The Food and Drug Administration has approved an additional indication for plecanatide (Trulance) as a 3-mg, once-daily treatment for irritable bowel syndrome with constipation (IBS-C).

Plecanatide had previously been approved to treat adults with chronic idiopathic constipation (CIC).

Plecanatide was approved on the findings of two randomized, double-blind, 12-week, placebo-controlled clinical trials. More than 2,100 adult patients across both trials received either a 3-mg or 6-mg once-daily tablet of plecanatide, or a placebo. The primary endpoints of both studies were greater than 30% reduction in worst abdominal pain and an increase of at least one complete spontaneous bowel movement (CSBM) for at least half of the 12 treatment weeks.

Plecanatide met both of its primary endpoints, with reductions in abdominal pain in both studies, compared with placebo (30.2% vs. 17.8% in study 1, P < .001; 21.5% vs. 14.2% in study 2, P = .009).

Plecanatide is the only prescription, once-daily medication that treats both CIC and IBS-C in adults. The drug should be available in the first quarter of 2018.

ilacy@frontlinemedcom.com

AGA offers free patient education materials to help your patients better understand how to live with and manage their IBS. Visit www.gastro.org/ibs.

The Food and Drug Administration has approved an additional indication for plecanatide (Trulance) as a 3-mg, once-daily treatment for irritable bowel syndrome with constipation (IBS-C).

Plecanatide had previously been approved to treat adults with chronic idiopathic constipation (CIC).

Plecanatide was approved on the findings of two randomized, double-blind, 12-week, placebo-controlled clinical trials. More than 2,100 adult patients across both trials received either a 3-mg or 6-mg once-daily tablet of plecanatide, or a placebo. The primary endpoints of both studies were greater than 30% reduction in worst abdominal pain and an increase of at least one complete spontaneous bowel movement (CSBM) for at least half of the 12 treatment weeks.

Plecanatide met both of its primary endpoints, with reductions in abdominal pain in both studies, compared with placebo (30.2% vs. 17.8% in study 1, P < .001; 21.5% vs. 14.2% in study 2, P = .009).

Plecanatide is the only prescription, once-daily medication that treats both CIC and IBS-C in adults. The drug should be available in the first quarter of 2018.

ilacy@frontlinemedcom.com

AGA offers free patient education materials to help your patients better understand how to live with and manage their IBS. Visit www.gastro.org/ibs.

The Food and Drug Administration has approved an additional indication for plecanatide (Trulance) as a 3-mg, once-daily treatment for irritable bowel syndrome with constipation (IBS-C).

Plecanatide had previously been approved to treat adults with chronic idiopathic constipation (CIC).

Plecanatide was approved on the findings of two randomized, double-blind, 12-week, placebo-controlled clinical trials. More than 2,100 adult patients across both trials received either a 3-mg or 6-mg once-daily tablet of plecanatide, or a placebo. The primary endpoints of both studies were greater than 30% reduction in worst abdominal pain and an increase of at least one complete spontaneous bowel movement (CSBM) for at least half of the 12 treatment weeks.

Plecanatide met both of its primary endpoints, with reductions in abdominal pain in both studies, compared with placebo (30.2% vs. 17.8% in study 1, P < .001; 21.5% vs. 14.2% in study 2, P = .009).

Plecanatide is the only prescription, once-daily medication that treats both CIC and IBS-C in adults. The drug should be available in the first quarter of 2018.

ilacy@frontlinemedcom.com

AGA offers free patient education materials to help your patients better understand how to live with and manage their IBS. Visit www.gastro.org/ibs.

CASE Managing pain associated with prolapse and SUI surgery

A 46-year-old woman (G4P4) described 3 years of worsening symptoms related to recurrent stage-3 palpable uterine prolapse. She had associated symptomatic stress urinary incontinence. She had been treated for uterine prolapse 5 years ago with vaginal hysterectomy, bilateral salpingectomy, and high uterosacral-ligament suspension.

After consultation, the patient elected to undergo laparoscopic sacral colpopexy, a mid-urethral sling, and possible anterior and posterior colporrhaphy. Appropriate discussion about the risks and benefits of mesh was provided preoperatively. The surgical team judged her to be highly motivated; she wanted same-day outpatient surgery so that she could go home and then return to work. She had excellent support at home.

How would you counsel this patient about expected postoperative pain? Which medications would you administer to her preoperatively and perioperatively? Which ones would you prescribe for her to manage pain postoperatively?

Adverse impact of prescription opioids in the United States

Although fewer than 5% of the world’s population live in the United States, nearly 80% of the world’s opioids are written for them.¹ In 2012, 259 million prescriptions were written for opioids in the United States—more than enough to give every American adult their own bottle of pills.² Sadly, drug overdose is now a leading cause of accidental death in the United States, with 52,404 lethal drug overdoses in 2015. A startling statistic is that prescription opioid abuse is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers and 12,990 overdose deaths related to heroin in 2015.³

It is likely that there are multiple reasons prescribing of opioids is epidemic. Surgical pain is a common indication for opioid prescriptions; fewer than half of patients who undergo surgery report adequate postoperative pain relief.⁴ Recognition of these deficits in pain management has inspired national campaigns to improve patients’ experience with pain and aggressively address pain with drugs such as opioids.⁵

At the same time, marketing efforts by the pharmaceutical industry sought to reassure the medical community that patients would not become addicted to prescription opioid pain relievers if physical pain was the indication for such prescriptions. In response, health care providers began to prescribe opioids at a greater rate. As providers were encouraged to increase prescriptions, opioid medications began to be misused—and only then did it become clear that these medications are, in fact, highly addictive.⁶ Opioid abuse and overdose rates began to increase; in 2015, more than 33,000 Americans died because of an opioid overdose, including prescription opioids and heroin⁷ (FIGURE). In fact, although most people recognize the threat posed by illegal heroin, most of the 2 million who abused opioids in 2015 in the United States suffered from prescription abuse; only about a quarter, or about 600,000, abused heroin.⁸ In addition, more than 80% of people who abuse heroin initially abused prescription opioids.⁹

Read about medications and strategies for multimodal pain management.

Multimodal approach to pain management

The goals of postsurgical pain treatment are to relieve suffering, optimize bodily functioning after surgery, limit length of the stay, and optimize patient satisfaction. Pain-control regimens should consider the specific surgical procedure and the patient’s medical, psychological, and physical conditions; age; level of fear or anxiety; personal preference; and response to previous treatments.¹⁰

Optimally, postsurgical pain management starts well before the day of surgery. Employing such strategies as Enhanced Recovery after Surgery (ERAS) protocols does not necessarily mean providing the same care for every patient, every time. Rather, ERAS serves as a checklist to ensure that all applicable categories of pain medication and pain-control strategies are considered, selected, and dosed according to individual needs.¹¹ (See “Preoperative management of pain expectations.”)

Opioids

Opioids have been employed to treat pain for 700 years.¹² They are powerful pain relievers because they target central mechanisms involved in the perception of pain. Regrettably, because of their central action, opioids have many adverse effects in addition to being highly addictive.

Nonopioid alternatives

Expert consensus, including recommendations of the World Health Organization,¹¹ favors using nonopioids as first-line medications to address surgical pain. Nonopioid analgesic options are acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and adjuvant medications. In addition, nonanalgesic medications such as sedatives, sleep aids, and muscle relaxants can relieve postsurgical pain. Optimal use of these nonopioid medications can significantly reduce or eliminate the need for opioid medications to treat pain. Goals are to 1) reserve opioids for the most severe pain and 2) minimize the number of doses/pills of opioids required to control postsurgical pain.

Acetaminophen. At dosages of 325 to 1,000 mg orally every 4 to 6 hours, to a maximum dosage of 4,000 mg/d, acetaminophen can be used to treat mild pain and, in combination with other medications, moderate-to-severe pain. The drug also can be administered intravenously (IV), although use of the IV route is limited in many hospitals because of its significantly higher expense compared to the oral form.

The mechanism of action of acetaminophen is unique among pain relievers; it can therefore be used in combination with other pain relievers to more effectively treat pain with fewer concerns about medication-induced adverse effects or opioid overdose. However, keep in mind when considering combining analgesics, that acetaminophen is an active ingredient in hundreds of over-the-counter (OTC) and prescription formulations, and that a combination of more than one acetaminophen-containing product can create the risk of overdose.

Acetaminophen should be used with caution in patients with liver disease. That being said, multiple trials have documented safe use in normal body weight adults who do not have hepatic disease, at dosages as high as 4,000 mg over a 24-hour period.¹³

NSAIDs. A combination of an NSAID and acetaminophen has been documented to reduce the amount of opioid medications required to treat postsurgical pain. In most circumstances, especially for minor surgery, acetaminophen and NSAIDS can be administered just before surgery starts. This preoperative treatment, called “preventive analgesia” or “preemptive analgesia,” has been demonstrated in multiple clinical trials to reduce postoperative pain.¹⁴

Adjuvant pain medications. Antidepressants, antiepileptic agents, and muscle relaxants—agents that have a primary indication for a condition (or conditions) other than pain and do not directly provide analgesia—have been used as adjuvant pain medications. When employed with traditional analgesics, they have been demonstrated to reduce postsurgical pain scores and the amount of opioids required. These medications need to be used cautiously because some are associated with serious sedation and vertigo (TABLE). Take caution when using adjuvant pain medications in patients older than 65 years; guidance on their use in older patients has been outlined by the American Geriatrics Society and other professional organizations.¹⁵

Case Continued

The patient was given the expectation that the 11-mm left lower-quadrant port site would likely be the most bothersome site of pain—a rating of 4 or 5 on a visual analogue scale of 1 to 10, on postoperative day 1, while standing. The other 3 (5-mm) laparoscopic ports, she was told, would, typically, be less bothersome. The patient was educated regarding the role of analgesics and adjuvant medications and cautioned not to exceed 4,000 mg of acetaminophen in any 24-hour period. She was told that gabapentin may make her feel sedated or dizzy, or both; she was encouraged to hold this medication if she found these adverse effects bothersome or limiting.

