfunction, Dr. Williams said, but it is on many minds. “If I have a program on intimacy in MS, people are out the door.”

She urged colleagues to understand that MS can affect sexuality through three routes: primary, secondary, and tertiary dysfunction.

In primary sexual dysfunction, brain and spinal lesions directly related to MS can cause problems such as lack of sensation or abnormal sensations, decreased libido, vaginal dryness, and difficult orgasm.

Secondary sexual dysfunction refers to problems caused by symptoms of MS such as fatigue, which can worsen as the day progresses and affect nighttime intimacy, she said. Bladder dysfunction is another sensitive area in sexuality, with patients – especially women – “concerned that they will lose control of their bladder or they have already lost control.”

Cognitive dysfunction also can disrupt sexual function. “It is important to focus, and certain things cannot happen if you do not. If you are not able to focus and concentrate, it can affect interest,” Dr. Williams said.

Additionally, medications can improve some symptoms while making others worse. For example, a drug may relieve spasticity but boost fatigue. “We have to walk this tightrope,” she said. “But if we are not asking our patients, they may not volunteer this information.”

Finally, she said, MS can spark tertiary sexual dysfunction – poor body image, depression, anxiety, and disruptive changes in familial roles. For example, one partner may become a caregiver, and “it is hard to go from caregiving to sexy time.”

“It is something we have to acknowledge and find ways to deal with,” Dr. Williams said.

To address these issues, she pointed to strategies for symptomatic relief and disease-modifying therapy (DMT) and pinpointed several treatment options.

• Fatigue – stimulants, diet, exercise.
• Spasticity – muscle relaxants, exercise.
• Bladder dysfunction – fluid restriction, medication.
• Paresthesia – antidepressants, anticonvulsants.
• Numbness – vibrators, devices to increase stimulation.

Sexual therapy, couples therapy, and pelvic floor physical therapy also can be helpful.

Be aware of special needs during prepregnancy and pregnancy

“MS itself does not have a lot of effects on fertility, pregnancy, or pregnancy outcomes,” Dr. Williams said. However, “medications cause concern about how we manage pregnancy and fertility.”

In vitro fertilization may increase the risk of relapse, she added, and patients on dimethyl fumarate who experience vomiting or diarrhea may not be able to properly absorb oral contraceptives.

Women with MS may not need to go off DMT when they are trying to conceive, she said. “If patients have very aggressive disease, they may need to be on DMT through conception, through the first trimester, and even the entire pregnancy to prevent long-term disability.”

What about pregnancy itself? “An MS diagnosis alone does not mean that a pregnancy is high risk,” she said. “There are not necessarily additional tests and ultrasounds that are recommended for our patients based on MS diagnosis alone.”

Treatment discontinuation may be warranted during pregnancy, when MS generally improves. However, some MS symptoms – fatigue, bladder dysfunction, and balance – may increase. Corticosteroids can be appropriate if relapses occur during pregnancy.

Menopause and MS symptoms may overlap

Symptoms such as hot flashes, mood changes, sleep disturbance, bladder dysfunction, and decreased energy may be signs of MS, or they could indicate menopause, Dr. Williams said. “Sometimes patients come in and they are getting worse, and we look into it and discover they are premenopausal.”

A decline in estrogen during menopause may worsen MS symptoms, she added, and hormone therapy may be appropriate. A phase 2 study found a benefit in menopausal patients with MS for estriol in conjunction with a DMT, but more studies are needed.

Dr. Williams reported no relevant financial disclosures.

The other day, I saw a patient who really brought home the importance of considering culture in psychiatry. The patient’s chief complaint was that he had been hearing the voice of an “invisible man.” I noticed he had an accent I was familiar with, and it sounded like he was from Haiti. Indeed, he was born there.

Accordingly, I asked him about voodoo. He said he is not a voodoo worshiper but he believes in voodoo – and he thought that that was what was happening to him. He reported this was the second time he heard the voices – the last time was less than a year ago. He said he came to the hospital because he was trying to wash dishes when he felt some invisible force holding him down. The patient got upset, and he broke the dishes he was washing. Of course, a big melee ensued, and the police were called. They brought the patient to my hospital.

When I spoke with him, he said he was doing pretty well with his Parkinson’s disease but he was a little stiff. The patient was on carbidopa-levodopa 25-100 mg 1.5 t.i.d. for his Parkinson’s, quetiapine 50 mg b.i.d. for his psychotic symptoms, amantadine 100 mg b.i.d. to stimulate his dopamine, ropinirole 1 mg t.i.d. for restless legs, and baclofen 10 mg t.i.d. for muscle spasms.

