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Manic after having found a ‘cure’ for Alzheimer’s disease
CASE Reckless driving, impulse buying
Mr. A, age 73, is admitted to the inpatient psychiatric unit at a community hospital for evaluation of a psychotic episode. His admission to the unit was initiated by his primary care physician, who noted that Mr. A was “not making sense” during a routine visit. Mr. A was speaking rapidly about how he had discovered that high-dose omega-3 fatty acid supplements were a “cure” for Alzheimer’s disease. He also believes that he was recently appointed as CEO of Microsoft and Apple for his discoveries.
Three months earlier, Mr. A had started taking high doses of omega-3 fatty acid supplements (10 to 15 g/d) because he believed they were the cure for memory problems, pain, and depression. At that time, he discontinued taking nortriptyline, 25 mg/d, and citalopram, 40 mg/d, which his outpatient psychiatrist had prescribed for major depressive disorder (MDD). Mr. A also had stopped taking buprenorphine, 2 mg, sublingual, 4 times a day, which he had been prescribed for chronic pain.
Mr. A’s wife reports that during the last 2 months, her husband had become irritable, impulsive, grandiose, and was sleeping very little. She added that although her husband’s ophthalmologist had advised him to not drive due to impaired vision, he had been driving recklessly across the metropolitan area. He had also spent nearly $15,000 buying furniture and other items for their home.
In addition to MDD, Mr. A has a history of chronic kidney disease, Leber’s hereditary optic neuropathy, and chronic pain. He has been taking vitamin D3, 2,000 U/d, as a nutritional supplement.
[polldaddy:10091672]
The authors’ observations
Mr. A met the DSM-5 criteria for a manic episode (Table 11). His manic and delusional symptoms are new. He has a long-standing diagnosis of MDD, which for many years had been successfully treated with antidepressants without a manic switch. The absence of a manic switch when treated with antidepressants without a mood stabilizer suggested that Mr. A did not have bipolarity in terms of a mood disorder diathesis.2 In addition, it would be unusual for an individual to develop a new-onset or primary bipolar disorder after age 60. Individuals in this age group who present with manic symptoms for the first time are preponderantly found to have a general medical or iatrogenic cause for the emergence of these symptoms.3 Mr. A has a history of chronic kidney disease, Leber’s hereditary optic neuropathy, and chronic pain.
Typically a sedentary man, Mr. A had been exhibiting disinhibited behavior, grandiosity, insomnia, and psychosis. These symptoms began 3 months before he was admitted to the psychiatric unit, when he had started taking high doses of omega-3 fatty acid supplements.
Continue to: EVALUATION Persistent mania
EVALUATION Persistent mania
On initial examination, Mr. A is upset and irritable. He is casually dressed and well-groomed. He lacks insight and says he was brought to the hospital against his will, and it is his wife “who is the one who is crazy.” He is oriented to person, place, and time. At times he is found roaming the hallways, being intrusive, hyperverbal, and tangential with pressured speech. He is very difficult to redirect, and regularly interrupts the interview. His vital signs are stable. He walks well, with slow and steady gait, and displays no tremor or bradykinesia.
[polldaddy:10091674]
The authors’ observations
In order to rule out organic causes, a complete blood count, comprehensive metabolic panel, thyroid profile, urine drug screen, and brain MRI were ordered. No abnormalities were found. DHA and EPA levels were not measured because such testing was not available at the laboratory at the hospital.
Mania emerging after the sixth decade of life is a rare occurrence. Therefore, we made a substantial effort to try to find another cause that might explain Mr. A’s unusual presentation (Table 2).
Omega-3 fatty acid–induced mania. The major types of omega-3 polyunsaturated fatty acids are EPA and DHA and their precursor, alpha-linolenic acid (ALA). EPA and DHA are found primarily in fatty fish, such as salmon, and in fish oil supplements. Omega-3 fatty acids have beneficial anti-inflammatory, antioxidative, and neuroplastic effects.4 Having properties similar to selective serotonin reuptake inhibitors, omega-3 fatty acids are thought to help prevent depression, have few interactions with other medications, and have a lower adverse-effect burden than antidepressants. They have been found to be beneficial as a maintenance treatment and for prevention of depressive episodes in bipolar depression, but no positive association has been found for bipolar mania.5
Continue to: However, very limited evidence suggests...
However, very limited evidence suggests that omega-3 fatty acid supplements, particularly those with flaxseed oil, can induce hypomania or mania. This association was first reported by Rudin6 in 1981, and later reported in other studies.7 How omega-3 fatty acids might induce mania is unclear.
Mr. A was reportedly taking high doses of an omega-3 fatty acid supplement. We hypothesized that the antidepressant effect of this supplement may have precipitated a manic episode. Mr. A had no history of manic episodes in the past and was stable during the treatment with the outpatient psychiatrist. A first episode mania in the seventh decade of life would be highly unusual without an organic etiology. After laboratory tests found no abnormalities that would point to an organic etiology, iatrogenic causes were considered. After a review of the literature, there was anecdotal evidence for the induction of mania in clinical trials studying the effects of omega-3 supplements on affective disorders.
This led us to ask: How much omega-3 fatty acid supplements, if any, can a patient with a depressive or bipolar disorder safely take? Currently, omega-3 fatty acid supplements are not FDA-approved for the treatment of depression or bipolar disorder. However, patients may take 1.5 to 2 g/d for MDD. Further research is needed to determine the optimal dose. It is unclear at this time if omega-3 fatty acid supplementation has any benefit in the acute or maintenance treatment of bipolar disorder.
Alternative nutritional supplements for mood disorders. Traditionally, mood disorders, such as MDD and bipolar disorder, have been treated with psychotropic medications. However, through the years, sporadic studies have examined the efficacy of nutritional interventions as a cost-effective approach to preventing and treating these conditions.5 Proponents of this approach believe such supplements can increase efficacy, as well as decrease the required dose of psychotropic medications, thus potentially minimizing adverse effects. However, their overuse can pose a potential threat of toxicity or unexpected adverse effects, such as precipitation of mania. Table 38 lists over-the-counter nutritional and/or herbal agents that may cause mania.
Continue to: TREATMENT Nonadherence leads to a court order
TREATMENT Nonadherence leads to a court order
On admission, Mr. A receives a dose of
[polldaddy:10091676]
The authors’ observations
During an acute manic episode, the goal of treatment is urgent mood stabilization. Monotherapy can be used; however, in emergent settings, a combination is often used for a rapid response. The most commonly used agents are lithium, anticonvulsants such as valproic acid, and antipsychotics.9 In addition, benzodiazepines can be used for insomnia, agitation, or anxiety. The decision to use lithium, an anticonvulsant, or an antipsychotic depends upon the specific medication’s adverse effects, the patient’s medical history, previous medication trials, drug–drug interactions, patient preference, and cost.
Because Mr. A has a history of chronic kidney disease, lithium was contraindicated.
[polldaddy:10091678]
Continue to: The authors' observations
The authors’ observations
After the acute episode of mania resolves, maintenance pharmacotherapy typically involves continuing the same regimen that achieved mood stabilization. Monotherapy is typically preferred to combination therapy, but it is not always possible after a manic episode.10 A reasonable approach is to slowly taper the antipsychotic after several months of dual therapy if symptoms continue to be well-controlled. Further adjustments may be necessary, depending on the medications’ adverse effects. Moreover, further acute episodes of mania or depression will also determine future treatment.
OUTCOME Resolution of delusions
Mr. A is discharged 30 days after admission. At this point, his acute manic episode has resolved with non-tangential, non-pressured speech, improved sleep, and decreased impulsivity. His grandiose delusions also have resolved. He is prescribed valproic acid, 1,000 mg/d, and risperidone, 6 mg/d at bedtime, under the care of his outpatient psychiatrist.
Bottom Line
Initial presentation of a manic episode in an older patient is rare. It is important to rule out organic causes. Weak evidence suggests omega-3 fatty acid supplements may have the potential to induce mania in certain patients.
Related Resource
- Ramaswamy S, Driscoll D, Rodriguez A, et al. Nutraceuticals for traumatic brain injury: Should you recommend their use? Current Psychiatry. 2017;16(7):34-38,40,41-45.
Drug Brand Names
Buprenorphine • Suboxone, Subutex
Citalopram • Celexa
Hydrocodone/acetaminophen • Vicodin
Lithium • Eskalith, Lithobid
Lorazepam• Ativan
Nortriptyline • Pamelor
Risperidone • Risperdal
Valproic acid • Depakote
1. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Goodwin GM, Haddad PM, Ferrier IN, et al. Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30(6):495-553.
3. Sami M, Khan H, Nilforooshan R. Late onset mania as an organic syndrome: a review of case reports in the literature. J Affect Disord. 2015:188:226-231.
4. Su KP, Matsuoka Y, Pae CU. Omega-3 polyunsaturated fatty acids in prevention of mood and anxiety disorders. Clin Psychopharmacol Neurosci. 2015;13(2):129-137.
5. Sarris J, Mischoulon D, Schweitzer I. Omega-3 for bipolar disorder: meta-analyses of use in mania and bipolar depression. J Clin Psychiatry. 2012;73(1):81-86.
6. Rudin DO. The major psychoses and neuroses as omega-3 essential fatty acid deficiency syndrome: substrate pellagra. Biol Psychiatry. 1981;16(9):837-850.
7. Su KP, Shen WW, Huang SY. Are omega3 fatty acids beneficial in depression but not mania? Arch Gen Psychiatry. 2000;57(7):716-717.
8. Joshi K, Faubion M. Mania and psychosis associated with St. John’s wort and ginseng. Psychiatry (Edgmont). 2005;2(9):56-61.
9. Grunze H, Vieta E, Goodwin GM, et al. The world federation of societies of biological psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treatment of acute mania. World J Biol Psychiatry. 2009;10(2):85-116.
10. Suppes T, Vieta E, Liu S, et al; Trial 127 Investigators. Maintenance treatment for patients with bipolar I disorder: results from a North American study of quetiapine in combination with lithium or divalproex (trial 127). Am J Psychiatry. 2009;166(4):476-488.
CASE Reckless driving, impulse buying
Mr. A, age 73, is admitted to the inpatient psychiatric unit at a community hospital for evaluation of a psychotic episode. His admission to the unit was initiated by his primary care physician, who noted that Mr. A was “not making sense” during a routine visit. Mr. A was speaking rapidly about how he had discovered that high-dose omega-3 fatty acid supplements were a “cure” for Alzheimer’s disease. He also believes that he was recently appointed as CEO of Microsoft and Apple for his discoveries.
Three months earlier, Mr. A had started taking high doses of omega-3 fatty acid supplements (10 to 15 g/d) because he believed they were the cure for memory problems, pain, and depression. At that time, he discontinued taking nortriptyline, 25 mg/d, and citalopram, 40 mg/d, which his outpatient psychiatrist had prescribed for major depressive disorder (MDD). Mr. A also had stopped taking buprenorphine, 2 mg, sublingual, 4 times a day, which he had been prescribed for chronic pain.
Mr. A’s wife reports that during the last 2 months, her husband had become irritable, impulsive, grandiose, and was sleeping very little. She added that although her husband’s ophthalmologist had advised him to not drive due to impaired vision, he had been driving recklessly across the metropolitan area. He had also spent nearly $15,000 buying furniture and other items for their home.
In addition to MDD, Mr. A has a history of chronic kidney disease, Leber’s hereditary optic neuropathy, and chronic pain. He has been taking vitamin D3, 2,000 U/d, as a nutritional supplement.
[polldaddy:10091672]
The authors’ observations
Mr. A met the DSM-5 criteria for a manic episode (Table 11). His manic and delusional symptoms are new. He has a long-standing diagnosis of MDD, which for many years had been successfully treated with antidepressants without a manic switch. The absence of a manic switch when treated with antidepressants without a mood stabilizer suggested that Mr. A did not have bipolarity in terms of a mood disorder diathesis.2 In addition, it would be unusual for an individual to develop a new-onset or primary bipolar disorder after age 60. Individuals in this age group who present with manic symptoms for the first time are preponderantly found to have a general medical or iatrogenic cause for the emergence of these symptoms.3 Mr. A has a history of chronic kidney disease, Leber’s hereditary optic neuropathy, and chronic pain.