The following multimodal pain management was established.

Preoperatively, the patient was given:

• Acetaminophen 1.5 g orally (as a liquid, 45 mL of a suspension of 500 mg/15 mL liquid), 2 to 3 hours preoperatively; the surgical suite did not stock IV acetaminophen.
• Gabapentin 600 mg orally, with a sip of water, the morning of surgery.
• Celecoxib 100 mg orally, with a sip of water, the morning of surgery.

Prescriptions for home postoperative pain management were provided preoperatively:

• OTC acetaminophen 1,000 mg (as 2 500-mgtablets) taken as a scheduled dose every 8 hours for the first 48 hours postoperatively.
• Meloxicam 15 mg daily as the NSAID, taken as a scheduled dose once per day for the first 48 hours postoperatively, then as needed.
• Gabapentin 300 mg (in addition to the preoperative dose, above), taken as a scheduled dose every 8 hours for the first 48 hours postoperatively, then as needed.
• Oxycodone 5 mg (without acetaminophen) for breakthrough pain.

Intraoperatively:

• Meticulous attention was paid to patient positioning, to reduce the possibility of back and upper- and lower-extremity injury postoperatively.
• A corticosteroid (dexamethasone 8 mg IV) was administered to minimize postoperative nausea and vomiting and as an adjuvant medication for postoperative pain control.
• Careful attention was paid to limit residual CO₂ gas and intraoperative intra-abdominal pressures.
• All laparoscopic port sites were injected with 30 mL of 0.25% bupivacaine with epinephrine, extending to subcutaneous, fascial, and peritoneal layers.

Read about why a multimodal approach is best for postsurgical pain.

Why a multimodal plan to treat pain?

Pain following laparoscopy has been associated with many variables, including patient positioning, port size and placement, amount of port manipulation, and gas retention. After a laparoscopic surgical procedure, patients report pain in the abdomen, back, and shoulders.

Postsurgical pain has 3 components:

• Shoulder pain, thought to result from phrenic nerve irritation caused by lingering CO₂ in the abdominal cavity.
• Visceral pain, occurring secondary to stretching of the abdominal cavity.
• Somatic pain, caused by the surgical incision; of the 3 components to pain, somatic pain can have the least impact because laparoscopic incisions are small.

For our patient, prior to the incisions being made, she received local anesthesia intraoperatively to the laparoscopic port sites to include the subcutaneous, fascial, and peritoneal layers. Involving these layers allows for more of a block. An ultrasonography-guided transversus abdominis plane (TAP) block, if available, is highly effective at decreasing postoperative pain, but its efficacy is dependent on the anatomy and the skill of the physician (whether anesthesiologist, gynecologist, or surgeon) who is placing it.¹⁶

We used dexamethasone 8 mg IV, intraoperatively because this single dose has been shown to decrease the perception of pain postoperatively. Dexamethasone also has been shown to decrease consumption of oxycodone during the 24 hours after laparoscopic gynecologic surgery.¹⁷

CO₂ used to insufflate the patient’s abdomen can take as long as 2 days to fully resorb, resulting in increased pain. This discomfort has been described as delayed; the patient might not notice it until she goes home. In a study, 70% of patients had shoulder discomfort following laparoscopy 24 hours after their procedure.¹⁸ For this reason, we employed several techniques to reduce this effect:

• We reduced the intra-abdominal pressure limit to 10 mm Hg (from 15 mm Hg) once dissection was complete.
• At the end of the procedure, careful attention was paid to removing as much intra-abdominal gas as possible, including placing the patient in the Trendelenburg position and having the anesthesiologist induce a Valsalva maneuver. This action has been shown to significantly improve pain control compared to placebo intervention.¹⁹
• We used humidified CO₂, which has been demonstrated to reduce pain in laparoscopic surgery.²⁰

Preemptively, we provided this patient with acetaminophen, celecoxib, and gabapentin, which have been demonstrated to be effective in gynecologic patients to decrease the need for postoperative opioids.²¹ Also, our patient received counseling, with specific expectations for what to expect following the surgical procedure.

CASE Resolved

Our patient did exceptionally well following surgery. She used only one of the oxycodone pills and did not require unplanned interventions. She took gabapentin, acetaminophen, and meloxicam at their scheduled doses for 2 days. She continued to use meloxicam for 4 more days for mild abdominal pain, then discontinued all medications.She flushed her 9 unused oxycodone pills down the toilet. (See “A word about disposal of ‘excess’ opioids”²²) The patient returned to her administrative duties at work 2 weeks after the procedure and reported that she was “very satisfied” with her surgical experience.

In conclusion

Postoperative pain is a complex entity that must be considered to require individualized strategies and, possibly, multiple interventions. Optimally, thorough education, including pain management options, is provided to the patient prior to surgery. Given the current state of opioid abuse in the United States, all gynecologic surgeons should be familiar with multimodal pain therapy and how to employ nonmedical techniques to reduce postsurgical pain without relying solely on opioids. (See “Online resources for pain management”.)

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

CASE Managing pain associated with prolapse and SUI surgery

A 46-year-old woman (G4P4) described 3 years of worsening symptoms related to recurrent stage-3 palpable uterine prolapse. She had associated symptomatic stress urinary incontinence. She had been treated for uterine prolapse 5 years ago with vaginal hysterectomy, bilateral salpingectomy, and high uterosacral-ligament suspension.

After consultation, the patient elected to undergo laparoscopic sacral colpopexy, a mid-urethral sling, and possible anterior and posterior colporrhaphy. Appropriate discussion about the risks and benefits of mesh was provided preoperatively. The surgical team judged her to be highly motivated; she wanted same-day outpatient surgery so that she could go home and then return to work. She had excellent support at home.

How would you counsel this patient about expected postoperative pain? Which medications would you administer to her preoperatively and perioperatively? Which ones would you prescribe for her to manage pain postoperatively?

Adverse impact of prescription opioids in the United States

Although fewer than 5% of the world’s population live in the United States, nearly 80% of the world’s opioids are written for them.¹ In 2012, 259 million prescriptions were written for opioids in the United States—more than enough to give every American adult their own bottle of pills.² Sadly, drug overdose is now a leading cause of accidental death in the United States, with 52,404 lethal drug overdoses in 2015. A startling statistic is that prescription opioid abuse is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers and 12,990 overdose deaths related to heroin in 2015.³

It is likely that there are multiple reasons prescribing of opioids is epidemic. Surgical pain is a common indication for opioid prescriptions; fewer than half of patients who undergo surgery report adequate postoperative pain relief.⁴ Recognition of these deficits in pain management has inspired national campaigns to improve patients’ experience with pain and aggressively address pain with drugs such as opioids.⁵

At the same time, marketing efforts by the pharmaceutical industry sought to reassure the medical community that patients would not become addicted to prescription opioid pain relievers if physical pain was the indication for such prescriptions. In response, health care providers began to prescribe opioids at a greater rate. As providers were encouraged to increase prescriptions, opioid medications began to be misused—and only then did it become clear that these medications are, in fact, highly addictive.⁶ Opioid abuse and overdose rates began to increase; in 2015, more than 33,000 Americans died because of an opioid overdose, including prescription opioids and heroin⁷ (FIGURE). In fact, although most people recognize the threat posed by illegal heroin, most of the 2 million who abused opioids in 2015 in the United States suffered from prescription abuse; only about a quarter, or about 600,000, abused heroin.⁸ In addition, more than 80% of people who abuse heroin initially abused prescription opioids.⁹

Read about medications and strategies for multimodal pain management.

Multimodal approach to pain management

The goals of postsurgical pain treatment are to relieve suffering, optimize bodily functioning after surgery, limit length of the stay, and optimize patient satisfaction. Pain-control regimens should consider the specific surgical procedure and the patient’s medical, psychological, and physical conditions; age; level of fear or anxiety; personal preference; and response to previous treatments.¹⁰

Optimally, postsurgical pain management starts well before the day of surgery. Employing such strategies as Enhanced Recovery after Surgery (ERAS) protocols does not necessarily mean providing the same care for every patient, every time. Rather, ERAS serves as a checklist to ensure that all applicable categories of pain medication and pain-control strategies are considered, selected, and dosed according to individual needs.¹¹ (See “Preoperative management of pain expectations.”)

Opioids

Opioids have been employed to treat pain for 700 years.¹² They are powerful pain relievers because they target central mechanisms involved in the perception of pain. Regrettably, because of their central action, opioids have many adverse effects in addition to being highly addictive.

Nonopioid alternatives

Expert consensus, including recommendations of the World Health Organization,¹¹ favors using nonopioids as first-line medications to address surgical pain. Nonopioid analgesic options are acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and adjuvant medications. In addition, nonanalgesic medications such as sedatives, sleep aids, and muscle relaxants can relieve postsurgical pain. Optimal use of these nonopioid medications can significantly reduce or eliminate the need for opioid medications to treat pain. Goals are to 1) reserve opioids for the most severe pain and 2) minimize the number of doses/pills of opioids required to control postsurgical pain.

Acetaminophen. At dosages of 325 to 1,000 mg orally every 4 to 6 hours, to a maximum dosage of 4,000 mg/d, acetaminophen can be used to treat mild pain and, in combination with other medications, moderate-to-severe pain. The drug also can be administered intravenously (IV), although use of the IV route is limited in many hospitals because of its significantly higher expense compared to the oral form.