This is a 66-year-old male who was appropriately groomed and who was cooperative with the interview. He was not hyperactive or lethargic. His mood was euthymic, and he had a wide range of affect as he was able to smile, get serious, and be sad (about his problems). His speech was relevant, linear, and goal directed. His thought processes did not show any signs of loose associations, tangentiality or circumstantiality, but he did have delusions, and current auditory and visual hallucinations. His thought content was surrounding his problems, which because of the culture he is from, were attributed by him to voodoo. He was attentive, and his recent and remote memory were intact. Clinical estimate of his intelligence was average. Despite my explaining to him that his psychotic symptoms were caused by the medication he was taking, his judgment and insight were fair as he explained to me the things that were happening to him were so tangible they had to be real. He had no suicidal or homicidal ideation.

I decided to leave his meds as is, and I gave him 25 mg loxapine at h.s.

When I saw him a few days later, I asked him how he was doing, and he reported that the invisible man and all of his shenanigans were gone. I again explained that the medication he was taking for his Parkinson’s was causing his psychotic symptoms, and now I had proof. Had the voices been tied to voodoo, the medication would not have stopped the symptoms. He looked skeptical.

This struck me as a perfect example of the importance of culture in psychiatry, and I thought it instructive to share.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit; clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago; former president/CEO of the Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), all in Chicago. He is recipient of the American Psychiatric Association’s 2019 Adolph Meyer Award for Lifetime Achievement in Psychiatric Research. Check out Dr. Bell’s new book, Fetal Alcohol Exposure in the African-American Community, at https://thirdworldpressfoundation.org/product/pre-order-fetal-alcohol-exposure-in-the-african-american-community.

The other day, I saw a patient who really brought home the importance of considering culture in psychiatry. The patient’s chief complaint was that he had been hearing the voice of an “invisible man.” I noticed he had an accent I was familiar with, and it sounded like he was from Haiti. Indeed, he was born there.

Accordingly, I asked him about voodoo. He said he is not a voodoo worshiper but he believes in voodoo – and he thought that that was what was happening to him. He reported this was the second time he heard the voices – the last time was less than a year ago. He said he came to the hospital because he was trying to wash dishes when he felt some invisible force holding him down. The patient got upset, and he broke the dishes he was washing. Of course, a big melee ensued, and the police were called. They brought the patient to my hospital.

When I spoke with him, he said he was doing pretty well with his Parkinson’s disease but he was a little stiff. The patient was on carbidopa-levodopa 25-100 mg 1.5 t.i.d. for his Parkinson’s, quetiapine 50 mg b.i.d. for his psychotic symptoms, amantadine 100 mg b.i.d. to stimulate his dopamine, ropinirole 1 mg t.i.d. for restless legs, and baclofen 10 mg t.i.d. for muscle spasms.

This is a 66-year-old male who was appropriately groomed and who was cooperative with the interview. He was not hyperactive or lethargic. His mood was euthymic, and he had a wide range of affect as he was able to smile, get serious, and be sad (about his problems). His speech was relevant, linear, and goal directed. His thought processes did not show any signs of loose associations, tangentiality or circumstantiality, but he did have delusions, and current auditory and visual hallucinations. His thought content was surrounding his problems, which because of the culture he is from, were attributed by him to voodoo. He was attentive, and his recent and remote memory were intact. Clinical estimate of his intelligence was average. Despite my explaining to him that his psychotic symptoms were caused by the medication he was taking, his judgment and insight were fair as he explained to me the things that were happening to him were so tangible they had to be real. He had no suicidal or homicidal ideation.

I decided to leave his meds as is, and I gave him 25 mg loxapine at h.s.

When I saw him a few days later, I asked him how he was doing, and he reported that the invisible man and all of his shenanigans were gone. I again explained that the medication he was taking for his Parkinson’s was causing his psychotic symptoms, and now I had proof. Had the voices been tied to voodoo, the medication would not have stopped the symptoms. He looked skeptical.

This struck me as a perfect example of the importance of culture in psychiatry, and I thought it instructive to share.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit; clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago; former president/CEO of the Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), all in Chicago. He is recipient of the American Psychiatric Association’s 2019 Adolph Meyer Award for Lifetime Achievement in Psychiatric Research. Check out Dr. Bell’s new book, Fetal Alcohol Exposure in the African-American Community, at https://thirdworldpressfoundation.org/product/pre-order-fetal-alcohol-exposure-in-the-african-american-community.