Typically a sedentary man, Mr. A had been exhibiting disinhibited behavior, grandiosity, insomnia, and psychosis. These symptoms began 3 months before he was admitted to the psychiatric unit, when he had started taking high doses of omega-3 fatty acid supplements.
Continue to: EVALUATION Persistent mania
EVALUATION Persistent mania
On initial examination, Mr. A is upset and irritable. He is casually dressed and well-groomed. He lacks insight and says he was brought to the hospital against his will, and it is his wife “who is the one who is crazy.” He is oriented to person, place, and time. At times he is found roaming the hallways, being intrusive, hyperverbal, and tangential with pressured speech. He is very difficult to redirect, and regularly interrupts the interview. His vital signs are stable. He walks well, with slow and steady gait, and displays no tremor or bradykinesia.
[polldaddy:10091674]
The authors’ observations
In order to rule out organic causes, a complete blood count, comprehensive metabolic panel, thyroid profile, urine drug screen, and brain MRI were ordered. No abnormalities were found. DHA and EPA levels were not measured because such testing was not available at the laboratory at the hospital.
Mania emerging after the sixth decade of life is a rare occurrence. Therefore, we made a substantial effort to try to find another cause that might explain Mr. A’s unusual presentation (Table 2).
Omega-3 fatty acid–induced mania. The major types of omega-3 polyunsaturated fatty acids are EPA and DHA and their precursor, alpha-linolenic acid (ALA). EPA and DHA are found primarily in fatty fish, such as salmon, and in fish oil supplements. Omega-3 fatty acids have beneficial anti-inflammatory, antioxidative, and neuroplastic effects.4 Having properties similar to selective serotonin reuptake inhibitors, omega-3 fatty acids are thought to help prevent depression, have few interactions with other medications, and have a lower adverse-effect burden than antidepressants. They have been found to be beneficial as a maintenance treatment and for prevention of depressive episodes in bipolar depression, but no positive association has been found for bipolar mania.5
Continue to: However, very limited evidence suggests...
However, very limited evidence suggests that omega-3 fatty acid supplements, particularly those with flaxseed oil, can induce hypomania or mania. This association was first reported by Rudin6 in 1981, and later reported in other studies.7 How omega-3 fatty acids might induce mania is unclear.
Mr. A was reportedly taking high doses of an omega-3 fatty acid supplement. We hypothesized that the antidepressant effect of this supplement may have precipitated a manic episode. Mr. A had no history of manic episodes in the past and was stable during the treatment with the outpatient psychiatrist. A first episode mania in the seventh decade of life would be highly unusual without an organic etiology. After laboratory tests found no abnormalities that would point to an organic etiology, iatrogenic causes were considered. After a review of the literature, there was anecdotal evidence for the induction of mania in clinical trials studying the effects of omega-3 supplements on affective disorders.
This led us to ask: How much omega-3 fatty acid supplements, if any, can a patient with a depressive or bipolar disorder safely take? Currently, omega-3 fatty acid supplements are not FDA-approved for the treatment of depression or bipolar disorder. However, patients may take 1.5 to 2 g/d for MDD. Further research is needed to determine the optimal dose. It is unclear at this time if omega-3 fatty acid supplementation has any benefit in the acute or maintenance treatment of bipolar disorder.
Alternative nutritional supplements for mood disorders. Traditionally, mood disorders, such as MDD and bipolar disorder, have been treated with psychotropic medications. However, through the years, sporadic studies have examined the efficacy of nutritional interventions as a cost-effective approach to preventing and treating these conditions.5 Proponents of this approach believe such supplements can increase efficacy, as well as decrease the required dose of psychotropic medications, thus potentially minimizing adverse effects. However, their overuse can pose a potential threat of toxicity or unexpected adverse effects, such as precipitation of mania. Table 38 lists over-the-counter nutritional and/or herbal agents that may cause mania.
Continue to: TREATMENT Nonadherence leads to a court order
TREATMENT Nonadherence leads to a court order
On admission, Mr. A receives a dose of
[polldaddy:10091676]
The authors’ observations
During an acute manic episode, the goal of treatment is urgent mood stabilization. Monotherapy can be used; however, in emergent settings, a combination is often used for a rapid response. The most commonly used agents are lithium, anticonvulsants such as valproic acid, and antipsychotics.9 In addition, benzodiazepines can be used for insomnia, agitation, or anxiety. The decision to use lithium, an anticonvulsant, or an antipsychotic depends upon the specific medication’s adverse effects, the patient’s medical history, previous medication trials, drug–drug interactions, patient preference, and cost.
Because Mr. A has a history of chronic kidney disease, lithium was contraindicated.
[polldaddy:10091678]
Continue to: The authors' observations
The authors’ observations
After the acute episode of mania resolves, maintenance pharmacotherapy typically involves continuing the same regimen that achieved mood stabilization. Monotherapy is typically preferred to combination therapy, but it is not always possible after a manic episode.10 A reasonable approach is to slowly taper the antipsychotic after several months of dual therapy if symptoms continue to be well-controlled. Further adjustments may be necessary, depending on the medications’ adverse effects. Moreover, further acute episodes of mania or depression will also determine future treatment.
OUTCOME Resolution of delusions
Mr. A is discharged 30 days after admission. At this point, his acute manic episode has resolved with non-tangential, non-pressured speech, improved sleep, and decreased impulsivity. His grandiose delusions also have resolved. He is prescribed valproic acid, 1,000 mg/d, and risperidone, 6 mg/d at bedtime, under the care of his outpatient psychiatrist.
Bottom Line
Initial presentation of a manic episode in an older patient is rare. It is important to rule out organic causes. Weak evidence suggests omega-3 fatty acid supplements may have the potential to induce mania in certain patients.
Related Resource
- Ramaswamy S, Driscoll D, Rodriguez A, et al. Nutraceuticals for traumatic brain injury: Should you recommend their use? Current Psychiatry. 2017;16(7):34-38,40,41-45.
Drug Brand Names
Buprenorphine • Suboxone, Subutex
Citalopram • Celexa
Hydrocodone/acetaminophen • Vicodin
Lithium • Eskalith, Lithobid
Lorazepam• Ativan
Nortriptyline • Pamelor
Risperidone • Risperdal
Valproic acid • Depakote
CASE Reckless driving, impulse buying
Mr. A, age 73, is admitted to the inpatient psychiatric unit at a community hospital for evaluation of a psychotic episode. His admission to the unit was initiated by his primary care physician, who noted that Mr. A was “not making sense” during a routine visit. Mr. A was speaking rapidly about how he had discovered that high-dose omega-3 fatty acid supplements were a “cure” for Alzheimer’s disease. He also believes that he was recently appointed as CEO of Microsoft and Apple for his discoveries.
Three months earlier, Mr. A had started taking high doses of omega-3 fatty acid supplements (10 to 15 g/d) because he believed they were the cure for memory problems, pain, and depression. At that time, he discontinued taking nortriptyline, 25 mg/d, and citalopram, 40 mg/d, which his outpatient psychiatrist had prescribed for major depressive disorder (MDD). Mr. A also had stopped taking buprenorphine, 2 mg, sublingual, 4 times a day, which he had been prescribed for chronic pain.
Mr. A’s wife reports that during the last 2 months, her husband had become irritable, impulsive, grandiose, and was sleeping very little. She added that although her husband’s ophthalmologist had advised him to not drive due to impaired vision, he had been driving recklessly across the metropolitan area. He had also spent nearly $15,000 buying furniture and other items for their home.
In addition to MDD, Mr. A has a history of chronic kidney disease, Leber’s hereditary optic neuropathy, and chronic pain. He has been taking vitamin D3, 2,000 U/d, as a nutritional supplement.
[polldaddy:10091672]
The authors’ observations
Mr. A met the DSM-5 criteria for a manic episode (Table 11). His manic and delusional symptoms are new. He has a long-standing diagnosis of MDD, which for many years had been successfully treated with antidepressants without a manic switch. The absence of a manic switch when treated with antidepressants without a mood stabilizer suggested that Mr. A did not have bipolarity in terms of a mood disorder diathesis.2 In addition, it would be unusual for an individual to develop a new-onset or primary bipolar disorder after age 60. Individuals in this age group who present with manic symptoms for the first time are preponderantly found to have a general medical or iatrogenic cause for the emergence of these symptoms.3 Mr. A has a history of chronic kidney disease, Leber’s hereditary optic neuropathy, and chronic pain.
Typically a sedentary man, Mr. A had been exhibiting disinhibited behavior, grandiosity, insomnia, and psychosis. These symptoms began 3 months before he was admitted to the psychiatric unit, when he had started taking high doses of omega-3 fatty acid supplements.
Continue to: EVALUATION Persistent mania
EVALUATION Persistent mania
On initial examination, Mr. A is upset and irritable. He is casually dressed and well-groomed. He lacks insight and says he was brought to the hospital against his will, and it is his wife “who is the one who is crazy.” He is oriented to person, place, and time. At times he is found roaming the hallways, being intrusive, hyperverbal, and tangential with pressured speech. He is very difficult to redirect, and regularly interrupts the interview. His vital signs are stable. He walks well, with slow and steady gait, and displays no tremor or bradykinesia.
[polldaddy:10091674]
The authors’ observations
In order to rule out organic causes, a complete blood count, comprehensive metabolic panel, thyroid profile, urine drug screen, and brain MRI were ordered. No abnormalities were found. DHA and EPA levels were not measured because such testing was not available at the laboratory at the hospital.
Mania emerging after the sixth decade of life is a rare occurrence. Therefore, we made a substantial effort to try to find another cause that might explain Mr. A’s unusual presentation (Table 2).
Omega-3 fatty acid–induced mania. The major types of omega-3 polyunsaturated fatty acids are EPA and DHA and their precursor, alpha-linolenic acid (ALA). EPA and DHA are found primarily in fatty fish, such as salmon, and in fish oil supplements. Omega-3 fatty acids have beneficial anti-inflammatory, antioxidative, and neuroplastic effects.4 Having properties similar to selective serotonin reuptake inhibitors, omega-3 fatty acids are thought to help prevent depression, have few interactions with other medications, and have a lower adverse-effect burden than antidepressants. They have been found to be beneficial as a maintenance treatment and for prevention of depressive episodes in bipolar depression, but no positive association has been found for bipolar mania.5
Continue to: However, very limited evidence suggests...
However, very limited evidence suggests that omega-3 fatty acid supplements, particularly those with flaxseed oil, can induce hypomania or mania. This association was first reported by Rudin6 in 1981, and later reported in other studies.7 How omega-3 fatty acids might induce mania is unclear.
Mr. A was reportedly taking high doses of an omega-3 fatty acid supplement. We hypothesized that the antidepressant effect of this supplement may have precipitated a manic episode. Mr. A had no history of manic episodes in the past and was stable during the treatment with the outpatient psychiatrist. A first episode mania in the seventh decade of life would be highly unusual without an organic etiology. After laboratory tests found no abnormalities that would point to an organic etiology, iatrogenic causes were considered. After a review of the literature, there was anecdotal evidence for the induction of mania in clinical trials studying the effects of omega-3 supplements on affective disorders.
This led us to ask: How much omega-3 fatty acid supplements, if any, can a patient with a depressive or bipolar disorder safely take? Currently, omega-3 fatty acid supplements are not FDA-approved for the treatment of depression or bipolar disorder. However, patients may take 1.5 to 2 g/d for MDD. Further research is needed to determine the optimal dose. It is unclear at this time if omega-3 fatty acid supplementation has any benefit in the acute or maintenance treatment of bipolar disorder.