The mechanism of action of acetaminophen is unique among pain relievers; it can therefore be used in combination with other pain relievers to more effectively treat pain with fewer concerns about medication-induced adverse effects or opioid overdose. However, keep in mind when considering combining analgesics, that acetaminophen is an active ingredient in hundreds of over-the-counter (OTC) and prescription formulations, and that a combination of more than one acetaminophen-containing product can create the risk of overdose.

Acetaminophen should be used with caution in patients with liver disease. That being said, multiple trials have documented safe use in normal body weight adults who do not have hepatic disease, at dosages as high as 4,000 mg over a 24-hour period.¹³

NSAIDs. A combination of an NSAID and acetaminophen has been documented to reduce the amount of opioid medications required to treat postsurgical pain. In most circumstances, especially for minor surgery, acetaminophen and NSAIDS can be administered just before surgery starts. This preoperative treatment, called “preventive analgesia” or “preemptive analgesia,” has been demonstrated in multiple clinical trials to reduce postoperative pain.¹⁴

Adjuvant pain medications. Antidepressants, antiepileptic agents, and muscle relaxants—agents that have a primary indication for a condition (or conditions) other than pain and do not directly provide analgesia—have been used as adjuvant pain medications. When employed with traditional analgesics, they have been demonstrated to reduce postsurgical pain scores and the amount of opioids required. These medications need to be used cautiously because some are associated with serious sedation and vertigo (TABLE). Take caution when using adjuvant pain medications in patients older than 65 years; guidance on their use in older patients has been outlined by the American Geriatrics Society and other professional organizations.¹⁵

Case Continued

The patient was given the expectation that the 11-mm left lower-quadrant port site would likely be the most bothersome site of pain—a rating of 4 or 5 on a visual analogue scale of 1 to 10, on postoperative day 1, while standing. The other 3 (5-mm) laparoscopic ports, she was told, would, typically, be less bothersome. The patient was educated regarding the role of analgesics and adjuvant medications and cautioned not to exceed 4,000 mg of acetaminophen in any 24-hour period. She was told that gabapentin may make her feel sedated or dizzy, or both; she was encouraged to hold this medication if she found these adverse effects bothersome or limiting.

The following multimodal pain management was established.

Preoperatively, the patient was given:

• Acetaminophen 1.5 g orally (as a liquid, 45 mL of a suspension of 500 mg/15 mL liquid), 2 to 3 hours preoperatively; the surgical suite did not stock IV acetaminophen.
• Gabapentin 600 mg orally, with a sip of water, the morning of surgery.
• Celecoxib 100 mg orally, with a sip of water, the morning of surgery.

Prescriptions for home postoperative pain management were provided preoperatively:

• OTC acetaminophen 1,000 mg (as 2 500-mgtablets) taken as a scheduled dose every 8 hours for the first 48 hours postoperatively.
• Meloxicam 15 mg daily as the NSAID, taken as a scheduled dose once per day for the first 48 hours postoperatively, then as needed.
• Gabapentin 300 mg (in addition to the preoperative dose, above), taken as a scheduled dose every 8 hours for the first 48 hours postoperatively, then as needed.
• Oxycodone 5 mg (without acetaminophen) for breakthrough pain.

Intraoperatively:

• Meticulous attention was paid to patient positioning, to reduce the possibility of back and upper- and lower-extremity injury postoperatively.
• A corticosteroid (dexamethasone 8 mg IV) was administered to minimize postoperative nausea and vomiting and as an adjuvant medication for postoperative pain control.
• Careful attention was paid to limit residual CO₂ gas and intraoperative intra-abdominal pressures.
• All laparoscopic port sites were injected with 30 mL of 0.25% bupivacaine with epinephrine, extending to subcutaneous, fascial, and peritoneal layers.

Read about why a multimodal approach is best for postsurgical pain.

Why a multimodal plan to treat pain?

Pain following laparoscopy has been associated with many variables, including patient positioning, port size and placement, amount of port manipulation, and gas retention. After a laparoscopic surgical procedure, patients report pain in the abdomen, back, and shoulders.

Postsurgical pain has 3 components:

• Shoulder pain, thought to result from phrenic nerve irritation caused by lingering CO₂ in the abdominal cavity.
• Visceral pain, occurring secondary to stretching of the abdominal cavity.
• Somatic pain, caused by the surgical incision; of the 3 components to pain, somatic pain can have the least impact because laparoscopic incisions are small.

For our patient, prior to the incisions being made, she received local anesthesia intraoperatively to the laparoscopic port sites to include the subcutaneous, fascial, and peritoneal layers. Involving these layers allows for more of a block. An ultrasonography-guided transversus abdominis plane (TAP) block, if available, is highly effective at decreasing postoperative pain, but its efficacy is dependent on the anatomy and the skill of the physician (whether anesthesiologist, gynecologist, or surgeon) who is placing it.¹⁶

We used dexamethasone 8 mg IV, intraoperatively because this single dose has been shown to decrease the perception of pain postoperatively. Dexamethasone also has been shown to decrease consumption of oxycodone during the 24 hours after laparoscopic gynecologic surgery.¹⁷

CO₂ used to insufflate the patient’s abdomen can take as long as 2 days to fully resorb, resulting in increased pain. This discomfort has been described as delayed; the patient might not notice it until she goes home. In a study, 70% of patients had shoulder discomfort following laparoscopy 24 hours after their procedure.¹⁸ For this reason, we employed several techniques to reduce this effect:

• We reduced the intra-abdominal pressure limit to 10 mm Hg (from 15 mm Hg) once dissection was complete.
• At the end of the procedure, careful attention was paid to removing as much intra-abdominal gas as possible, including placing the patient in the Trendelenburg position and having the anesthesiologist induce a Valsalva maneuver. This action has been shown to significantly improve pain control compared to placebo intervention.¹⁹
• We used humidified CO₂, which has been demonstrated to reduce pain in laparoscopic surgery.²⁰

Preemptively, we provided this patient with acetaminophen, celecoxib, and gabapentin, which have been demonstrated to be effective in gynecologic patients to decrease the need for postoperative opioids.²¹ Also, our patient received counseling, with specific expectations for what to expect following the surgical procedure.

CASE Resolved

Our patient did exceptionally well following surgery. She used only one of the oxycodone pills and did not require unplanned interventions. She took gabapentin, acetaminophen, and meloxicam at their scheduled doses for 2 days. She continued to use meloxicam for 4 more days for mild abdominal pain, then discontinued all medications.She flushed her 9 unused oxycodone pills down the toilet. (See “A word about disposal of ‘excess’ opioids”²²) The patient returned to her administrative duties at work 2 weeks after the procedure and reported that she was “very satisfied” with her surgical experience.

In conclusion

Postoperative pain is a complex entity that must be considered to require individualized strategies and, possibly, multiple interventions. Optimally, thorough education, including pain management options, is provided to the patient prior to surgery. Given the current state of opioid abuse in the United States, all gynecologic surgeons should be familiar with multimodal pain therapy and how to employ nonmedical techniques to reduce postsurgical pain without relying solely on opioids. (See “Online resources for pain management”.)

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

CASE Managing pain associated with prolapse and SUI surgery

A 46-year-old woman (G4P4) described 3 years of worsening symptoms related to recurrent stage-3 palpable uterine prolapse. She had associated symptomatic stress urinary incontinence. She had been treated for uterine prolapse 5 years ago with vaginal hysterectomy, bilateral salpingectomy, and high uterosacral-ligament suspension.

After consultation, the patient elected to undergo laparoscopic sacral colpopexy, a mid-urethral sling, and possible anterior and posterior colporrhaphy. Appropriate discussion about the risks and benefits of mesh was provided preoperatively. The surgical team judged her to be highly motivated; she wanted same-day outpatient surgery so that she could go home and then return to work. She had excellent support at home.

How would you counsel this patient about expected postoperative pain? Which medications would you administer to her preoperatively and perioperatively? Which ones would you prescribe for her to manage pain postoperatively?

Adverse impact of prescription opioids in the United States

Although fewer than 5% of the world’s population live in the United States, nearly 80% of the world’s opioids are written for them.¹ In 2012, 259 million prescriptions were written for opioids in the United States—more than enough to give every American adult their own bottle of pills.² Sadly, drug overdose is now a leading cause of accidental death in the United States, with 52,404 lethal drug overdoses in 2015. A startling statistic is that prescription opioid abuse is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers and 12,990 overdose deaths related to heroin in 2015.³

It is likely that there are multiple reasons prescribing of opioids is epidemic. Surgical pain is a common indication for opioid prescriptions; fewer than half of patients who undergo surgery report adequate postoperative pain relief.⁴ Recognition of these deficits in pain management has inspired national campaigns to improve patients’ experience with pain and aggressively address pain with drugs such as opioids.⁵

At the same time, marketing efforts by the pharmaceutical industry sought to reassure the medical community that patients would not become addicted to prescription opioid pain relievers if physical pain was the indication for such prescriptions. In response, health care providers began to prescribe opioids at a greater rate. As providers were encouraged to increase prescriptions, opioid medications began to be misused—and only then did it become clear that these medications are, in fact, highly addictive.⁶ Opioid abuse and overdose rates began to increase; in 2015, more than 33,000 Americans died because of an opioid overdose, including prescription opioids and heroin⁷ (FIGURE). In fact, although most people recognize the threat posed by illegal heroin, most of the 2 million who abused opioids in 2015 in the United States suffered from prescription abuse; only about a quarter, or about 600,000, abused heroin.⁸ In addition, more than 80% of people who abuse heroin initially abused prescription opioids.⁹

Read about medications and strategies for multimodal pain management.