The other day, I saw a patient who really brought home the importance of considering culture in psychiatry. The patient’s chief complaint was that he had been hearing the voice of an “invisible man.” I noticed he had an accent I was familiar with, and it sounded like he was from Haiti. Indeed, he was born there.

Accordingly, I asked him about voodoo. He said he is not a voodoo worshiper but he believes in voodoo – and he thought that that was what was happening to him. He reported this was the second time he heard the voices – the last time was less than a year ago. He said he came to the hospital because he was trying to wash dishes when he felt some invisible force holding him down. The patient got upset, and he broke the dishes he was washing. Of course, a big melee ensued, and the police were called. They brought the patient to my hospital.

When I spoke with him, he said he was doing pretty well with his Parkinson’s disease but he was a little stiff. The patient was on carbidopa-levodopa 25-100 mg 1.5 t.i.d. for his Parkinson’s, quetiapine 50 mg b.i.d. for his psychotic symptoms, amantadine 100 mg b.i.d. to stimulate his dopamine, ropinirole 1 mg t.i.d. for restless legs, and baclofen 10 mg t.i.d. for muscle spasms.

This is a 66-year-old male who was appropriately groomed and who was cooperative with the interview. He was not hyperactive or lethargic. His mood was euthymic, and he had a wide range of affect as he was able to smile, get serious, and be sad (about his problems). His speech was relevant, linear, and goal directed. His thought processes did not show any signs of loose associations, tangentiality or circumstantiality, but he did have delusions, and current auditory and visual hallucinations. His thought content was surrounding his problems, which because of the culture he is from, were attributed by him to voodoo. He was attentive, and his recent and remote memory were intact. Clinical estimate of his intelligence was average. Despite my explaining to him that his psychotic symptoms were caused by the medication he was taking, his judgment and insight were fair as he explained to me the things that were happening to him were so tangible they had to be real. He had no suicidal or homicidal ideation.

I decided to leave his meds as is, and I gave him 25 mg loxapine at h.s.

When I saw him a few days later, I asked him how he was doing, and he reported that the invisible man and all of his shenanigans were gone. I again explained that the medication he was taking for his Parkinson’s was causing his psychotic symptoms, and now I had proof. Had the voices been tied to voodoo, the medication would not have stopped the symptoms. He looked skeptical.

This struck me as a perfect example of the importance of culture in psychiatry, and I thought it instructive to share.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit; clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago; former president/CEO of the Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), all in Chicago. He is recipient of the American Psychiatric Association’s 2019 Adolph Meyer Award for Lifetime Achievement in Psychiatric Research. Check out Dr. Bell’s new book, Fetal Alcohol Exposure in the African-American Community, at https://thirdworldpressfoundation.org/product/pre-order-fetal-alcohol-exposure-in-the-african-american-community.

Only a limited number of patients with von Willebrand disease (VWD) are likely to require treatment with von Willebrand factor (VWF) concentrates, according to results from a retrospective analysis.

The retrospective, single-center study sought to describe the need for VWF concentrates in a “real-life setting,” wrote Ana Boban, MD, PhD, of the University of Zagreb (Croatia) and colleagues in a letter to the editor published in Haemophilia. The study was conducted at the Saint‐Luc University Hospital in Brussels and included all the VWD patients listed in the hospital registry from 2000 to 2015.

The researchers evaluated the necessity for VWF concentrate therapy based on VWD severity (mild, moderate, severe) and type (1, 2A, 2B, 2M, 2N, or 3), in addition to therapeutic indication. Bleeding scores were not included in the analysis.

A total of 174 patients with VWD were included in the study, which consisted of 116 females and 61 males aged 3-81 years. The majority of study participants had type 1 VWD (n = 118, 67%).

Data collected included patient demographic information, disease type and severity, responses to specific tests, and type of treatment received.

The researchers found that just 18% (n = 32) of patients within the cohort required therapy with VWF concentrates over the study period. Additionally, the team reported that a large number of patients did not require any therapy (n = 79; 45%) or were or managed with DDAVP (desmopressin) (n = 61; 64%).

“When assessing the results according to disease severity, it clearly occurred that most patients with severe disease required VWF concentrates [100%, 75%, and 100% for type 1, type 2, and type 3 VWD, respectively],” the authors wrote.

With respect to therapeutic indication, apart from prophylaxis, contraindications to DDAVP (n = 5) and unresponsiveness to DDAVP (n = 7) were absolute indications for the use of VWF concentrates among patients within the cohort.