Alternative nutritional supplements for mood disorders. Traditionally, mood disorders, such as MDD and bipolar disorder, have been treated with psychotropic medications. However, through the years, sporadic studies have examined the efficacy of nutritional interventions as a cost-effective approach to preventing and treating these conditions.5 Proponents of this approach believe such supplements can increase efficacy, as well as decrease the required dose of psychotropic medications, thus potentially minimizing adverse effects. However, their overuse can pose a potential threat of toxicity or unexpected adverse effects, such as precipitation of mania. Table 38 lists over-the-counter nutritional and/or herbal agents that may cause mania.
Continue to: TREATMENT Nonadherence leads to a court order
TREATMENT Nonadherence leads to a court order
On admission, Mr. A receives a dose of
[polldaddy:10091676]
The authors’ observations
During an acute manic episode, the goal of treatment is urgent mood stabilization. Monotherapy can be used; however, in emergent settings, a combination is often used for a rapid response. The most commonly used agents are lithium, anticonvulsants such as valproic acid, and antipsychotics.9 In addition, benzodiazepines can be used for insomnia, agitation, or anxiety. The decision to use lithium, an anticonvulsant, or an antipsychotic depends upon the specific medication’s adverse effects, the patient’s medical history, previous medication trials, drug–drug interactions, patient preference, and cost.
Because Mr. A has a history of chronic kidney disease, lithium was contraindicated.
[polldaddy:10091678]
Continue to: The authors' observations
The authors’ observations
After the acute episode of mania resolves, maintenance pharmacotherapy typically involves continuing the same regimen that achieved mood stabilization. Monotherapy is typically preferred to combination therapy, but it is not always possible after a manic episode.10 A reasonable approach is to slowly taper the antipsychotic after several months of dual therapy if symptoms continue to be well-controlled. Further adjustments may be necessary, depending on the medications’ adverse effects. Moreover, further acute episodes of mania or depression will also determine future treatment.
OUTCOME Resolution of delusions
Mr. A is discharged 30 days after admission. At this point, his acute manic episode has resolved with non-tangential, non-pressured speech, improved sleep, and decreased impulsivity. His grandiose delusions also have resolved. He is prescribed valproic acid, 1,000 mg/d, and risperidone, 6 mg/d at bedtime, under the care of his outpatient psychiatrist.
Bottom Line
Initial presentation of a manic episode in an older patient is rare. It is important to rule out organic causes. Weak evidence suggests omega-3 fatty acid supplements may have the potential to induce mania in certain patients.
Related Resource
- Ramaswamy S, Driscoll D, Rodriguez A, et al. Nutraceuticals for traumatic brain injury: Should you recommend their use? Current Psychiatry. 2017;16(7):34-38,40,41-45.
Drug Brand Names
Buprenorphine • Suboxone, Subutex
Citalopram • Celexa
Hydrocodone/acetaminophen • Vicodin
Lithium • Eskalith, Lithobid
Lorazepam• Ativan
Nortriptyline • Pamelor
Risperidone • Risperdal
Valproic acid • Depakote
1. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Goodwin GM, Haddad PM, Ferrier IN, et al. Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30(6):495-553.
3. Sami M, Khan H, Nilforooshan R. Late onset mania as an organic syndrome: a review of case reports in the literature. J Affect Disord. 2015:188:226-231.
4. Su KP, Matsuoka Y, Pae CU. Omega-3 polyunsaturated fatty acids in prevention of mood and anxiety disorders. Clin Psychopharmacol Neurosci. 2015;13(2):129-137.
5. Sarris J, Mischoulon D, Schweitzer I. Omega-3 for bipolar disorder: meta-analyses of use in mania and bipolar depression. J Clin Psychiatry. 2012;73(1):81-86.
6. Rudin DO. The major psychoses and neuroses as omega-3 essential fatty acid deficiency syndrome: substrate pellagra. Biol Psychiatry. 1981;16(9):837-850.
7. Su KP, Shen WW, Huang SY. Are omega3 fatty acids beneficial in depression but not mania? Arch Gen Psychiatry. 2000;57(7):716-717.
8. Joshi K, Faubion M. Mania and psychosis associated with St. John’s wort and ginseng. Psychiatry (Edgmont). 2005;2(9):56-61.
9. Grunze H, Vieta E, Goodwin GM, et al. The world federation of societies of biological psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treatment of acute mania. World J Biol Psychiatry. 2009;10(2):85-116.
10. Suppes T, Vieta E, Liu S, et al; Trial 127 Investigators. Maintenance treatment for patients with bipolar I disorder: results from a North American study of quetiapine in combination with lithium or divalproex (trial 127). Am J Psychiatry. 2009;166(4):476-488.
1. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Goodwin GM, Haddad PM, Ferrier IN, et al. Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30(6):495-553.
3. Sami M, Khan H, Nilforooshan R. Late onset mania as an organic syndrome: a review of case reports in the literature. J Affect Disord. 2015:188:226-231.
4. Su KP, Matsuoka Y, Pae CU. Omega-3 polyunsaturated fatty acids in prevention of mood and anxiety disorders. Clin Psychopharmacol Neurosci. 2015;13(2):129-137.
5. Sarris J, Mischoulon D, Schweitzer I. Omega-3 for bipolar disorder: meta-analyses of use in mania and bipolar depression. J Clin Psychiatry. 2012;73(1):81-86.
6. Rudin DO. The major psychoses and neuroses as omega-3 essential fatty acid deficiency syndrome: substrate pellagra. Biol Psychiatry. 1981;16(9):837-850.
7. Su KP, Shen WW, Huang SY. Are omega3 fatty acids beneficial in depression but not mania? Arch Gen Psychiatry. 2000;57(7):716-717.
8. Joshi K, Faubion M. Mania and psychosis associated with St. John’s wort and ginseng. Psychiatry (Edgmont). 2005;2(9):56-61.
9. Grunze H, Vieta E, Goodwin GM, et al. The world federation of societies of biological psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treatment of acute mania. World J Biol Psychiatry. 2009;10(2):85-116.
10. Suppes T, Vieta E, Liu S, et al; Trial 127 Investigators. Maintenance treatment for patients with bipolar I disorder: results from a North American study of quetiapine in combination with lithium or divalproex (trial 127). Am J Psychiatry. 2009;166(4):476-488.
Outpatient costs soar for Medicare patients with chronic hepatitis B
The average cost of outpatient care for Medicare recipients with chronic hepatitis B (CH-B) rose by 400% from 2005 to 2014, according to investigators.
Inpatient costs also increased, although less dramatically, reported lead author Min Kim, MD, of the Inova Fairfax Hospital Center for Liver Diseases in Falls Church, Virginia, and her colleagues. The causes of these spending hikes may range from policy changes and expanded screening to an aging immigrant population.
“According to the National Health and Nutrition Examination Survey, from 1988 to 2012 most people with CH-B in the United States were foreign born and accounted for up to 70% of all CH-B infections,” the authors wrote in the Journal of Clinical Gastroenterology. “The Centers for Disease Control [and Prevention] estimates that Asians, who comprise 5% of the U.S. population, account for 50% of all chronic CH-B infections.” Despite these statistics, the clinical and economic impacts of an aging immigrant population are unknown. The investigators therefore assessed patient characteristics associated with increased 1-year mortality and the impact of demographic changes on Medicare costs.
The retrospective study began with a random sample of Medicare beneficiaries from 2005 to 2014. From this group, 18,603 patients with CH-B were identified by ICD-9 codes V02.61, 070.2, 070.3, 070.42, and 070.52. Patients with ICD-9-CM codes of 197.7, 155.1, or 155.2 were excluded, as were records containing insufficient information about year, region, or race. Patients were analyzed collectively and as inpatients (n = 6,550) or outpatients (n = 13,648).
Cost of care (per patient, per year) and 1-year mortality were evaluated. Patient characteristics included age, sex, race/ethnicity, geographic region, type of Medicare eligibility, length of stay, Charlson comorbidity index, presence of decompensated cirrhosis, and/or hepatocellular carcinoma (HCC).
Most dramatically, outpatient charges rose more than 400% during the study period, from $9,257 in 2005 to $47,864 in 2014 (P less than .001). Inpatient charges increased by almost 50%, from $66,610 to $94,221 (P less than .001). (All values converted to 2016 dollars.)
Although the increase in outpatient costs appears seismic, the authors noted that costs held steady from 2005 to 2010 before spiking dramatically, reaching a peak of $58,450 in 2013 before settling down to $47,864 the following year. This spike may be caused by changes in screening measures and policies. In 2009, the American Association for the Study of Liver Diseases expanded screening guidelines to include previously ineligible patients with CH-B, and in 2010, the Centers for Medicare & Medicaid Services expanded ICD-9 and ICD-10 codes for CH-B from 9 to 25.
“It seems plausible that the increase in CH-B prevalence, and its associated costs, might actually be a reflection of [these factors],” the authors noted. Still, “additional studies are needed to clarify this observation.”
Turning to patient characteristics, the authors reported that 1-year mortality was independently associated most strongly with decompensated cirrhosis (odds ratio, 3.02) and hepatocellular carcinoma (OR, 2.64). In comparison with white patients, Asians were less likely to die (OR, 0.47).
“It is possible that this can be explained through differences in transmission mode and disease progression of CH-B between these two demographics,” the authors wrote. “A majority of Asian Medicare recipients with CH-B likely acquired it perinatally and did not develop significant liver disease. In contrast, whites with CH-B generally acquired it in adulthood, increasing the chance of developing liver disease.”
Over the 10-year study period, Medicare beneficiaries with CH-B became more frequently Asian and less frequently male. While the number of outpatient visits and average Charlson comorbidity index increased, decreases were reported for length of stay, rates of 1-year mortality, hospitalization, and HCC – the latter of which is most closely associated with higher costs of care.
The investigators suggested that the decreased incidence of HCC was caused by “better screening programs for HCC and/or more widespread use of antiviral treatment for CH-B.”
“Although advances in antiviral treatment have effectively reduced hospitalization and disease progression,” the authors wrote, “vulnerable groups – especially immigrants and individuals living in poverty – present an important challenge for better identification of infected individuals and their linkage to care. In this context, it is vital to target these cohorts to reduce further mortality and resource utilization, as well as optimize long-term public health and financial benefits.”
Study funding was provided by Seattle Genetics. One coauthor reported compensation from Gilead Sciences, AbbVie, Intercept Pharmaceuticals, GlaxoSmithKline, and Bristol-Myers Squibb.
SOURCE: Kim M et al. J Clin Gastro. 2018 Aug 13. doi: 10.1097/MCG.0000000000001110.
The average cost of outpatient care for Medicare recipients with chronic hepatitis B (CH-B) rose by 400% from 2005 to 2014, according to investigators.
Inpatient costs also increased, although less dramatically, reported lead author Min Kim, MD, of the Inova Fairfax Hospital Center for Liver Diseases in Falls Church, Virginia, and her colleagues. The causes of these spending hikes may range from policy changes and expanded screening to an aging immigrant population.
“According to the National Health and Nutrition Examination Survey, from 1988 to 2012 most people with CH-B in the United States were foreign born and accounted for up to 70% of all CH-B infections,” the authors wrote in the Journal of Clinical Gastroenterology. “The Centers for Disease Control [and Prevention] estimates that Asians, who comprise 5% of the U.S. population, account for 50% of all chronic CH-B infections.” Despite these statistics, the clinical and economic impacts of an aging immigrant population are unknown. The investigators therefore assessed patient characteristics associated with increased 1-year mortality and the impact of demographic changes on Medicare costs.
The retrospective study began with a random sample of Medicare beneficiaries from 2005 to 2014. From this group, 18,603 patients with CH-B were identified by ICD-9 codes V02.61, 070.2, 070.3, 070.42, and 070.52. Patients with ICD-9-CM codes of 197.7, 155.1, or 155.2 were excluded, as were records containing insufficient information about year, region, or race. Patients were analyzed collectively and as inpatients (n = 6,550) or outpatients (n = 13,648).