Multimodal approach to pain management

The goals of postsurgical pain treatment are to relieve suffering, optimize bodily functioning after surgery, limit length of the stay, and optimize patient satisfaction. Pain-control regimens should consider the specific surgical procedure and the patient’s medical, psychological, and physical conditions; age; level of fear or anxiety; personal preference; and response to previous treatments.¹⁰

Optimally, postsurgical pain management starts well before the day of surgery. Employing such strategies as Enhanced Recovery after Surgery (ERAS) protocols does not necessarily mean providing the same care for every patient, every time. Rather, ERAS serves as a checklist to ensure that all applicable categories of pain medication and pain-control strategies are considered, selected, and dosed according to individual needs.¹¹ (See “Preoperative management of pain expectations.”)

Opioids

Opioids have been employed to treat pain for 700 years.¹² They are powerful pain relievers because they target central mechanisms involved in the perception of pain. Regrettably, because of their central action, opioids have many adverse effects in addition to being highly addictive.

Nonopioid alternatives

Expert consensus, including recommendations of the World Health Organization,¹¹ favors using nonopioids as first-line medications to address surgical pain. Nonopioid analgesic options are acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and adjuvant medications. In addition, nonanalgesic medications such as sedatives, sleep aids, and muscle relaxants can relieve postsurgical pain. Optimal use of these nonopioid medications can significantly reduce or eliminate the need for opioid medications to treat pain. Goals are to 1) reserve opioids for the most severe pain and 2) minimize the number of doses/pills of opioids required to control postsurgical pain.

Acetaminophen. At dosages of 325 to 1,000 mg orally every 4 to 6 hours, to a maximum dosage of 4,000 mg/d, acetaminophen can be used to treat mild pain and, in combination with other medications, moderate-to-severe pain. The drug also can be administered intravenously (IV), although use of the IV route is limited in many hospitals because of its significantly higher expense compared to the oral form.

The mechanism of action of acetaminophen is unique among pain relievers; it can therefore be used in combination with other pain relievers to more effectively treat pain with fewer concerns about medication-induced adverse effects or opioid overdose. However, keep in mind when considering combining analgesics, that acetaminophen is an active ingredient in hundreds of over-the-counter (OTC) and prescription formulations, and that a combination of more than one acetaminophen-containing product can create the risk of overdose.

Acetaminophen should be used with caution in patients with liver disease. That being said, multiple trials have documented safe use in normal body weight adults who do not have hepatic disease, at dosages as high as 4,000 mg over a 24-hour period.¹³

NSAIDs. A combination of an NSAID and acetaminophen has been documented to reduce the amount of opioid medications required to treat postsurgical pain. In most circumstances, especially for minor surgery, acetaminophen and NSAIDS can be administered just before surgery starts. This preoperative treatment, called “preventive analgesia” or “preemptive analgesia,” has been demonstrated in multiple clinical trials to reduce postoperative pain.¹⁴

Adjuvant pain medications. Antidepressants, antiepileptic agents, and muscle relaxants—agents that have a primary indication for a condition (or conditions) other than pain and do not directly provide analgesia—have been used as adjuvant pain medications. When employed with traditional analgesics, they have been demonstrated to reduce postsurgical pain scores and the amount of opioids required. These medications need to be used cautiously because some are associated with serious sedation and vertigo (TABLE). Take caution when using adjuvant pain medications in patients older than 65 years; guidance on their use in older patients has been outlined by the American Geriatrics Society and other professional organizations.¹⁵

Case Continued

The patient was given the expectation that the 11-mm left lower-quadrant port site would likely be the most bothersome site of pain—a rating of 4 or 5 on a visual analogue scale of 1 to 10, on postoperative day 1, while standing. The other 3 (5-mm) laparoscopic ports, she was told, would, typically, be less bothersome. The patient was educated regarding the role of analgesics and adjuvant medications and cautioned not to exceed 4,000 mg of acetaminophen in any 24-hour period. She was told that gabapentin may make her feel sedated or dizzy, or both; she was encouraged to hold this medication if she found these adverse effects bothersome or limiting.

The following multimodal pain management was established.

Preoperatively, the patient was given:

• Acetaminophen 1.5 g orally (as a liquid, 45 mL of a suspension of 500 mg/15 mL liquid), 2 to 3 hours preoperatively; the surgical suite did not stock IV acetaminophen.
• Gabapentin 600 mg orally, with a sip of water, the morning of surgery.
• Celecoxib 100 mg orally, with a sip of water, the morning of surgery.

Prescriptions for home postoperative pain management were provided preoperatively:

• OTC acetaminophen 1,000 mg (as 2 500-mgtablets) taken as a scheduled dose every 8 hours for the first 48 hours postoperatively.
• Meloxicam 15 mg daily as the NSAID, taken as a scheduled dose once per day for the first 48 hours postoperatively, then as needed.
• Gabapentin 300 mg (in addition to the preoperative dose, above), taken as a scheduled dose every 8 hours for the first 48 hours postoperatively, then as needed.
• Oxycodone 5 mg (without acetaminophen) for breakthrough pain.

Intraoperatively:

• Meticulous attention was paid to patient positioning, to reduce the possibility of back and upper- and lower-extremity injury postoperatively.
• A corticosteroid (dexamethasone 8 mg IV) was administered to minimize postoperative nausea and vomiting and as an adjuvant medication for postoperative pain control.
• Careful attention was paid to limit residual CO₂ gas and intraoperative intra-abdominal pressures.
• All laparoscopic port sites were injected with 30 mL of 0.25% bupivacaine with epinephrine, extending to subcutaneous, fascial, and peritoneal layers.

Read about why a multimodal approach is best for postsurgical pain.

Why a multimodal plan to treat pain?

Pain following laparoscopy has been associated with many variables, including patient positioning, port size and placement, amount of port manipulation, and gas retention. After a laparoscopic surgical procedure, patients report pain in the abdomen, back, and shoulders.

Postsurgical pain has 3 components:

• Shoulder pain, thought to result from phrenic nerve irritation caused by lingering CO₂ in the abdominal cavity.
• Visceral pain, occurring secondary to stretching of the abdominal cavity.
• Somatic pain, caused by the surgical incision; of the 3 components to pain, somatic pain can have the least impact because laparoscopic incisions are small.

For our patient, prior to the incisions being made, she received local anesthesia intraoperatively to the laparoscopic port sites to include the subcutaneous, fascial, and peritoneal layers. Involving these layers allows for more of a block. An ultrasonography-guided transversus abdominis plane (TAP) block, if available, is highly effective at decreasing postoperative pain, but its efficacy is dependent on the anatomy and the skill of the physician (whether anesthesiologist, gynecologist, or surgeon) who is placing it.¹⁶

We used dexamethasone 8 mg IV, intraoperatively because this single dose has been shown to decrease the perception of pain postoperatively. Dexamethasone also has been shown to decrease consumption of oxycodone during the 24 hours after laparoscopic gynecologic surgery.¹⁷

CO₂ used to insufflate the patient’s abdomen can take as long as 2 days to fully resorb, resulting in increased pain. This discomfort has been described as delayed; the patient might not notice it until she goes home. In a study, 70% of patients had shoulder discomfort following laparoscopy 24 hours after their procedure.¹⁸ For this reason, we employed several techniques to reduce this effect:

• We reduced the intra-abdominal pressure limit to 10 mm Hg (from 15 mm Hg) once dissection was complete.
• At the end of the procedure, careful attention was paid to removing as much intra-abdominal gas as possible, including placing the patient in the Trendelenburg position and having the anesthesiologist induce a Valsalva maneuver. This action has been shown to significantly improve pain control compared to placebo intervention.¹⁹
• We used humidified CO₂, which has been demonstrated to reduce pain in laparoscopic surgery.²⁰

Preemptively, we provided this patient with acetaminophen, celecoxib, and gabapentin, which have been demonstrated to be effective in gynecologic patients to decrease the need for postoperative opioids.²¹ Also, our patient received counseling, with specific expectations for what to expect following the surgical procedure.

CASE Resolved

Our patient did exceptionally well following surgery. She used only one of the oxycodone pills and did not require unplanned interventions. She took gabapentin, acetaminophen, and meloxicam at their scheduled doses for 2 days. She continued to use meloxicam for 4 more days for mild abdominal pain, then discontinued all medications.She flushed her 9 unused oxycodone pills down the toilet. (See “A word about disposal of ‘excess’ opioids”²²) The patient returned to her administrative duties at work 2 weeks after the procedure and reported that she was “very satisfied” with her surgical experience.

In conclusion

Postoperative pain is a complex entity that must be considered to require individualized strategies and, possibly, multiple interventions. Optimally, thorough education, including pain management options, is provided to the patient prior to surgery. Given the current state of opioid abuse in the United States, all gynecologic surgeons should be familiar with multimodal pain therapy and how to employ nonmedical techniques to reduce postsurgical pain without relying solely on opioids. (See “Online resources for pain management”.)

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

If they’re too infrequent, alerts can delay sepsis identification and treatment. If they’re too abundant, the alerts can overwhelm providers. Finding the sweet spot for sepsis alerts, QI leaders say, can require time, technology, patience – and sometimes trial and error.

University Hospital in Salt Lake City wanted to broaden its sepsis recognition system to ensure that decompensating patients were seen and resuscitated quickly, regardless of the cause. Another hospital offered a lesson in what not to do when a staff member cautioned that a sepsis alert system based on SIRS alone had been a “total disaster” and left providers fuming. One report suggested that nearly half of all ward patients meet SIRS criteria at some point during their hospitalization, and that using the criteria for sepsis screening in hospital wards is both “time consuming and impractical.”¹

References

1. Churpek MM et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med. 2015 Oct 15;192(8):958-64.

2. Umscheid CA et al. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med. 2015 Jan;10: 26-31.

If they’re too infrequent, alerts can delay sepsis identification and treatment. If they’re too abundant, the alerts can overwhelm providers. Finding the sweet spot for sepsis alerts, QI leaders say, can require time, technology, patience – and sometimes trial and error.