“Our study has confirmed that the absolute indications for using VWF concentrates in VWD patients are prophylaxis, major surgeries, and nonresponsiveness/contraindications to DDAVP,” they concluded.

No funding sources were reported. The authors reported having no conflicts of interest.

SOURCE: Boban A et al. Haemophilia. 2019 May 20. doi: 10.1111/hae.13779.

Only a limited number of patients with von Willebrand disease (VWD) are likely to require treatment with von Willebrand factor (VWF) concentrates, according to results from a retrospective analysis.

The retrospective, single-center study sought to describe the need for VWF concentrates in a “real-life setting,” wrote Ana Boban, MD, PhD, of the University of Zagreb (Croatia) and colleagues in a letter to the editor published in Haemophilia. The study was conducted at the Saint‐Luc University Hospital in Brussels and included all the VWD patients listed in the hospital registry from 2000 to 2015.

The researchers evaluated the necessity for VWF concentrate therapy based on VWD severity (mild, moderate, severe) and type (1, 2A, 2B, 2M, 2N, or 3), in addition to therapeutic indication. Bleeding scores were not included in the analysis.

A total of 174 patients with VWD were included in the study, which consisted of 116 females and 61 males aged 3-81 years. The majority of study participants had type 1 VWD (n = 118, 67%).

Data collected included patient demographic information, disease type and severity, responses to specific tests, and type of treatment received.

The researchers found that just 18% (n = 32) of patients within the cohort required therapy with VWF concentrates over the study period. Additionally, the team reported that a large number of patients did not require any therapy (n = 79; 45%) or were or managed with DDAVP (desmopressin) (n = 61; 64%).

“When assessing the results according to disease severity, it clearly occurred that most patients with severe disease required VWF concentrates [100%, 75%, and 100% for type 1, type 2, and type 3 VWD, respectively],” the authors wrote.

With respect to therapeutic indication, apart from prophylaxis, contraindications to DDAVP (n = 5) and unresponsiveness to DDAVP (n = 7) were absolute indications for the use of VWF concentrates among patients within the cohort.

“Our study has confirmed that the absolute indications for using VWF concentrates in VWD patients are prophylaxis, major surgeries, and nonresponsiveness/contraindications to DDAVP,” they concluded.

No funding sources were reported. The authors reported having no conflicts of interest.

SOURCE: Boban A et al. Haemophilia. 2019 May 20. doi: 10.1111/hae.13779.

Only a limited number of patients with von Willebrand disease (VWD) are likely to require treatment with von Willebrand factor (VWF) concentrates, according to results from a retrospective analysis.

The retrospective, single-center study sought to describe the need for VWF concentrates in a “real-life setting,” wrote Ana Boban, MD, PhD, of the University of Zagreb (Croatia) and colleagues in a letter to the editor published in Haemophilia. The study was conducted at the Saint‐Luc University Hospital in Brussels and included all the VWD patients listed in the hospital registry from 2000 to 2015.

The researchers evaluated the necessity for VWF concentrate therapy based on VWD severity (mild, moderate, severe) and type (1, 2A, 2B, 2M, 2N, or 3), in addition to therapeutic indication. Bleeding scores were not included in the analysis.

A total of 174 patients with VWD were included in the study, which consisted of 116 females and 61 males aged 3-81 years. The majority of study participants had type 1 VWD (n = 118, 67%).

Data collected included patient demographic information, disease type and severity, responses to specific tests, and type of treatment received.

The researchers found that just 18% (n = 32) of patients within the cohort required therapy with VWF concentrates over the study period. Additionally, the team reported that a large number of patients did not require any therapy (n = 79; 45%) or were or managed with DDAVP (desmopressin) (n = 61; 64%).

“When assessing the results according to disease severity, it clearly occurred that most patients with severe disease required VWF concentrates [100%, 75%, and 100% for type 1, type 2, and type 3 VWD, respectively],” the authors wrote.

With respect to therapeutic indication, apart from prophylaxis, contraindications to DDAVP (n = 5) and unresponsiveness to DDAVP (n = 7) were absolute indications for the use of VWF concentrates among patients within the cohort.

“Our study has confirmed that the absolute indications for using VWF concentrates in VWD patients are prophylaxis, major surgeries, and nonresponsiveness/contraindications to DDAVP,” they concluded.

No funding sources were reported. The authors reported having no conflicts of interest.

SOURCE: Boban A et al. Haemophilia. 2019 May 20. doi: 10.1111/hae.13779.