Cost of care (per patient, per year) and 1-year mortality were evaluated. Patient characteristics included age, sex, race/ethnicity, geographic region, type of Medicare eligibility, length of stay, Charlson comorbidity index, presence of decompensated cirrhosis, and/or hepatocellular carcinoma (HCC).
Most dramatically, outpatient charges rose more than 400% during the study period, from $9,257 in 2005 to $47,864 in 2014 (P less than .001). Inpatient charges increased by almost 50%, from $66,610 to $94,221 (P less than .001). (All values converted to 2016 dollars.)
Although the increase in outpatient costs appears seismic, the authors noted that costs held steady from 2005 to 2010 before spiking dramatically, reaching a peak of $58,450 in 2013 before settling down to $47,864 the following year. This spike may be caused by changes in screening measures and policies. In 2009, the American Association for the Study of Liver Diseases expanded screening guidelines to include previously ineligible patients with CH-B, and in 2010, the Centers for Medicare & Medicaid Services expanded ICD-9 and ICD-10 codes for CH-B from 9 to 25.
“It seems plausible that the increase in CH-B prevalence, and its associated costs, might actually be a reflection of [these factors],” the authors noted. Still, “additional studies are needed to clarify this observation.”
Turning to patient characteristics, the authors reported that 1-year mortality was independently associated most strongly with decompensated cirrhosis (odds ratio, 3.02) and hepatocellular carcinoma (OR, 2.64). In comparison with white patients, Asians were less likely to die (OR, 0.47).
“It is possible that this can be explained through differences in transmission mode and disease progression of CH-B between these two demographics,” the authors wrote. “A majority of Asian Medicare recipients with CH-B likely acquired it perinatally and did not develop significant liver disease. In contrast, whites with CH-B generally acquired it in adulthood, increasing the chance of developing liver disease.”
Over the 10-year study period, Medicare beneficiaries with CH-B became more frequently Asian and less frequently male. While the number of outpatient visits and average Charlson comorbidity index increased, decreases were reported for length of stay, rates of 1-year mortality, hospitalization, and HCC – the latter of which is most closely associated with higher costs of care.
The investigators suggested that the decreased incidence of HCC was caused by “better screening programs for HCC and/or more widespread use of antiviral treatment for CH-B.”
“Although advances in antiviral treatment have effectively reduced hospitalization and disease progression,” the authors wrote, “vulnerable groups – especially immigrants and individuals living in poverty – present an important challenge for better identification of infected individuals and their linkage to care. In this context, it is vital to target these cohorts to reduce further mortality and resource utilization, as well as optimize long-term public health and financial benefits.”
Study funding was provided by Seattle Genetics. One coauthor reported compensation from Gilead Sciences, AbbVie, Intercept Pharmaceuticals, GlaxoSmithKline, and Bristol-Myers Squibb.
SOURCE: Kim M et al. J Clin Gastro. 2018 Aug 13. doi: 10.1097/MCG.0000000000001110.
The average cost of outpatient care for Medicare recipients with chronic hepatitis B (CH-B) rose by 400% from 2005 to 2014, according to investigators.
Inpatient costs also increased, although less dramatically, reported lead author Min Kim, MD, of the Inova Fairfax Hospital Center for Liver Diseases in Falls Church, Virginia, and her colleagues. The causes of these spending hikes may range from policy changes and expanded screening to an aging immigrant population.
“According to the National Health and Nutrition Examination Survey, from 1988 to 2012 most people with CH-B in the United States were foreign born and accounted for up to 70% of all CH-B infections,” the authors wrote in the Journal of Clinical Gastroenterology. “The Centers for Disease Control [and Prevention] estimates that Asians, who comprise 5% of the U.S. population, account for 50% of all chronic CH-B infections.” Despite these statistics, the clinical and economic impacts of an aging immigrant population are unknown. The investigators therefore assessed patient characteristics associated with increased 1-year mortality and the impact of demographic changes on Medicare costs.
The retrospective study began with a random sample of Medicare beneficiaries from 2005 to 2014. From this group, 18,603 patients with CH-B were identified by ICD-9 codes V02.61, 070.2, 070.3, 070.42, and 070.52. Patients with ICD-9-CM codes of 197.7, 155.1, or 155.2 were excluded, as were records containing insufficient information about year, region, or race. Patients were analyzed collectively and as inpatients (n = 6,550) or outpatients (n = 13,648).
Cost of care (per patient, per year) and 1-year mortality were evaluated. Patient characteristics included age, sex, race/ethnicity, geographic region, type of Medicare eligibility, length of stay, Charlson comorbidity index, presence of decompensated cirrhosis, and/or hepatocellular carcinoma (HCC).
Most dramatically, outpatient charges rose more than 400% during the study period, from $9,257 in 2005 to $47,864 in 2014 (P less than .001). Inpatient charges increased by almost 50%, from $66,610 to $94,221 (P less than .001). (All values converted to 2016 dollars.)
Although the increase in outpatient costs appears seismic, the authors noted that costs held steady from 2005 to 2010 before spiking dramatically, reaching a peak of $58,450 in 2013 before settling down to $47,864 the following year. This spike may be caused by changes in screening measures and policies. In 2009, the American Association for the Study of Liver Diseases expanded screening guidelines to include previously ineligible patients with CH-B, and in 2010, the Centers for Medicare & Medicaid Services expanded ICD-9 and ICD-10 codes for CH-B from 9 to 25.
“It seems plausible that the increase in CH-B prevalence, and its associated costs, might actually be a reflection of [these factors],” the authors noted. Still, “additional studies are needed to clarify this observation.”
Turning to patient characteristics, the authors reported that 1-year mortality was independently associated most strongly with decompensated cirrhosis (odds ratio, 3.02) and hepatocellular carcinoma (OR, 2.64). In comparison with white patients, Asians were less likely to die (OR, 0.47).
“It is possible that this can be explained through differences in transmission mode and disease progression of CH-B between these two demographics,” the authors wrote. “A majority of Asian Medicare recipients with CH-B likely acquired it perinatally and did not develop significant liver disease. In contrast, whites with CH-B generally acquired it in adulthood, increasing the chance of developing liver disease.”
Over the 10-year study period, Medicare beneficiaries with CH-B became more frequently Asian and less frequently male. While the number of outpatient visits and average Charlson comorbidity index increased, decreases were reported for length of stay, rates of 1-year mortality, hospitalization, and HCC – the latter of which is most closely associated with higher costs of care.
The investigators suggested that the decreased incidence of HCC was caused by “better screening programs for HCC and/or more widespread use of antiviral treatment for CH-B.”
“Although advances in antiviral treatment have effectively reduced hospitalization and disease progression,” the authors wrote, “vulnerable groups – especially immigrants and individuals living in poverty – present an important challenge for better identification of infected individuals and their linkage to care. In this context, it is vital to target these cohorts to reduce further mortality and resource utilization, as well as optimize long-term public health and financial benefits.”
Study funding was provided by Seattle Genetics. One coauthor reported compensation from Gilead Sciences, AbbVie, Intercept Pharmaceuticals, GlaxoSmithKline, and Bristol-Myers Squibb.
SOURCE: Kim M et al. J Clin Gastro. 2018 Aug 13. doi: 10.1097/MCG.0000000000001110.
FROM THE JOURNAL OF CLINICAL GASTROENTEROLOGY
Key clinical point: Outpatient care for patients with chronic hepatitis B is becoming more expensive; the trend may be tied to an aging immigrant population.
Major finding: The average Medicare charge for outpatient care per patient increased from $9,257 in 2005 to $47,864 in 2014 (P less than .001).
Study details: A retrospective study involving 18,603 Medicare recipients with chronic hepatitis B who filed claims between 2005 and 2014.
Disclosures: Study funding was provided by the Beatty Center for Integrated Research. One coauthor reported compensation from Gilead Sciences, AbbVie, Intercept Pharmaceuticals, GlaxoSmithKline, and Bristol-Myers Squibb.
Source: Kim M et al. J Clin Gastro. 2018 Aug 13. doi: 10.1097/MCG.0000000000001110.
Pediatric ED diagnoses vary with the season
The two most common reasons for pediatric emergency department visits exhibit considerable and opposing seasonal variations, according to the Agency for Healthcare Research and Quality.
Of the 30 million ED visits by children aged 18 years and younger during fiscal year 2015, about 9.6 million, or just under 24%, were for respiratory disorders, making it the most common diagnosis by body system. The second-most common reason, injuries, was associated with approximately 7.9 million visits in 2015, the AHRQ reported recently in a statistical brief.
Over the 4-year period from 2011 to 2015, pediatric ED visits for respiratory disorders peaked during the months from October to March and dropped during April-September. In 2015, for example, there was a 43% difference between October-December, which was the highest-volume quarter, and July-September, which had the lowest volume of visits, the report showed.
The opposite pattern of seasonality was seen with visits for injury-related visits: The high point each year occurs in April-September, with the low in October-March. In 2015, there was a 30% difference between the lowest-volume quarter of January-March and the highest-volume quarter of July-September, based on the analysis of data from the Nationwide Emergency Department Sample.
The two most common reasons for pediatric emergency department visits exhibit considerable and opposing seasonal variations, according to the Agency for Healthcare Research and Quality.
Of the 30 million ED visits by children aged 18 years and younger during fiscal year 2015, about 9.6 million, or just under 24%, were for respiratory disorders, making it the most common diagnosis by body system. The second-most common reason, injuries, was associated with approximately 7.9 million visits in 2015, the AHRQ reported recently in a statistical brief.
Over the 4-year period from 2011 to 2015, pediatric ED visits for respiratory disorders peaked during the months from October to March and dropped during April-September. In 2015, for example, there was a 43% difference between October-December, which was the highest-volume quarter, and July-September, which had the lowest volume of visits, the report showed.
The opposite pattern of seasonality was seen with visits for injury-related visits: The high point each year occurs in April-September, with the low in October-March. In 2015, there was a 30% difference between the lowest-volume quarter of January-March and the highest-volume quarter of July-September, based on the analysis of data from the Nationwide Emergency Department Sample.
The two most common reasons for pediatric emergency department visits exhibit considerable and opposing seasonal variations, according to the Agency for Healthcare Research and Quality.
Of the 30 million ED visits by children aged 18 years and younger during fiscal year 2015, about 9.6 million, or just under 24%, were for respiratory disorders, making it the most common diagnosis by body system. The second-most common reason, injuries, was associated with approximately 7.9 million visits in 2015, the AHRQ reported recently in a statistical brief.
Over the 4-year period from 2011 to 2015, pediatric ED visits for respiratory disorders peaked during the months from October to March and dropped during April-September. In 2015, for example, there was a 43% difference between October-December, which was the highest-volume quarter, and July-September, which had the lowest volume of visits, the report showed.
The opposite pattern of seasonality was seen with visits for injury-related visits: The high point each year occurs in April-September, with the low in October-March. In 2015, there was a 30% difference between the lowest-volume quarter of January-March and the highest-volume quarter of July-September, based on the analysis of data from the Nationwide Emergency Department Sample.
Social media: ‘The more you do, the easier it gets’
SAN DIEGO – , the first question to ask yourself is why.
“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”
Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”
She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”
According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.
Achieving success in social media takes patience, perseverance, and authenticity. “The more you do, the easier it gets,” said Dr. Day, who earned a master’s degree in journalism from NYU. “I have a group of people who tend to like my posts consistently, comment consistently, share consistently, and I respond consistently. That’s how you build relationships. When somebody posts, respond.”
Video content is being consumed online more than ever before, but Dr. Day emphasized that such visual content should “have a purpose and be directed to your specific audience – not just making video for the sake of it.” She recommends being selective when choosing your content, and where you post it. “Don’t stretch your brand over multiple [social media] channels if your team can’t support it.” If you thrive in a multichannel environment, BuzzBundle integrates Facebook, Twitter, Google+, LinkedIn, blogs, forums, and Q&A sites for posting with a purpose and a converged strategy across all sites.