University Hospital in Salt Lake City wanted to broaden its sepsis recognition system to ensure that decompensating patients were seen and resuscitated quickly, regardless of the cause. Another hospital offered a lesson in what not to do when a staff member cautioned that a sepsis alert system based on SIRS alone had been a “total disaster” and left providers fuming. One report suggested that nearly half of all ward patients meet SIRS criteria at some point during their hospitalization, and that using the criteria for sepsis screening in hospital wards is both “time consuming and impractical.”¹

References

1. Churpek MM et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med. 2015 Oct 15;192(8):958-64.

2. Umscheid CA et al. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med. 2015 Jan;10: 26-31.

If they’re too infrequent, alerts can delay sepsis identification and treatment. If they’re too abundant, the alerts can overwhelm providers. Finding the sweet spot for sepsis alerts, QI leaders say, can require time, technology, patience – and sometimes trial and error.

University Hospital in Salt Lake City wanted to broaden its sepsis recognition system to ensure that decompensating patients were seen and resuscitated quickly, regardless of the cause. Another hospital offered a lesson in what not to do when a staff member cautioned that a sepsis alert system based on SIRS alone had been a “total disaster” and left providers fuming. One report suggested that nearly half of all ward patients meet SIRS criteria at some point during their hospitalization, and that using the criteria for sepsis screening in hospital wards is both “time consuming and impractical.”¹

References

1. Churpek MM et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med. 2015 Oct 15;192(8):958-64.

2. Umscheid CA et al. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med. 2015 Jan;10: 26-31.

Follicle abnormalities were identified on the apparently healthy skin of women with acne, in a study that used confocal microscopy to evaluate skin structures in adult women with acne.

The finding was seen in women with both types of acne – diffuse and mandibular – and in patients with both inflammatory and hyperkeratinization features, wrote Louise M. Guenot, MD, of the dermatology department at CHU Nantes, France, and her coauthors. In the women with mandibular acne, there were significantly more follicle abnormalities on the mandibular area of the face, compared with the forehead area, with no acne lesions.

Obencem/Thinkstock

SOURCE: Guenot et al. Int J Dermatol. 2018 Jan 25. doi: 10.1111/ijd.13910.

Follicle abnormalities were identified on the apparently healthy skin of women with acne, in a study that used confocal microscopy to evaluate skin structures in adult women with acne.

The finding was seen in women with both types of acne – diffuse and mandibular – and in patients with both inflammatory and hyperkeratinization features, wrote Louise M. Guenot, MD, of the dermatology department at CHU Nantes, France, and her coauthors. In the women with mandibular acne, there were significantly more follicle abnormalities on the mandibular area of the face, compared with the forehead area, with no acne lesions.

Obencem/Thinkstock

SOURCE: Guenot et al. Int J Dermatol. 2018 Jan 25. doi: 10.1111/ijd.13910.

Follicle abnormalities were identified on the apparently healthy skin of women with acne, in a study that used confocal microscopy to evaluate skin structures in adult women with acne.

The finding was seen in women with both types of acne – diffuse and mandibular – and in patients with both inflammatory and hyperkeratinization features, wrote Louise M. Guenot, MD, of the dermatology department at CHU Nantes, France, and her coauthors. In the women with mandibular acne, there were significantly more follicle abnormalities on the mandibular area of the face, compared with the forehead area, with no acne lesions.

Obencem/Thinkstock

SOURCE: Guenot et al. Int J Dermatol. 2018 Jan 25. doi: 10.1111/ijd.13910.

Persistent and severe postpartum depression in mothers may be associated with behavioral problems, poor mathematics grades, and a higher risk of depression in their offspring, research published Jan. 31 in JAMA Psychiatry showed.

In the study, Elena Netsi, DPhil, and her associates presented an analysis of data from 9,848 mothers and 8,287 children enrolled in the observational Avon Longitudinal Study of Parents and Children.

This analysis revealed that postpartum depression of any severity or level of persistence was associated with a two- to fourfold increase in the risk of children showing behavioral problems at age 3.5 years. In women with marked but not persistent postpartum depression, the odds ratio for child behavioral disturbance was 1.91, in mothers with severe but not persistent depression it was 2.39, and in mothers with severe persistent depression, the odds ratio was 4.84 – all of which were highly significant (P less than .001).

However, when it came to children’s mathematics grades at age 16 and their risk of depression at age 18, only severe persistent postpartum depression in mothers appeared to have a significant adverse effect, the authors reported.

It was associated with a 2.65-fold increase in the likelihood of a child having mathematics grades of D or below (P = .01), and a more than sevenfold increase in the prevalence of depression in offspring at 18 years (P less than .001). There also was a 2.3-fold increase in depression at 18 years in the children of mothers who experienced marked but not persistent postpartum depression (P = .04).

Dr. Netsi of the department of psychiatry at the University of Oxford (England) and her coauthors noted that, in women with persistent postpartum depression, mean Edinburgh Postpartum Depression Scale scores remained relatively stable, from 21 months to 11 years, suggesting an increased risk for prolonged depression.

“Identification of women with [postpartum depression] may be associated with increased treatment costs, but the overall cost to the public sector of perinatal mental health problems is five times more than the cost of improving services, further highlighting that early intervention and effective treatment of perinatal depression are a public health priority,” they wrote.

However, they acknowledged that there were mixed findings in the literature with respect to the impact on child outcomes of treating maternal depression.

“Treatments for [postpartum depression] have been relatively brief in duration and moderate in intensity; therefore, it is perhaps unsurprising that such interventions have not shown long-term benefits for either the mother or the child,” the investigators wrote.

The Avon Longitudinal Study of Parents and Children is supported by the U.K. Medical Research Council, the Wellcome Trust, and the University of Bristol. This study was supported by the Wellcome Trust, the National Institute for Health Research Biomedical Research Centre, the University of Bristol, and the NIHR Oxford Health Biomedical Research Centre. No conflicts of interest were declared.

SOURCE: Netsi E et al. JAMA Psychiatry. 2018 Jan 31. doi: 10.1001/jamapsychiatry.2017.4363.

Persistent and severe postpartum depression in mothers may be associated with behavioral problems, poor mathematics grades, and a higher risk of depression in their offspring, research published Jan. 31 in JAMA Psychiatry showed.

In the study, Elena Netsi, DPhil, and her associates presented an analysis of data from 9,848 mothers and 8,287 children enrolled in the observational Avon Longitudinal Study of Parents and Children.

This analysis revealed that postpartum depression of any severity or level of persistence was associated with a two- to fourfold increase in the risk of children showing behavioral problems at age 3.5 years. In women with marked but not persistent postpartum depression, the odds ratio for child behavioral disturbance was 1.91, in mothers with severe but not persistent depression it was 2.39, and in mothers with severe persistent depression, the odds ratio was 4.84 – all of which were highly significant (P less than .001).

However, when it came to children’s mathematics grades at age 16 and their risk of depression at age 18, only severe persistent postpartum depression in mothers appeared to have a significant adverse effect, the authors reported.

It was associated with a 2.65-fold increase in the likelihood of a child having mathematics grades of D or below (P = .01), and a more than sevenfold increase in the prevalence of depression in offspring at 18 years (P less than .001). There also was a 2.3-fold increase in depression at 18 years in the children of mothers who experienced marked but not persistent postpartum depression (P = .04).

Dr. Netsi of the department of psychiatry at the University of Oxford (England) and her coauthors noted that, in women with persistent postpartum depression, mean Edinburgh Postpartum Depression Scale scores remained relatively stable, from 21 months to 11 years, suggesting an increased risk for prolonged depression.

“Identification of women with [postpartum depression] may be associated with increased treatment costs, but the overall cost to the public sector of perinatal mental health problems is five times more than the cost of improving services, further highlighting that early intervention and effective treatment of perinatal depression are a public health priority,” they wrote.

However, they acknowledged that there were mixed findings in the literature with respect to the impact on child outcomes of treating maternal depression.

“Treatments for [postpartum depression] have been relatively brief in duration and moderate in intensity; therefore, it is perhaps unsurprising that such interventions have not shown long-term benefits for either the mother or the child,” the investigators wrote.

The Avon Longitudinal Study of Parents and Children is supported by the U.K. Medical Research Council, the Wellcome Trust, and the University of Bristol. This study was supported by the Wellcome Trust, the National Institute for Health Research Biomedical Research Centre, the University of Bristol, and the NIHR Oxford Health Biomedical Research Centre. No conflicts of interest were declared.

SOURCE: Netsi E et al. JAMA Psychiatry. 2018 Jan 31. doi: 10.1001/jamapsychiatry.2017.4363.

Persistent and severe postpartum depression in mothers may be associated with behavioral problems, poor mathematics grades, and a higher risk of depression in their offspring, research published Jan. 31 in JAMA Psychiatry showed.

In the study, Elena Netsi, DPhil, and her associates presented an analysis of data from 9,848 mothers and 8,287 children enrolled in the observational Avon Longitudinal Study of Parents and Children.

This analysis revealed that postpartum depression of any severity or level of persistence was associated with a two- to fourfold increase in the risk of children showing behavioral problems at age 3.5 years. In women with marked but not persistent postpartum depression, the odds ratio for child behavioral disturbance was 1.91, in mothers with severe but not persistent depression it was 2.39, and in mothers with severe persistent depression, the odds ratio was 4.84 – all of which were highly significant (P less than .001).

However, when it came to children’s mathematics grades at age 16 and their risk of depression at age 18, only severe persistent postpartum depression in mothers appeared to have a significant adverse effect, the authors reported.

It was associated with a 2.65-fold increase in the likelihood of a child having mathematics grades of D or below (P = .01), and a more than sevenfold increase in the prevalence of depression in offspring at 18 years (P less than .001). There also was a 2.3-fold increase in depression at 18 years in the children of mothers who experienced marked but not persistent postpartum depression (P = .04).

Dr. Netsi of the department of psychiatry at the University of Oxford (England) and her coauthors noted that, in women with persistent postpartum depression, mean Edinburgh Postpartum Depression Scale scores remained relatively stable, from 21 months to 11 years, suggesting an increased risk for prolonged depression.

“Identification of women with [postpartum depression] may be associated with increased treatment costs, but the overall cost to the public sector of perinatal mental health problems is five times more than the cost of improving services, further highlighting that early intervention and effective treatment of perinatal depression are a public health priority,” they wrote.

However, they acknowledged that there were mixed findings in the literature with respect to the impact on child outcomes of treating maternal depression.

“Treatments for [postpartum depression] have been relatively brief in duration and moderate in intensity; therefore, it is perhaps unsurprising that such interventions have not shown long-term benefits for either the mother or the child,” the investigators wrote.

The Avon Longitudinal Study of Parents and Children is supported by the U.K. Medical Research Council, the Wellcome Trust, and the University of Bristol. This study was supported by the Wellcome Trust, the National Institute for Health Research Biomedical Research Centre, the University of Bristol, and the NIHR Oxford Health Biomedical Research Centre. No conflicts of interest were declared.

SOURCE: Netsi E et al. JAMA Psychiatry. 2018 Jan 31. doi: 10.1001/jamapsychiatry.2017.4363.

A combination of curcumin extracted from the turmeric rhizome and boswellic acid extracted from Indian frankincense root beat placebo for reducing pain-related symptoms from knee osteoarthritis in a 12-week clinical trial from Armenia with 201 patients 40-70 years old.

The combination (Curamin) also beat a standalone curcumin preparation (CuraMed), according to a report in BMC Complementary and Alternative Medicine.

©pixologicstudio/Thinkstock

aotto@frontlinemedcom.com

SOURCE: Haroyan A et al. BMC Complement Altern Med. 2018 Jan 9;18:7. doi: 10.1186/s12906-017-2062-z

A combination of curcumin extracted from the turmeric rhizome and boswellic acid extracted from Indian frankincense root beat placebo for reducing pain-related symptoms from knee osteoarthritis in a 12-week clinical trial from Armenia with 201 patients 40-70 years old.

The combination (Curamin) also beat a standalone curcumin preparation (CuraMed), according to a report in BMC Complementary and Alternative Medicine.

©pixologicstudio/Thinkstock

aotto@frontlinemedcom.com

SOURCE: Haroyan A et al. BMC Complement Altern Med. 2018 Jan 9;18:7. doi: 10.1186/s12906-017-2062-z

A combination of curcumin extracted from the turmeric rhizome and boswellic acid extracted from Indian frankincense root beat placebo for reducing pain-related symptoms from knee osteoarthritis in a 12-week clinical trial from Armenia with 201 patients 40-70 years old.

The combination (Curamin) also beat a standalone curcumin preparation (CuraMed), according to a report in BMC Complementary and Alternative Medicine.

©pixologicstudio/Thinkstock

aotto@frontlinemedcom.com

SOURCE: Haroyan A et al. BMC Complement Altern Med. 2018 Jan 9;18:7. doi: 10.1186/s12906-017-2062-z

To improve patient care and outcomes, leading dermatologists offered their recommendations on bar soaps. Consideration must be given to:

• Avène Cold Cream Ultra-Rich Cleansing Bar
  Pierre Fabre Dermo-Cosmetique USA
  “This gentle cleansing bar is not only hypoallergenic, soap free, and lanolin free, it also has Avène’s soothing Thermal Spring Water, plus white beeswax and a noncomedogenic, pharmaceutical-grade paraffin oil to protect the skin.”—Jeannette Graf, MD, Great Neck, New York
   
• Hydrating Cleanser Bar
  CeraVe
  Recommended by Shari Lipner, MD, PhD, New York, New York
   
• Vanicream Cleansing Bar
  Pharmaceutical Specialties, Inc
  “This is a great option for patients with eczema or dry, sensitive skin.”—Gary Goldenberg, MD, New York, New York

Cutis invites readers to send us their recommendations. Lip plumpers, shaving lotions for men, and night creams will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on bar soaps. Consideration must be given to:

• Avène Cold Cream Ultra-Rich Cleansing Bar
  Pierre Fabre Dermo-Cosmetique USA
  “This gentle cleansing bar is not only hypoallergenic, soap free, and lanolin free, it also has Avène’s soothing Thermal Spring Water, plus white beeswax and a noncomedogenic, pharmaceutical-grade paraffin oil to protect the skin.”—Jeannette Graf, MD, Great Neck, New York
   
• Hydrating Cleanser Bar
  CeraVe
  Recommended by Shari Lipner, MD, PhD, New York, New York
   
• Vanicream Cleansing Bar
  Pharmaceutical Specialties, Inc
  “This is a great option for patients with eczema or dry, sensitive skin.”—Gary Goldenberg, MD, New York, New York

Cutis invites readers to send us their recommendations. Lip plumpers, shaving lotions for men, and night creams will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on bar soaps. Consideration must be given to:

• Avène Cold Cream Ultra-Rich Cleansing Bar
  Pierre Fabre Dermo-Cosmetique USA
  “This gentle cleansing bar is not only hypoallergenic, soap free, and lanolin free, it also has Avène’s soothing Thermal Spring Water, plus white beeswax and a noncomedogenic, pharmaceutical-grade paraffin oil to protect the skin.”—Jeannette Graf, MD, Great Neck, New York
   
• Hydrating Cleanser Bar
  CeraVe
  Recommended by Shari Lipner, MD, PhD, New York, New York
   
• Vanicream Cleansing Bar
  Pharmaceutical Specialties, Inc
  “This is a great option for patients with eczema or dry, sensitive skin.”—Gary Goldenberg, MD, New York, New York

Cutis invites readers to send us their recommendations. Lip plumpers, shaving lotions for men, and night creams will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

An announcement Jan. 30 by three of the nation’s corporate titans – Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. – that they are joining forces to address the high costs of employee health care has stirred the health policy pot. It immediately sent shock waves through the health sector of the stock market and reinvigorated talk about health care technology, value, and quality.

Though details regarding the undertaking are thin, the companies said in a statement that their partnership’s intent is to improve employee satisfaction and hold down costs by bringing “their scale and complementary expertise to this long-term effort.”

They plan to create an independent company, “free from profit-making incentives and constraints,” to focus on “technology solutions.”

Berkshire Hathaway CEO Warren Buffett described health care costs as “a hungry tapeworm on the American economy,” and Amazon founder and CEO Jeff Bezos said the partnership was “open-eyed about the degree of difficulty” ahead. Jamie Dimon, chairman and CEO of JPMorgan, said the results could benefit the employees of these companies and possibly all Americans.

But what does all of this mean and how can it be successful when so many other initiatives have fallen short? Kaiser Health News asked a variety of health policy experts for their thoughts on this venture, and what advice they would offer these CEOs as they go forward. Some of the advice has been edited for clarity and length.
 

Tom Miller, resident fellow, American Enterprise Institute:

“It’s great that someone theoretically with resources would try to build a better mousetrap. But it’s been difficult to do, and part of it is regulatory and competitive barriers are well-constructed in the health care sphere, which tend to make it less receptive or subject to competitive pressures.

“I welcome any new capital trying to disrupt health care. … The incumbents are comfortable and could use disruption. If Amazon has an idea, and is willing to put some money behind it, that’s wonderful. What they are willing to do other than fly low-cost providers for home visits in drones – I don’t know. They’d probably have to miniaturize them, wouldn’t they?”
 

Stan Dorn, senior fellow, Families USA:

“Number one, look at prices. America doesn’t use more health care than European countries, but we pay a lot more and that’s because of prices more than anything else. Look at hospital prices and prescription drug prices. I would also say, look to eliminate middlemen operating in darkness. I’m thinking in particular of pharmacy benefit managers. Often, the supply chain is hidden and complex, and every step along the way the middlemen are taking their share, and it winds up costing a huge amount of money.”

Bob Kocher, MD, partner, Venrock:

“It has been said that health care is complicated. One thing that is not complicated is that the way to save money is to focus on the sickest patients. And that’s the only thing that has proven to work in great primary care. I hope Amazon realizes this early and does not think that [its smart digital assistant] Alexa and apps are going to make us healthier and save any money.

“It would sure be nice if they invest in a ‘post-CPT-ICD-10-and-many-bills-per-visit’ world where we know prices, can easily know what is known about quality and experience, and have same-day service.”
 

Tracy Watts, senior partner, Mercer:

“Everyone thinks millennials want to do everything on their phones. But that’s not necessarily the case.

“[There was a recent] survey about this – specifically, millennials are the most interested in new health care offerings, but it wasn’t as much high-tech as it is convenience they are interested in – same-day appointments with a family doctor, guaranteed appointments with specialists, home visits, a wider array of services available at retail clinics. That was kind of an ‘aha’ – this kind of convenience and high-touch experience is what they’re looking for. And when you think of ‘health care of the future,’ that’s not what comes to mind.”
 

John Rother, president and CEO, National Coalition on Health Care:

“Health care is complex and expensive, so the aim should always be simplicity and affordability. Three keys to success: Manage chronic conditions recognizing the life context of the patient, emphasize primary care-based medical homes, and aggressively negotiate prescription drug costs.”