“As with any smart strategy, make sure you are tracking your progress,” she said, suggesting AddThis analytics as one way to track how, where, and by whom your content is being shared.
Dr. Day reported having no relevant financial disclosures.
SAN DIEGO – , the first question to ask yourself is why.
“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”
Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”
She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”
According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.
Achieving success in social media takes patience, perseverance, and authenticity. “The more you do, the easier it gets,” said Dr. Day, who earned a master’s degree in journalism from NYU. “I have a group of people who tend to like my posts consistently, comment consistently, share consistently, and I respond consistently. That’s how you build relationships. When somebody posts, respond.”
Video content is being consumed online more than ever before, but Dr. Day emphasized that such visual content should “have a purpose and be directed to your specific audience – not just making video for the sake of it.” She recommends being selective when choosing your content, and where you post it. “Don’t stretch your brand over multiple [social media] channels if your team can’t support it.” If you thrive in a multichannel environment, BuzzBundle integrates Facebook, Twitter, Google+, LinkedIn, blogs, forums, and Q&A sites for posting with a purpose and a converged strategy across all sites.
“As with any smart strategy, make sure you are tracking your progress,” she said, suggesting AddThis analytics as one way to track how, where, and by whom your content is being shared.
Dr. Day reported having no relevant financial disclosures.
SAN DIEGO – , the first question to ask yourself is why.
“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”
Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”
She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”
According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.
Achieving success in social media takes patience, perseverance, and authenticity. “The more you do, the easier it gets,” said Dr. Day, who earned a master’s degree in journalism from NYU. “I have a group of people who tend to like my posts consistently, comment consistently, share consistently, and I respond consistently. That’s how you build relationships. When somebody posts, respond.”
Video content is being consumed online more than ever before, but Dr. Day emphasized that such visual content should “have a purpose and be directed to your specific audience – not just making video for the sake of it.” She recommends being selective when choosing your content, and where you post it. “Don’t stretch your brand over multiple [social media] channels if your team can’t support it.” If you thrive in a multichannel environment, BuzzBundle integrates Facebook, Twitter, Google+, LinkedIn, blogs, forums, and Q&A sites for posting with a purpose and a converged strategy across all sites.
“As with any smart strategy, make sure you are tracking your progress,” she said, suggesting AddThis analytics as one way to track how, where, and by whom your content is being shared.
Dr. Day reported having no relevant financial disclosures.
AT MOAS 2018
Reflectance confocal microscopy: The future looks bright
CHICAGO – The future looks bright for to rule out malignancy, Ann M. John, MD, asserted at the annual meeting of the American College of Mohs Surgery.
“With the advent of dermoscopy, dermatologists were able to elucidate both benign and malignant patterns to help further guide their decision to biopsy or not. This increased diagnostic accuracy of suspicious lesions by 30%, while reducing the benign to malignant ratio of biopsies performed from 18:1 to 4:1. However, there are still lesions that are equivocal on dermoscopy, as we all know, and for this, there’s reflectance confocal microscopy,” observed Dr. John, of Robert Wood Johnson Medical School, New Brunswick, N.J.
RCM is a device technology that’s been cleared by the Food and Drug Administration since 2008 for the imaging of clinically suspicious lesions. It employs laser scanning to assess the light-scattering properties of cells in the epidermis and dermis, generating images with resolution comparable to histology.
RCM took a back seat initially while American dermatologists were gradually coming to embrace dermoscopy, which their European colleagues had done years earlier. Now, with the availability of handheld RCM for use in the dermatology clinic, expect RCM to assume a growing role in daily practice.
To illustrate the power of RCM as a diagnostic aid, she presented a single-center retrospective study of 1,189 clinically suspicious skin lesions that were equivocal on dermoscopy and then assessed using RCM with 1 year of subsequent patient follow-up. Overall, 155 lesions were deemed positive for cancer or atypia by RCM, while 1,034 were determined to be benign. Of those 155, 46 lesions were considered false positives because of their benign appearance on histologic inspection of the biopsy sample. Only 2 of the 1,034 lesions identified as negative by RCM proved to be false negatives on the basis of clinical changes within 1 year.
The overall sensitivity and specificity of RCM was 98.2% and 99.8%, respectively, with a positive predictive value of 70.3% and a negative predictive value of 99.8%.
The entire RCM procedure takes a skilled technician 15-20 minutes per lesion. As a practical matter, other investigators have estimated that RCM results in a cost savings of about $308,000 per million health plan members per year by reducing the need for biopsies (Dermatol Clin. 2016 Oct;34[4]:367-75).
In addition to evaluating clinically suspicious lesions, other situations in which RCM offers practical value include its use directly before the first cut during Mohs surgery in order to determine the margins of atypia; ex vivo imaging of Mohs margins, which has been shown to be comparable with frozen sections in accuracy but takes only one-third of the time; and imaging of biopsied lesions in order to determine the diagnosis relatively quickly, Dr. John noted.
She reported having no financial conflicts regarding her study.
CHICAGO – The future looks bright for to rule out malignancy, Ann M. John, MD, asserted at the annual meeting of the American College of Mohs Surgery.
“With the advent of dermoscopy, dermatologists were able to elucidate both benign and malignant patterns to help further guide their decision to biopsy or not. This increased diagnostic accuracy of suspicious lesions by 30%, while reducing the benign to malignant ratio of biopsies performed from 18:1 to 4:1. However, there are still lesions that are equivocal on dermoscopy, as we all know, and for this, there’s reflectance confocal microscopy,” observed Dr. John, of Robert Wood Johnson Medical School, New Brunswick, N.J.
RCM is a device technology that’s been cleared by the Food and Drug Administration since 2008 for the imaging of clinically suspicious lesions. It employs laser scanning to assess the light-scattering properties of cells in the epidermis and dermis, generating images with resolution comparable to histology.
RCM took a back seat initially while American dermatologists were gradually coming to embrace dermoscopy, which their European colleagues had done years earlier. Now, with the availability of handheld RCM for use in the dermatology clinic, expect RCM to assume a growing role in daily practice.
To illustrate the power of RCM as a diagnostic aid, she presented a single-center retrospective study of 1,189 clinically suspicious skin lesions that were equivocal on dermoscopy and then assessed using RCM with 1 year of subsequent patient follow-up. Overall, 155 lesions were deemed positive for cancer or atypia by RCM, while 1,034 were determined to be benign. Of those 155, 46 lesions were considered false positives because of their benign appearance on histologic inspection of the biopsy sample. Only 2 of the 1,034 lesions identified as negative by RCM proved to be false negatives on the basis of clinical changes within 1 year.
The overall sensitivity and specificity of RCM was 98.2% and 99.8%, respectively, with a positive predictive value of 70.3% and a negative predictive value of 99.8%.
The entire RCM procedure takes a skilled technician 15-20 minutes per lesion. As a practical matter, other investigators have estimated that RCM results in a cost savings of about $308,000 per million health plan members per year by reducing the need for biopsies (Dermatol Clin. 2016 Oct;34[4]:367-75).
In addition to evaluating clinically suspicious lesions, other situations in which RCM offers practical value include its use directly before the first cut during Mohs surgery in order to determine the margins of atypia; ex vivo imaging of Mohs margins, which has been shown to be comparable with frozen sections in accuracy but takes only one-third of the time; and imaging of biopsied lesions in order to determine the diagnosis relatively quickly, Dr. John noted.
She reported having no financial conflicts regarding her study.
CHICAGO – The future looks bright for to rule out malignancy, Ann M. John, MD, asserted at the annual meeting of the American College of Mohs Surgery.
“With the advent of dermoscopy, dermatologists were able to elucidate both benign and malignant patterns to help further guide their decision to biopsy or not. This increased diagnostic accuracy of suspicious lesions by 30%, while reducing the benign to malignant ratio of biopsies performed from 18:1 to 4:1. However, there are still lesions that are equivocal on dermoscopy, as we all know, and for this, there’s reflectance confocal microscopy,” observed Dr. John, of Robert Wood Johnson Medical School, New Brunswick, N.J.
RCM is a device technology that’s been cleared by the Food and Drug Administration since 2008 for the imaging of clinically suspicious lesions. It employs laser scanning to assess the light-scattering properties of cells in the epidermis and dermis, generating images with resolution comparable to histology.
RCM took a back seat initially while American dermatologists were gradually coming to embrace dermoscopy, which their European colleagues had done years earlier. Now, with the availability of handheld RCM for use in the dermatology clinic, expect RCM to assume a growing role in daily practice.
To illustrate the power of RCM as a diagnostic aid, she presented a single-center retrospective study of 1,189 clinically suspicious skin lesions that were equivocal on dermoscopy and then assessed using RCM with 1 year of subsequent patient follow-up. Overall, 155 lesions were deemed positive for cancer or atypia by RCM, while 1,034 were determined to be benign. Of those 155, 46 lesions were considered false positives because of their benign appearance on histologic inspection of the biopsy sample. Only 2 of the 1,034 lesions identified as negative by RCM proved to be false negatives on the basis of clinical changes within 1 year.
The overall sensitivity and specificity of RCM was 98.2% and 99.8%, respectively, with a positive predictive value of 70.3% and a negative predictive value of 99.8%.
The entire RCM procedure takes a skilled technician 15-20 minutes per lesion. As a practical matter, other investigators have estimated that RCM results in a cost savings of about $308,000 per million health plan members per year by reducing the need for biopsies (Dermatol Clin. 2016 Oct;34[4]:367-75).
In addition to evaluating clinically suspicious lesions, other situations in which RCM offers practical value include its use directly before the first cut during Mohs surgery in order to determine the margins of atypia; ex vivo imaging of Mohs margins, which has been shown to be comparable with frozen sections in accuracy but takes only one-third of the time; and imaging of biopsied lesions in order to determine the diagnosis relatively quickly, Dr. John noted.
She reported having no financial conflicts regarding her study.
REPORTING FROM THE ACMS ANNUAL MEETING
Key clinical point: The future looks bright for reflectance confocal microscopy in dermatology.
Major finding: The sensitivity and specificity of reflectance confocal microscopy for diagnosis of skin cancer in patients with equivocal dermoscopic findings was 98.2% and 99.8%, respectively.
Study details: This retrospective single center study included 1,189 clinically suspicious skin lesions with equivocal dermoscopy findings, which were then evaluated using reflectance confocal microscopy.
Disclosures: The presenter reported having no financial conflicts regarding her study.
Mohs underutilized for melanoma of head and neck
CHICAGO – Contemporary national guidelines undervalue the benefits of Mohs micrographic surgery for patients with melanoma of the head and neck, William C. Fix asserted at the annual meeting of the American College of Mohs Surgery.
Mr. Fix, a medical student at the University of Pennsylvania, Philadelphia, presented a single-center retrospective study of 13,644 cases of head and neck skin cancer treated with Mohs micrographic surgery (MMS) for margin control. The cohort included 1,065 melanomas in situ, 410 invasive melanomas, more than 8,700 basal cell carcinomas, and 3,343 squamous cell carcinomas.
Mr. Fix and his coinvestigators undertook this observational study because they identified a gap in current guidelines for treatment of skin cancers of the head and neck. For example, the National Comprehensive Cancer Network recommends margin control at the time of primary surgery for BCCs and SCCs deemed at high risk for local recurrence and defines what those high-risk features are. For melanomas, however, the guidelines recommend wide local excision, even though that approach has roughly a 10% recurrence rate, compared with less than 1% for MMS.
Moreover, the 2012 appropriate use criteria for MMS put forth by the American Academy of Dermatology in concert with several other medical societies are unclear about invasive melanoma. As a result of this lack of guidance, the use of margin control in primary surgery for melanoma is applied in less than 4% of cases, according to Mr. Fix.
The University of Pennsylvania data he presented showed that melanomas of the head and neck were significantly more likely to be large in size, to be poorly defined, and to have other high-risk features for local recurrence than were the BCCs and SCCs. In a multivariate logistic regression analysis controlling for high-risk characteristics, melanomas were independently associated with a twofold increased likelihood of requiring flap reconstruction compared with BCCs and SCCs of the head and neck.