Suzanne Delbanco, executive director, Catalyst for Payment Reform:

“The biggest driver of health care costs is prices. Those are being driven up by health care providers who have consolidated and will continue to consolidate and amass more market power.

“It sounds like they [the companies] are limiting the use of health plans, but if they’re going to get into that business, they’re going to come up with the same challenges health plans face. What would be really innovative would be to build some provider systems from the ground up where they can truly get a handle on the actual costs and eliminate the market power that drives the prices up, and they can have control over their prices.”
 

Brian Marcotte, president and CEO, National Business Group on Health:

“They recognize this is [a] long-term play to get involved in this. I’d have to say, this industry is ripe for disruption.

“I think we know technology will continue to play an increasing role in how consumers access and receive health care. We’ve also learned most consumers do not touch the health care delivery system with enough frequency to ever be a sophisticated consumer. What’s intriguing about this partnership is Amazon for many consumers has become part of their day-to-day world, part of their routine. It’s intriguing to consider the possibilities of integrating health care into consumer routine.

“And I think that therein lies the opportunity. Employers offer a lot of resources to their employees to help them maximize their experience, and their No. 1 challenge is engagement.”
 

Joseph Antos, health economist, American Enterprise Institute:

“My first suggestion is to look at what other employers have done (some unsuccessfully) and consider how to adapt those ideas for the three companies and more broadly. Change incentives for providers. Change incentives for consumers. Work on ways to reduce the effects of market consolidation. The bottom line: Don’t keep doing what we are doing now. I don’t see that these three companies have enough presence in health markets to pull this off anytime soon, but perhaps this should be viewed as the private-sector version of the Affordable Care Act’s Innovation Center – except, this time, there may be some new ideas to test.”

Ceci Connolly, president and CEO, Alliance of Community Health Plans:

“We know that 5% of any population consumes 50% of the health care dollar. I would encourage this group to focus on how to better serve those individuals who need help managing multiple chronic conditions.”

David Lansky, CEO, Pacific Business Group on Health:

“The incumbent providers of services to our members are not doing as much as we need done for affordability and quality. So, we are pleased to see them go down this path. We don’t know what piece of the puzzle they will tackle.

“We know well-intended efforts over the years haven’t added up to material impact on cost and quality. I would suspect they are looking at doing something broader, more disruptive than initiatives we have tried before.

“I think across the board they have the opportunity to set high standards for the health system in whatever platform they use. These companies have a history of raising the bar. Potentially, it could be a help to all of us.”
 

Staff writers Julie Appleby, Rachel Bluth, Jenny Gold, Jay Hancock, Shefali Luthra, Jordan Rau, Julie Rovner and Chad Terhune contributed to this report. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

An announcement Jan. 30 by three of the nation’s corporate titans – Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. – that they are joining forces to address the high costs of employee health care has stirred the health policy pot. It immediately sent shock waves through the health sector of the stock market and reinvigorated talk about health care technology, value, and quality.

Though details regarding the undertaking are thin, the companies said in a statement that their partnership’s intent is to improve employee satisfaction and hold down costs by bringing “their scale and complementary expertise to this long-term effort.”

They plan to create an independent company, “free from profit-making incentives and constraints,” to focus on “technology solutions.”

Berkshire Hathaway CEO Warren Buffett described health care costs as “a hungry tapeworm on the American economy,” and Amazon founder and CEO Jeff Bezos said the partnership was “open-eyed about the degree of difficulty” ahead. Jamie Dimon, chairman and CEO of JPMorgan, said the results could benefit the employees of these companies and possibly all Americans.

But what does all of this mean and how can it be successful when so many other initiatives have fallen short? Kaiser Health News asked a variety of health policy experts for their thoughts on this venture, and what advice they would offer these CEOs as they go forward. Some of the advice has been edited for clarity and length.
 

Tom Miller, resident fellow, American Enterprise Institute:

“It’s great that someone theoretically with resources would try to build a better mousetrap. But it’s been difficult to do, and part of it is regulatory and competitive barriers are well-constructed in the health care sphere, which tend to make it less receptive or subject to competitive pressures.

“I welcome any new capital trying to disrupt health care. … The incumbents are comfortable and could use disruption. If Amazon has an idea, and is willing to put some money behind it, that’s wonderful. What they are willing to do other than fly low-cost providers for home visits in drones – I don’t know. They’d probably have to miniaturize them, wouldn’t they?”
 

Stan Dorn, senior fellow, Families USA:

“Number one, look at prices. America doesn’t use more health care than European countries, but we pay a lot more and that’s because of prices more than anything else. Look at hospital prices and prescription drug prices. I would also say, look to eliminate middlemen operating in darkness. I’m thinking in particular of pharmacy benefit managers. Often, the supply chain is hidden and complex, and every step along the way the middlemen are taking their share, and it winds up costing a huge amount of money.”

Bob Kocher, MD, partner, Venrock:

“It has been said that health care is complicated. One thing that is not complicated is that the way to save money is to focus on the sickest patients. And that’s the only thing that has proven to work in great primary care. I hope Amazon realizes this early and does not think that [its smart digital assistant] Alexa and apps are going to make us healthier and save any money.

“It would sure be nice if they invest in a ‘post-CPT-ICD-10-and-many-bills-per-visit’ world where we know prices, can easily know what is known about quality and experience, and have same-day service.”
 

Tracy Watts, senior partner, Mercer:

“Everyone thinks millennials want to do everything on their phones. But that’s not necessarily the case.

“[There was a recent] survey about this – specifically, millennials are the most interested in new health care offerings, but it wasn’t as much high-tech as it is convenience they are interested in – same-day appointments with a family doctor, guaranteed appointments with specialists, home visits, a wider array of services available at retail clinics. That was kind of an ‘aha’ – this kind of convenience and high-touch experience is what they’re looking for. And when you think of ‘health care of the future,’ that’s not what comes to mind.”
 

John Rother, president and CEO, National Coalition on Health Care:

“Health care is complex and expensive, so the aim should always be simplicity and affordability. Three keys to success: Manage chronic conditions recognizing the life context of the patient, emphasize primary care-based medical homes, and aggressively negotiate prescription drug costs.”

Suzanne Delbanco, executive director, Catalyst for Payment Reform:

“The biggest driver of health care costs is prices. Those are being driven up by health care providers who have consolidated and will continue to consolidate and amass more market power.

“It sounds like they [the companies] are limiting the use of health plans, but if they’re going to get into that business, they’re going to come up with the same challenges health plans face. What would be really innovative would be to build some provider systems from the ground up where they can truly get a handle on the actual costs and eliminate the market power that drives the prices up, and they can have control over their prices.”
 

Brian Marcotte, president and CEO, National Business Group on Health:

“They recognize this is [a] long-term play to get involved in this. I’d have to say, this industry is ripe for disruption.

“I think we know technology will continue to play an increasing role in how consumers access and receive health care. We’ve also learned most consumers do not touch the health care delivery system with enough frequency to ever be a sophisticated consumer. What’s intriguing about this partnership is Amazon for many consumers has become part of their day-to-day world, part of their routine. It’s intriguing to consider the possibilities of integrating health care into consumer routine.

“And I think that therein lies the opportunity. Employers offer a lot of resources to their employees to help them maximize their experience, and their No. 1 challenge is engagement.”
 

Joseph Antos, health economist, American Enterprise Institute:

“My first suggestion is to look at what other employers have done (some unsuccessfully) and consider how to adapt those ideas for the three companies and more broadly. Change incentives for providers. Change incentives for consumers. Work on ways to reduce the effects of market consolidation. The bottom line: Don’t keep doing what we are doing now. I don’t see that these three companies have enough presence in health markets to pull this off anytime soon, but perhaps this should be viewed as the private-sector version of the Affordable Care Act’s Innovation Center – except, this time, there may be some new ideas to test.”

Ceci Connolly, president and CEO, Alliance of Community Health Plans:

“We know that 5% of any population consumes 50% of the health care dollar. I would encourage this group to focus on how to better serve those individuals who need help managing multiple chronic conditions.”

David Lansky, CEO, Pacific Business Group on Health:

“The incumbent providers of services to our members are not doing as much as we need done for affordability and quality. So, we are pleased to see them go down this path. We don’t know what piece of the puzzle they will tackle.

“We know well-intended efforts over the years haven’t added up to material impact on cost and quality. I would suspect they are looking at doing something broader, more disruptive than initiatives we have tried before.

“I think across the board they have the opportunity to set high standards for the health system in whatever platform they use. These companies have a history of raising the bar. Potentially, it could be a help to all of us.”
 

Staff writers Julie Appleby, Rachel Bluth, Jenny Gold, Jay Hancock, Shefali Luthra, Jordan Rau, Julie Rovner and Chad Terhune contributed to this report. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

An announcement Jan. 30 by three of the nation’s corporate titans – Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. – that they are joining forces to address the high costs of employee health care has stirred the health policy pot. It immediately sent shock waves through the health sector of the stock market and reinvigorated talk about health care technology, value, and quality.

Though details regarding the undertaking are thin, the companies said in a statement that their partnership’s intent is to improve employee satisfaction and hold down costs by bringing “their scale and complementary expertise to this long-term effort.”

They plan to create an independent company, “free from profit-making incentives and constraints,” to focus on “technology solutions.”

Berkshire Hathaway CEO Warren Buffett described health care costs as “a hungry tapeworm on the American economy,” and Amazon founder and CEO Jeff Bezos said the partnership was “open-eyed about the degree of difficulty” ahead. Jamie Dimon, chairman and CEO of JPMorgan, said the results could benefit the employees of these companies and possibly all Americans.