“We’ve shown that melanomas have high-risk features for local recurrence, possibly to a greater extent than BCCs and SCCs. These features help us triage resource use for BCC and SCC. Could these same features help us make decisions for melanomas?” he asked rhetorically.
Mr. Fix reported having no financial conflicts of interest regarding his study, which was conducted free of commercial support.
CHICAGO – Contemporary national guidelines undervalue the benefits of Mohs micrographic surgery for patients with melanoma of the head and neck, William C. Fix asserted at the annual meeting of the American College of Mohs Surgery.
Mr. Fix, a medical student at the University of Pennsylvania, Philadelphia, presented a single-center retrospective study of 13,644 cases of head and neck skin cancer treated with Mohs micrographic surgery (MMS) for margin control. The cohort included 1,065 melanomas in situ, 410 invasive melanomas, more than 8,700 basal cell carcinomas, and 3,343 squamous cell carcinomas.
Mr. Fix and his coinvestigators undertook this observational study because they identified a gap in current guidelines for treatment of skin cancers of the head and neck. For example, the National Comprehensive Cancer Network recommends margin control at the time of primary surgery for BCCs and SCCs deemed at high risk for local recurrence and defines what those high-risk features are. For melanomas, however, the guidelines recommend wide local excision, even though that approach has roughly a 10% recurrence rate, compared with less than 1% for MMS.
Moreover, the 2012 appropriate use criteria for MMS put forth by the American Academy of Dermatology in concert with several other medical societies are unclear about invasive melanoma. As a result of this lack of guidance, the use of margin control in primary surgery for melanoma is applied in less than 4% of cases, according to Mr. Fix.
The University of Pennsylvania data he presented showed that melanomas of the head and neck were significantly more likely to be large in size, to be poorly defined, and to have other high-risk features for local recurrence than were the BCCs and SCCs. In a multivariate logistic regression analysis controlling for high-risk characteristics, melanomas were independently associated with a twofold increased likelihood of requiring flap reconstruction compared with BCCs and SCCs of the head and neck.
“We’ve shown that melanomas have high-risk features for local recurrence, possibly to a greater extent than BCCs and SCCs. These features help us triage resource use for BCC and SCC. Could these same features help us make decisions for melanomas?” he asked rhetorically.
Mr. Fix reported having no financial conflicts of interest regarding his study, which was conducted free of commercial support.
CHICAGO – Contemporary national guidelines undervalue the benefits of Mohs micrographic surgery for patients with melanoma of the head and neck, William C. Fix asserted at the annual meeting of the American College of Mohs Surgery.
Mr. Fix, a medical student at the University of Pennsylvania, Philadelphia, presented a single-center retrospective study of 13,644 cases of head and neck skin cancer treated with Mohs micrographic surgery (MMS) for margin control. The cohort included 1,065 melanomas in situ, 410 invasive melanomas, more than 8,700 basal cell carcinomas, and 3,343 squamous cell carcinomas.
Mr. Fix and his coinvestigators undertook this observational study because they identified a gap in current guidelines for treatment of skin cancers of the head and neck. For example, the National Comprehensive Cancer Network recommends margin control at the time of primary surgery for BCCs and SCCs deemed at high risk for local recurrence and defines what those high-risk features are. For melanomas, however, the guidelines recommend wide local excision, even though that approach has roughly a 10% recurrence rate, compared with less than 1% for MMS.
Moreover, the 2012 appropriate use criteria for MMS put forth by the American Academy of Dermatology in concert with several other medical societies are unclear about invasive melanoma. As a result of this lack of guidance, the use of margin control in primary surgery for melanoma is applied in less than 4% of cases, according to Mr. Fix.
The University of Pennsylvania data he presented showed that melanomas of the head and neck were significantly more likely to be large in size, to be poorly defined, and to have other high-risk features for local recurrence than were the BCCs and SCCs. In a multivariate logistic regression analysis controlling for high-risk characteristics, melanomas were independently associated with a twofold increased likelihood of requiring flap reconstruction compared with BCCs and SCCs of the head and neck.
“We’ve shown that melanomas have high-risk features for local recurrence, possibly to a greater extent than BCCs and SCCs. These features help us triage resource use for BCC and SCC. Could these same features help us make decisions for melanomas?” he asked rhetorically.
Mr. Fix reported having no financial conflicts of interest regarding his study, which was conducted free of commercial support.
REPORTING FROM THE ACMS ANNUAL MEETING
Key clinical point: Margin control at the time of primary surgery for melanoma of the head and neck makes sense.
Major finding: Patients with a melanoma of the head and neck were twice as likely to require secondary flap reconstruction compared with patients with a basal cell carcinoma or squamous cell carcinoma of the head and neck.
Study details: A retrospective single-center study of 13,644 cases of skin cancer of the head and neck treated with Mohs surgery.
Disclosures: The presenter reported having no financial conflicts regarding the study, which was conducted free of commercial support.
One-quarter of ED sprained ankle diagnoses result in opioid prescription
One-quarter of patients who present at the ED with a , according to the findings of a large study using a national insurance claims database.
M. Kit Delgado, MD, of the Center for Emergency Care Policy and Research at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, and his coauthors analyzed private insurance claims for 30,832 opioid-naive patients who were treated in the emergency department for ankle sprains.
The researchers looked at the initial opioid prescription intensity and duration of subsequent opioid use. The study, published online in Annals of Emergency Medicine, also found a wide variation in prescribing by hospital and geographic region, and an association between higher-potency opioid prescriptions (hydrocodone and oxycodone) and likelihood of extended or prolonged opioid use.
Overall, 25.1% of patients received an opioid prescription, the median tablet quantity was 15 tablets, and median days of opioids supplied was 3 days. Only 5% of patients were prescribed more than 30 tablets, which suggested that the majority of prescriptions written were in agreement with guidelines, the authors wrote.
They noted that nonsteroidal anti-inflammatory drugs are the first-line treatment for ankle sprains, rather than opioids, and are as effective for pain reduction.
Among patients prescribed the equivalent of more than 30 tabs of oxycodone 5 mg, 4.9% of them showed prolonged opioid use – defined as filling four or more subsequent opioid prescriptions in the 30-180 days after the index visit – compared with 1.1% of patients who received fewer than 10 tabs, and 0.5% of those who did not fill an opioid prescription. This represented a nearly fivefold increased probability of transition to prolonged use. For every 26 patients exposed to the higher intensity prescription, 1 would go on to prolonged opioid use.
“We confirmed that the majority of subsequent prescriptions were unlikely to be related to the initial ankle sprain or chronic ankle pain,” the researchers wrote. “This suggests that association between larger prescriptions and increased likelihood of prolonged use could be due to other factors such as patients requesting opioids as default pain control, or the development of dependence or misuse.”
The most commonly prescribed opioid was hydrocodone (64.9%), followed by tramadol (16.2%), oxycodone (14.4%), and codeine (5.5%). The analysis found that patients prescribed higher-potency drugs – namely hydrocodone and oxycodone – were at even greater risk of developing prolonged use.
The researchers noted significant geographic differences in prescribing habits, with 40% of study participants in Arkansas receiving an opioid prescription, compared with 2.8% in North Dakota. Overall, southern states were more likely to overprescribe, and northern states more likely to underprescribe.
Women were at greater risk of transitioning to high-risk prolonged use, as were individuals aged 35-44 years, those with a higher comorbidity burden, or those with a history of drug abuse.
The study was supported by the National Institute on Drug Abuse, the National Institute of Child Health and Human Development, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania. One author declared an honorarium from the United Health Group.
SOURCE: Delgado MK et al. Ann Emerg Med. 2018. Jul 24. doi: 10.1016/j.annemergmed.2018.06.003.
One-quarter of patients who present at the ED with a , according to the findings of a large study using a national insurance claims database.
M. Kit Delgado, MD, of the Center for Emergency Care Policy and Research at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, and his coauthors analyzed private insurance claims for 30,832 opioid-naive patients who were treated in the emergency department for ankle sprains.
The researchers looked at the initial opioid prescription intensity and duration of subsequent opioid use. The study, published online in Annals of Emergency Medicine, also found a wide variation in prescribing by hospital and geographic region, and an association between higher-potency opioid prescriptions (hydrocodone and oxycodone) and likelihood of extended or prolonged opioid use.
Overall, 25.1% of patients received an opioid prescription, the median tablet quantity was 15 tablets, and median days of opioids supplied was 3 days. Only 5% of patients were prescribed more than 30 tablets, which suggested that the majority of prescriptions written were in agreement with guidelines, the authors wrote.
They noted that nonsteroidal anti-inflammatory drugs are the first-line treatment for ankle sprains, rather than opioids, and are as effective for pain reduction.
Among patients prescribed the equivalent of more than 30 tabs of oxycodone 5 mg, 4.9% of them showed prolonged opioid use – defined as filling four or more subsequent opioid prescriptions in the 30-180 days after the index visit – compared with 1.1% of patients who received fewer than 10 tabs, and 0.5% of those who did not fill an opioid prescription. This represented a nearly fivefold increased probability of transition to prolonged use. For every 26 patients exposed to the higher intensity prescription, 1 would go on to prolonged opioid use.
“We confirmed that the majority of subsequent prescriptions were unlikely to be related to the initial ankle sprain or chronic ankle pain,” the researchers wrote. “This suggests that association between larger prescriptions and increased likelihood of prolonged use could be due to other factors such as patients requesting opioids as default pain control, or the development of dependence or misuse.”
The most commonly prescribed opioid was hydrocodone (64.9%), followed by tramadol (16.2%), oxycodone (14.4%), and codeine (5.5%). The analysis found that patients prescribed higher-potency drugs – namely hydrocodone and oxycodone – were at even greater risk of developing prolonged use.
The researchers noted significant geographic differences in prescribing habits, with 40% of study participants in Arkansas receiving an opioid prescription, compared with 2.8% in North Dakota. Overall, southern states were more likely to overprescribe, and northern states more likely to underprescribe.
Women were at greater risk of transitioning to high-risk prolonged use, as were individuals aged 35-44 years, those with a higher comorbidity burden, or those with a history of drug abuse.
The study was supported by the National Institute on Drug Abuse, the National Institute of Child Health and Human Development, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania. One author declared an honorarium from the United Health Group.
SOURCE: Delgado MK et al. Ann Emerg Med. 2018. Jul 24. doi: 10.1016/j.annemergmed.2018.06.003.
One-quarter of patients who present at the ED with a , according to the findings of a large study using a national insurance claims database.
M. Kit Delgado, MD, of the Center for Emergency Care Policy and Research at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, and his coauthors analyzed private insurance claims for 30,832 opioid-naive patients who were treated in the emergency department for ankle sprains.
The researchers looked at the initial opioid prescription intensity and duration of subsequent opioid use. The study, published online in Annals of Emergency Medicine, also found a wide variation in prescribing by hospital and geographic region, and an association between higher-potency opioid prescriptions (hydrocodone and oxycodone) and likelihood of extended or prolonged opioid use.
Overall, 25.1% of patients received an opioid prescription, the median tablet quantity was 15 tablets, and median days of opioids supplied was 3 days. Only 5% of patients were prescribed more than 30 tablets, which suggested that the majority of prescriptions written were in agreement with guidelines, the authors wrote.
They noted that nonsteroidal anti-inflammatory drugs are the first-line treatment for ankle sprains, rather than opioids, and are as effective for pain reduction.
Among patients prescribed the equivalent of more than 30 tabs of oxycodone 5 mg, 4.9% of them showed prolonged opioid use – defined as filling four or more subsequent opioid prescriptions in the 30-180 days after the index visit – compared with 1.1% of patients who received fewer than 10 tabs, and 0.5% of those who did not fill an opioid prescription. This represented a nearly fivefold increased probability of transition to prolonged use. For every 26 patients exposed to the higher intensity prescription, 1 would go on to prolonged opioid use.
“We confirmed that the majority of subsequent prescriptions were unlikely to be related to the initial ankle sprain or chronic ankle pain,” the researchers wrote. “This suggests that association between larger prescriptions and increased likelihood of prolonged use could be due to other factors such as patients requesting opioids as default pain control, or the development of dependence or misuse.”
The most commonly prescribed opioid was hydrocodone (64.9%), followed by tramadol (16.2%), oxycodone (14.4%), and codeine (5.5%). The analysis found that patients prescribed higher-potency drugs – namely hydrocodone and oxycodone – were at even greater risk of developing prolonged use.
The researchers noted significant geographic differences in prescribing habits, with 40% of study participants in Arkansas receiving an opioid prescription, compared with 2.8% in North Dakota. Overall, southern states were more likely to overprescribe, and northern states more likely to underprescribe.
Women were at greater risk of transitioning to high-risk prolonged use, as were individuals aged 35-44 years, those with a higher comorbidity burden, or those with a history of drug abuse.
The study was supported by the National Institute on Drug Abuse, the National Institute of Child Health and Human Development, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania. One author declared an honorarium from the United Health Group.
SOURCE: Delgado MK et al. Ann Emerg Med. 2018. Jul 24. doi: 10.1016/j.annemergmed.2018.06.003.
FROM ANNALS OF EMERGENCY MEDICINE
Key clinical point: Opioids prescribed for sprained ankles increase the risk of prolonged use.
Major finding: High-intensity opioid prescriptions after a sprained ankle were linked to a fivefold higher risk of prolonged use.
Study details: Analysis of health insurance data from 30,832 patients treated in the emergency department for ankle sprains.
Disclosures: The study was supported by the National Institute on Drug Abuse, the National Institute of Child Health and Human Development, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania. One author declared an honorarium from the United Health Group.
Source: Delgado MK et al. Ann Emerg Med. 2018 Jul 24. doi: 10.1016/j.annemergmed.2018.06.003.
Increased COPD mortality with secondhand smoke exposure in childhood
Prolonged exposure to in adulthood, new research has found.
With data from 70,900 never-smoking men and women, most aged 50 years or over, in the Cancer Prevention Study–II Nutrition Cohort, researchers examined associations between childhood and adult secondhand smoke exposure and the risk of death during adulthood from all causes, heart disease, stroke, and COPD. Participants were followed from enrollment in 1992-1993 to 2016-2017.
In a paper published in the September issue of the American Journal of Preventive Medicine, they reported that individuals who had lived with a smoker throughout childhood (16-18 years) had a 31% higher risk of dying from COPD, compared with individuals not exposed to secondhand smoke during childhood (95% confidence interval 1.05-1.65, P = .06). Any exposure to secondhand smoke in childhood – defined as one or more hours of exposure per week – was associated with a 21% higher risk of COPD mortality.
“It is established that SHS [secondhand smoke] exposure in childhood can result in asthma, chronic wheezing, respiratory infections, and decreased lung function and growth in children,” wrote W. Ryan Diver, a cancer epidemiologist, and his colleagues from the Epidemiology Research Program at the American Cancer Society. “These respiratory illnesses in early life are associated with worse lung function in adolescence and adulthood, as indicated by a lower forced expiratory volume in a 1 second plateau, and ultimately diagnosis of COPD.”
The researchers did not see a significant association between childhood secondhand smoke exposure and the risk of death from ischemic heart disease or stroke in adulthood. But the authors said that there was compelling evidence that secondhand smoke exposure during childhood contributed to increased arterial stiffness, autonomic dysfunction, and other vascular effects, which had led to the hypothesis that such exposure might influence the risk of heart disease and stroke mortality in adulthood. They suggested that this effect might have been more apparent in generations born in the 1950s and 1960s, where both parents were likely to smoke at home, as opposed to just one parent, which would have meant higher levels of exposure to secondhand smoke.
Adult exposure to secondhand smoke showed a significant dose-response relationship with overall mortality. Those exposed for 10 or more hours a week showed a 9% higher risk of death from all causes (95% CI 1.04-1.14, P less than .0001), as well as a significant 27% higher risk of death from ischemic heart disease.
Any exposure to secondhand smoke in adulthood was associated with a 14% higher risk of stroke, with a trend of increasing risk with increasing exposure.
The researchers also saw a significant association between secondhand smoke exposure and COPD mortality, but only in adults who reported being exposed both outside and inside the home.
The authors noted that the most recent Surgeon General’s report found that the evidence on secondhand smoke and increased risk of death from COPD was “suggestive but not sufficient,” and further research was needed.
“The associations observed with both childhood exposure to SHS and adult exposure to SHS add to the mounting data relating SHS to COPD,” they wrote.
One limitation of the study was that it relied on self-report, which in the case of childhood exposure would have required some participants to recall at least 3 decades back. It also did not capture whether it was the mother or father who smoked, which meant the authors could not account for possible effects of smoking during pregnancy.
The investigators noted that “more than 50 years after the publication of the first Surgeon General report on smoking and health, these findings suggest that researchers and scientists still do not fully understand the long-term health consequences of smoking, particularly, the potential delayed effects of childhood SHS exposure in later adulthood.” Despite this, the authors said the findings “provide further support for implementation of smoke-free air laws, smoke-free home policies, and clinical interventions to reduce SHS exposure.”
No conflicts of interest were declared.
SOURCE: Diver WR et al. Am J Prev Med 2018;55[3]:345-52. doi: 10.1016/j.amepre.2018.05.005.
Prolonged exposure to in adulthood, new research has found.
With data from 70,900 never-smoking men and women, most aged 50 years or over, in the Cancer Prevention Study–II Nutrition Cohort, researchers examined associations between childhood and adult secondhand smoke exposure and the risk of death during adulthood from all causes, heart disease, stroke, and COPD. Participants were followed from enrollment in 1992-1993 to 2016-2017.
In a paper published in the September issue of the American Journal of Preventive Medicine, they reported that individuals who had lived with a smoker throughout childhood (16-18 years) had a 31% higher risk of dying from COPD, compared with individuals not exposed to secondhand smoke during childhood (95% confidence interval 1.05-1.65, P = .06). Any exposure to secondhand smoke in childhood – defined as one or more hours of exposure per week – was associated with a 21% higher risk of COPD mortality.
“It is established that SHS [secondhand smoke] exposure in childhood can result in asthma, chronic wheezing, respiratory infections, and decreased lung function and growth in children,” wrote W. Ryan Diver, a cancer epidemiologist, and his colleagues from the Epidemiology Research Program at the American Cancer Society. “These respiratory illnesses in early life are associated with worse lung function in adolescence and adulthood, as indicated by a lower forced expiratory volume in a 1 second plateau, and ultimately diagnosis of COPD.”
The researchers did not see a significant association between childhood secondhand smoke exposure and the risk of death from ischemic heart disease or stroke in adulthood. But the authors said that there was compelling evidence that secondhand smoke exposure during childhood contributed to increased arterial stiffness, autonomic dysfunction, and other vascular effects, which had led to the hypothesis that such exposure might influence the risk of heart disease and stroke mortality in adulthood. They suggested that this effect might have been more apparent in generations born in the 1950s and 1960s, where both parents were likely to smoke at home, as opposed to just one parent, which would have meant higher levels of exposure to secondhand smoke.
Adult exposure to secondhand smoke showed a significant dose-response relationship with overall mortality. Those exposed for 10 or more hours a week showed a 9% higher risk of death from all causes (95% CI 1.04-1.14, P less than .0001), as well as a significant 27% higher risk of death from ischemic heart disease.
Any exposure to secondhand smoke in adulthood was associated with a 14% higher risk of stroke, with a trend of increasing risk with increasing exposure.
The researchers also saw a significant association between secondhand smoke exposure and COPD mortality, but only in adults who reported being exposed both outside and inside the home.
The authors noted that the most recent Surgeon General’s report found that the evidence on secondhand smoke and increased risk of death from COPD was “suggestive but not sufficient,” and further research was needed.
“The associations observed with both childhood exposure to SHS and adult exposure to SHS add to the mounting data relating SHS to COPD,” they wrote.
One limitation of the study was that it relied on self-report, which in the case of childhood exposure would have required some participants to recall at least 3 decades back. It also did not capture whether it was the mother or father who smoked, which meant the authors could not account for possible effects of smoking during pregnancy.
The investigators noted that “more than 50 years after the publication of the first Surgeon General report on smoking and health, these findings suggest that researchers and scientists still do not fully understand the long-term health consequences of smoking, particularly, the potential delayed effects of childhood SHS exposure in later adulthood.” Despite this, the authors said the findings “provide further support for implementation of smoke-free air laws, smoke-free home policies, and clinical interventions to reduce SHS exposure.”
No conflicts of interest were declared.
SOURCE: Diver WR et al. Am J Prev Med 2018;55[3]:345-52. doi: 10.1016/j.amepre.2018.05.005.
Prolonged exposure to in adulthood, new research has found.
With data from 70,900 never-smoking men and women, most aged 50 years or over, in the Cancer Prevention Study–II Nutrition Cohort, researchers examined associations between childhood and adult secondhand smoke exposure and the risk of death during adulthood from all causes, heart disease, stroke, and COPD. Participants were followed from enrollment in 1992-1993 to 2016-2017.
In a paper published in the September issue of the American Journal of Preventive Medicine, they reported that individuals who had lived with a smoker throughout childhood (16-18 years) had a 31% higher risk of dying from COPD, compared with individuals not exposed to secondhand smoke during childhood (95% confidence interval 1.05-1.65, P = .06). Any exposure to secondhand smoke in childhood – defined as one or more hours of exposure per week – was associated with a 21% higher risk of COPD mortality.
“It is established that SHS [secondhand smoke] exposure in childhood can result in asthma, chronic wheezing, respiratory infections, and decreased lung function and growth in children,” wrote W. Ryan Diver, a cancer epidemiologist, and his colleagues from the Epidemiology Research Program at the American Cancer Society. “These respiratory illnesses in early life are associated with worse lung function in adolescence and adulthood, as indicated by a lower forced expiratory volume in a 1 second plateau, and ultimately diagnosis of COPD.”
The researchers did not see a significant association between childhood secondhand smoke exposure and the risk of death from ischemic heart disease or stroke in adulthood. But the authors said that there was compelling evidence that secondhand smoke exposure during childhood contributed to increased arterial stiffness, autonomic dysfunction, and other vascular effects, which had led to the hypothesis that such exposure might influence the risk of heart disease and stroke mortality in adulthood. They suggested that this effect might have been more apparent in generations born in the 1950s and 1960s, where both parents were likely to smoke at home, as opposed to just one parent, which would have meant higher levels of exposure to secondhand smoke.
Adult exposure to secondhand smoke showed a significant dose-response relationship with overall mortality. Those exposed for 10 or more hours a week showed a 9% higher risk of death from all causes (95% CI 1.04-1.14, P less than .0001), as well as a significant 27% higher risk of death from ischemic heart disease.
Any exposure to secondhand smoke in adulthood was associated with a 14% higher risk of stroke, with a trend of increasing risk with increasing exposure.
The researchers also saw a significant association between secondhand smoke exposure and COPD mortality, but only in adults who reported being exposed both outside and inside the home.
The authors noted that the most recent Surgeon General’s report found that the evidence on secondhand smoke and increased risk of death from COPD was “suggestive but not sufficient,” and further research was needed.
“The associations observed with both childhood exposure to SHS and adult exposure to SHS add to the mounting data relating SHS to COPD,” they wrote.
One limitation of the study was that it relied on self-report, which in the case of childhood exposure would have required some participants to recall at least 3 decades back. It also did not capture whether it was the mother or father who smoked, which meant the authors could not account for possible effects of smoking during pregnancy.
The investigators noted that “more than 50 years after the publication of the first Surgeon General report on smoking and health, these findings suggest that researchers and scientists still do not fully understand the long-term health consequences of smoking, particularly, the potential delayed effects of childhood SHS exposure in later adulthood.” Despite this, the authors said the findings “provide further support for implementation of smoke-free air laws, smoke-free home policies, and clinical interventions to reduce SHS exposure.”
No conflicts of interest were declared.
SOURCE: Diver WR et al. Am J Prev Med 2018;55[3]:345-52. doi: 10.1016/j.amepre.2018.05.005.
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Key clinical point: Childhood secondhand smoke exposure is linked to increased COPD mortality in adulthood.
Major finding: Adults who were exposed to secondhand smoke throughout childhood have a 31% higher risk of COPD mortality than do those not exposed.
Study details: Retrospective cohort study of 70,900 never-smoking men and women enrolled in the Cancer Prevention Study–II Nutrition Cohort.
Disclosures: No conflicts of interest were declared.
Source: Diver W et al. Am J Prev Med. 2018;55[3]:345-52. doi: 10.1016/j.amepre.2018.05.005.
Don’t forget about OSHA
With the bewildering array of new bureaucracies that private practices are now forced to contend with, it is easy to forget about the older ones – especially the Occupational Health and Safety Administration (OSHA).
with all the applicable regulations. Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain site, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s Web site or order it at no charge by calling 800-321-OSHA.
Next, how old is your written exposure control plan for blood-borne pathogens? It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at your decision and why you feel that your current protocol is as good or better.
Review your list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” (My favorite in that category is liquid nitrogen; it’s hard to envision anything less hazardous, since it evaporates instantly if spilled, and cannot injure skin, or anything else, without purposeful, sustained exposure – and is great, incidentally, for extinguishing small fires.) For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
Check out your building’s exits. Everyone must be able to evacuate your office quickly in case of fire or other emergencies. At a minimum, you (or the owner of the building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars.
How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections, as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
With the bewildering array of new bureaucracies that private practices are now forced to contend with, it is easy to forget about the older ones – especially the Occupational Health and Safety Administration (OSHA).
with all the applicable regulations. Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain site, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s Web site or order it at no charge by calling 800-321-OSHA.
Next, how old is your written exposure control plan for blood-borne pathogens? It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at your decision and why you feel that your current protocol is as good or better.
Review your list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” (My favorite in that category is liquid nitrogen; it’s hard to envision anything less hazardous, since it evaporates instantly if spilled, and cannot injure skin, or anything else, without purposeful, sustained exposure – and is great, incidentally, for extinguishing small fires.) For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
Check out your building’s exits. Everyone must be able to evacuate your office quickly in case of fire or other emergencies. At a minimum, you (or the owner of the building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars.
How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections, as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
With the bewildering array of new bureaucracies that private practices are now forced to contend with, it is easy to forget about the older ones – especially the Occupational Health and Safety Administration (OSHA).
with all the applicable regulations. Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain site, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s Web site or order it at no charge by calling 800-321-OSHA.
Next, how old is your written exposure control plan for blood-borne pathogens? It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at your decision and why you feel that your current protocol is as good or better.
Review your list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” (My favorite in that category is liquid nitrogen; it’s hard to envision anything less hazardous, since it evaporates instantly if spilled, and cannot injure skin, or anything else, without purposeful, sustained exposure – and is great, incidentally, for extinguishing small fires.) For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
Check out your building’s exits. Everyone must be able to evacuate your office quickly in case of fire or other emergencies. At a minimum, you (or the owner of the building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars.
How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections, as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
Review protocols, follow reprocessing guidelines to cut device-related HAIs
ATLANTA – Ongoing vigilance regarding the role of and transmission of antimicrobial-resistant pathogen is needed, according to Isaac Benowitz, MD, of the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion (DHQP).
A review of records from the DHQP, which investigates and responds to infections and related adverse events in health care settings upon invitation, showed that in 2017 environmental pathogens were most often the triggers for these investigations, said Dr. Benowitz, a medical epidemiologist.
He reviewed internal records for consultations with state and local health departments involving medical devices and collected data on health care setting, pathogen, investigation findings including possible exposure or transmission, and public health actions.
Of 285 consultations, 48 involved a specific medical device or general medical device reprocessing, he said, noting that most of those 48 were in an acute care hospital (63%) or clinic (19%).
“The most frequent pathogens noted in these consultations were nontuberculous mycobacteria at 21%, Candida species ... at 10%, and Burkholderia species ... at 8%,” he said, noting that a wide variety of devices were implicated.
In the inpatient setting these devices included ventilators, dialysis machines, breast pumps, central lines, and respiratory therapy equipment. In the outpatient setting they included glucometers and opthalmic equipment.
“In many settings we saw issues with endoscopes, including duodenoscopes, but also bronchoscopes,” he added.
Actions taken as part of the investigations included medical device recalls, improved infection control and reprocessing procedures, and patient notification, education, guidance, testing, and treatment.
In some cases there was disciplinary action or oversight for health care professionals, he added.
Investigations identified medical devices contaminated in manufacturing, incorrect reprocessing of endoscopes or ventilators, and inappropriate medical device use or reuse, he said.
A number of lessons can be learned from these and other investigations, he added.
“First, devices can be reservoirs and transmission vectors for health care–associated infections. Second, health care facilities, health care facility staff, and public health partners should take opportunities to review protocols and the practices within those protocol,” he said. “These are opportunities to strengthen infection control practices even in the absence of documented transmission.”
In fact, in most of the investigations he discussed, transmission was rarely confirmed to be associated with a medical device. This was largely because of a lack of “epidemiological rigor,” but associations between health care–associated infections and medical devices “are still quite meaningful and often actionable,” he said.
Dr. Benowitz stressed the importance of engaging public health partners to discuss findings and actions, explaining that “what may look like a single-facility issue may have a very different perspective when you realize that there’s a similar issue at another facility elsewhere.”
“For all devices, it’s important to ensure adherence to the device reprocessing guidelines, “ he added, noting that these include a combination of facility protocols, manufacturer instructions for use, and guidance from organizations like the Food and Drug Administration and the CDC.
Dr. Benowitz reported having no disclosures.
sworcester@mdedge.com
SOURCE: Benowitz I et al. ICEID 2018, Oral Abstract Presentation E2.
ATLANTA – Ongoing vigilance regarding the role of and transmission of antimicrobial-resistant pathogen is needed, according to Isaac Benowitz, MD, of the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion (DHQP).
A review of records from the DHQP, which investigates and responds to infections and related adverse events in health care settings upon invitation, showed that in 2017 environmental pathogens were most often the triggers for these investigations, said Dr. Benowitz, a medical epidemiologist.
He reviewed internal records for consultations with state and local health departments involving medical devices and collected data on health care setting, pathogen, investigation findings including possible exposure or transmission, and public health actions.
Of 285 consultations, 48 involved a specific medical device or general medical device reprocessing, he said, noting that most of those 48 were in an acute care hospital (63%) or clinic (19%).
“The most frequent pathogens noted in these consultations were nontuberculous mycobacteria at 21%, Candida species ... at 10%, and Burkholderia species ... at 8%,” he said, noting that a wide variety of devices were implicated.
In the inpatient setting these devices included ventilators, dialysis machines, breast pumps, central lines, and respiratory therapy equipment. In the outpatient setting they included glucometers and opthalmic equipment.
“In many settings we saw issues with endoscopes, including duodenoscopes, but also bronchoscopes,” he added.
Actions taken as part of the investigations included medical device recalls, improved infection control and reprocessing procedures, and patient notification, education, guidance, testing, and treatment.
In some cases there was disciplinary action or oversight for health care professionals, he added.
Investigations identified medical devices contaminated in manufacturing, incorrect reprocessing of endoscopes or ventilators, and inappropriate medical device use or reuse, he said.
A number of lessons can be learned from these and other investigations, he added.
“First, devices can be reservoirs and transmission vectors for health care–associated infections. Second, health care facilities, health care facility staff, and public health partners should take opportunities to review protocols and the practices within those protocol,” he said. “These are opportunities to strengthen infection control practices even in the absence of documented transmission.”
In fact, in most of the investigations he discussed, transmission was rarely confirmed to be associated with a medical device. This was largely because of a lack of “epidemiological rigor,” but associations between health care–associated infections and medical devices “are still quite meaningful and often actionable,” he said.
Dr. Benowitz stressed the importance of engaging public health partners to discuss findings and actions, explaining that “what may look like a single-facility issue may have a very different perspective when you realize that there’s a similar issue at another facility elsewhere.”
“For all devices, it’s important to ensure adherence to the device reprocessing guidelines, “ he added, noting that these include a combination of facility protocols, manufacturer instructions for use, and guidance from organizations like the Food and Drug Administration and the CDC.
Dr. Benowitz reported having no disclosures.
sworcester@mdedge.com
SOURCE: Benowitz I et al. ICEID 2018, Oral Abstract Presentation E2.
ATLANTA – Ongoing vigilance regarding the role of and transmission of antimicrobial-resistant pathogen is needed, according to Isaac Benowitz, MD, of the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion (DHQP).
A review of records from the DHQP, which investigates and responds to infections and related adverse events in health care settings upon invitation, showed that in 2017 environmental pathogens were most often the triggers for these investigations, said Dr. Benowitz, a medical epidemiologist.
He reviewed internal records for consultations with state and local health departments involving medical devices and collected data on health care setting, pathogen, investigation findings including possible exposure or transmission, and public health actions.
Of 285 consultations, 48 involved a specific medical device or general medical device reprocessing, he said, noting that most of those 48 were in an acute care hospital (63%) or clinic (19%).
“The most frequent pathogens noted in these consultations were nontuberculous mycobacteria at 21%, Candida species ... at 10%, and Burkholderia species ... at 8%,” he said, noting that a wide variety of devices were implicated.
In the inpatient setting these devices included ventilators, dialysis machines, breast pumps, central lines, and respiratory therapy equipment. In the outpatient setting they included glucometers and opthalmic equipment.
“In many settings we saw issues with endoscopes, including duodenoscopes, but also bronchoscopes,” he added.
Actions taken as part of the investigations included medical device recalls, improved infection control and reprocessing procedures, and patient notification, education, guidance, testing, and treatment.
In some cases there was disciplinary action or oversight for health care professionals, he added.
Investigations identified medical devices contaminated in manufacturing, incorrect reprocessing of endoscopes or ventilators, and inappropriate medical device use or reuse, he said.
A number of lessons can be learned from these and other investigations, he added.
“First, devices can be reservoirs and transmission vectors for health care–associated infections. Second, health care facilities, health care facility staff, and public health partners should take opportunities to review protocols and the practices within those protocol,” he said. “These are opportunities to strengthen infection control practices even in the absence of documented transmission.”
In fact, in most of the investigations he discussed, transmission was rarely confirmed to be associated with a medical device. This was largely because of a lack of “epidemiological rigor,” but associations between health care–associated infections and medical devices “are still quite meaningful and often actionable,” he said.
Dr. Benowitz stressed the importance of engaging public health partners to discuss findings and actions, explaining that “what may look like a single-facility issue may have a very different perspective when you realize that there’s a similar issue at another facility elsewhere.”
“For all devices, it’s important to ensure adherence to the device reprocessing guidelines, “ he added, noting that these include a combination of facility protocols, manufacturer instructions for use, and guidance from organizations like the Food and Drug Administration and the CDC.
Dr. Benowitz reported having no disclosures.
sworcester@mdedge.com
SOURCE: Benowitz I et al. ICEID 2018, Oral Abstract Presentation E2.
REPORTING FROM ICEID 2018
Key clinical point: Medical devices can be reservoirs and transmission vectors for health care–associated infections.
Major finding: Of 285 consultations, 48 involved medical devices or device reprocessing.
Study details: A review of records from 285 consultations
Disclosures: Dr. Benowitz reported having no disclosures
Source: Benowitz I et al. ICEID 2018, Oral Abstract Presentation E2.