But what does all of this mean and how can it be successful when so many other initiatives have fallen short? Kaiser Health News asked a variety of health policy experts for their thoughts on this venture, and what advice they would offer these CEOs as they go forward. Some of the advice has been edited for clarity and length.
 

Tom Miller, resident fellow, American Enterprise Institute:

“It’s great that someone theoretically with resources would try to build a better mousetrap. But it’s been difficult to do, and part of it is regulatory and competitive barriers are well-constructed in the health care sphere, which tend to make it less receptive or subject to competitive pressures.

“I welcome any new capital trying to disrupt health care. … The incumbents are comfortable and could use disruption. If Amazon has an idea, and is willing to put some money behind it, that’s wonderful. What they are willing to do other than fly low-cost providers for home visits in drones – I don’t know. They’d probably have to miniaturize them, wouldn’t they?”
 

Stan Dorn, senior fellow, Families USA:

“Number one, look at prices. America doesn’t use more health care than European countries, but we pay a lot more and that’s because of prices more than anything else. Look at hospital prices and prescription drug prices. I would also say, look to eliminate middlemen operating in darkness. I’m thinking in particular of pharmacy benefit managers. Often, the supply chain is hidden and complex, and every step along the way the middlemen are taking their share, and it winds up costing a huge amount of money.”

Bob Kocher, MD, partner, Venrock:

“It has been said that health care is complicated. One thing that is not complicated is that the way to save money is to focus on the sickest patients. And that’s the only thing that has proven to work in great primary care. I hope Amazon realizes this early and does not think that [its smart digital assistant] Alexa and apps are going to make us healthier and save any money.

“It would sure be nice if they invest in a ‘post-CPT-ICD-10-and-many-bills-per-visit’ world where we know prices, can easily know what is known about quality and experience, and have same-day service.”
 

Tracy Watts, senior partner, Mercer:

“Everyone thinks millennials want to do everything on their phones. But that’s not necessarily the case.

“[There was a recent] survey about this – specifically, millennials are the most interested in new health care offerings, but it wasn’t as much high-tech as it is convenience they are interested in – same-day appointments with a family doctor, guaranteed appointments with specialists, home visits, a wider array of services available at retail clinics. That was kind of an ‘aha’ – this kind of convenience and high-touch experience is what they’re looking for. And when you think of ‘health care of the future,’ that’s not what comes to mind.”
 

John Rother, president and CEO, National Coalition on Health Care:

“Health care is complex and expensive, so the aim should always be simplicity and affordability. Three keys to success: Manage chronic conditions recognizing the life context of the patient, emphasize primary care-based medical homes, and aggressively negotiate prescription drug costs.”

Suzanne Delbanco, executive director, Catalyst for Payment Reform:

“The biggest driver of health care costs is prices. Those are being driven up by health care providers who have consolidated and will continue to consolidate and amass more market power.

“It sounds like they [the companies] are limiting the use of health plans, but if they’re going to get into that business, they’re going to come up with the same challenges health plans face. What would be really innovative would be to build some provider systems from the ground up where they can truly get a handle on the actual costs and eliminate the market power that drives the prices up, and they can have control over their prices.”
 

Brian Marcotte, president and CEO, National Business Group on Health:

“They recognize this is [a] long-term play to get involved in this. I’d have to say, this industry is ripe for disruption.

“I think we know technology will continue to play an increasing role in how consumers access and receive health care. We’ve also learned most consumers do not touch the health care delivery system with enough frequency to ever be a sophisticated consumer. What’s intriguing about this partnership is Amazon for many consumers has become part of their day-to-day world, part of their routine. It’s intriguing to consider the possibilities of integrating health care into consumer routine.

“And I think that therein lies the opportunity. Employers offer a lot of resources to their employees to help them maximize their experience, and their No. 1 challenge is engagement.”
 

Joseph Antos, health economist, American Enterprise Institute:

“My first suggestion is to look at what other employers have done (some unsuccessfully) and consider how to adapt those ideas for the three companies and more broadly. Change incentives for providers. Change incentives for consumers. Work on ways to reduce the effects of market consolidation. The bottom line: Don’t keep doing what we are doing now. I don’t see that these three companies have enough presence in health markets to pull this off anytime soon, but perhaps this should be viewed as the private-sector version of the Affordable Care Act’s Innovation Center – except, this time, there may be some new ideas to test.”

Ceci Connolly, president and CEO, Alliance of Community Health Plans:

“We know that 5% of any population consumes 50% of the health care dollar. I would encourage this group to focus on how to better serve those individuals who need help managing multiple chronic conditions.”

David Lansky, CEO, Pacific Business Group on Health:

“The incumbent providers of services to our members are not doing as much as we need done for affordability and quality. So, we are pleased to see them go down this path. We don’t know what piece of the puzzle they will tackle.

“We know well-intended efforts over the years haven’t added up to material impact on cost and quality. I would suspect they are looking at doing something broader, more disruptive than initiatives we have tried before.

“I think across the board they have the opportunity to set high standards for the health system in whatever platform they use. These companies have a history of raising the bar. Potentially, it could be a help to all of us.”
 

Staff writers Julie Appleby, Rachel Bluth, Jenny Gold, Jay Hancock, Shefali Luthra, Jordan Rau, Julie Rovner and Chad Terhune contributed to this report. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Janus kinase inhibitors look promising in the treatment of severe alopecia areata, particularly in adolescents, said Lucy Yichu Liu, MD, and Brett Andrew King, MD, of Yale University, New Haven, Conn.

Standard medical therapies for alopecia areata – usually topical or injected corticosteroids and allergic contact sensitization – are not very effective for severe disease, particularly alopecia totalis and alopecia universalis. The Janus kinase (JAK) pathway recently has been suggested as a target for treatment.

Dr. Liu and Dr. King reviewed several studies, including a retrospective cohort study of 13 patients aged 12-17 years, in which 7 patients had 100% hair loss and 6 had 20%-70% scalp hair loss. The adolescents were treated with the JAK1/3 inhibitor tofacitinib citrate 5 mg twice daily for 2-16 months (median, 5 months). That led to 93% median improvement in Severity of Alopecia Tool (SALT) score (range, 1%-100%) from baseline. Nine patients experienced hair regrowth. There were mild adverse effects, such as upper respiratory infections and headaches.

Courtesy RegionalDerm.com

SOURCE: Liu LY et al. J Investig Dermatol Symp Proc. 2018 Jan. doi: 10.1016/j.jisp.2017.10.003.

Janus kinase inhibitors look promising in the treatment of severe alopecia areata, particularly in adolescents, said Lucy Yichu Liu, MD, and Brett Andrew King, MD, of Yale University, New Haven, Conn.

Standard medical therapies for alopecia areata – usually topical or injected corticosteroids and allergic contact sensitization – are not very effective for severe disease, particularly alopecia totalis and alopecia universalis. The Janus kinase (JAK) pathway recently has been suggested as a target for treatment.

Dr. Liu and Dr. King reviewed several studies, including a retrospective cohort study of 13 patients aged 12-17 years, in which 7 patients had 100% hair loss and 6 had 20%-70% scalp hair loss. The adolescents were treated with the JAK1/3 inhibitor tofacitinib citrate 5 mg twice daily for 2-16 months (median, 5 months). That led to 93% median improvement in Severity of Alopecia Tool (SALT) score (range, 1%-100%) from baseline. Nine patients experienced hair regrowth. There were mild adverse effects, such as upper respiratory infections and headaches.

Courtesy RegionalDerm.com

SOURCE: Liu LY et al. J Investig Dermatol Symp Proc. 2018 Jan. doi: 10.1016/j.jisp.2017.10.003.

Janus kinase inhibitors look promising in the treatment of severe alopecia areata, particularly in adolescents, said Lucy Yichu Liu, MD, and Brett Andrew King, MD, of Yale University, New Haven, Conn.

Standard medical therapies for alopecia areata – usually topical or injected corticosteroids and allergic contact sensitization – are not very effective for severe disease, particularly alopecia totalis and alopecia universalis. The Janus kinase (JAK) pathway recently has been suggested as a target for treatment.

Dr. Liu and Dr. King reviewed several studies, including a retrospective cohort study of 13 patients aged 12-17 years, in which 7 patients had 100% hair loss and 6 had 20%-70% scalp hair loss. The adolescents were treated with the JAK1/3 inhibitor tofacitinib citrate 5 mg twice daily for 2-16 months (median, 5 months). That led to 93% median improvement in Severity of Alopecia Tool (SALT) score (range, 1%-100%) from baseline. Nine patients experienced hair regrowth. There were mild adverse effects, such as upper respiratory infections and headaches.

Courtesy RegionalDerm.com

SOURCE: Liu LY et al. J Investig Dermatol Symp Proc. 2018 Jan. doi: 10.1016/j.jisp.2017.10.003.

Brenda Fitzgerald, MD, director of the Centers for Disease Control and Prevention, resigned Jan. 31 after reports surfaced on the public affairs website Politico that she purchased shares of Japan Tobacco about 1 month after becoming the agency’s director.

Dr. Fitzgerald, an ob.gyn., also bought stock in Merck & Co., Bayer, and Humana after joining the Trump Administration in July 2017, according to the report. Financial disclosure records confirm that she sold the tobacco stock in October and “all of her stock holdings above $1,000 by Nov. 21, more than 4 months after she became CDC director,” according to the Politico report.

According to a spokesperson for the Health and Human Services department, “This morning Secretary Azar accepted Dr. Brenda Fitzgerald’s resignation as Director of the Centers for Disease Control and Prevention.

“Dr. Fitzgerald owns certain complex financial interests that have imposed a broad recusal limiting her ability to complete all of her duties as the CDC Director. Due to the nature of these financial interests, Dr. Fitzgerald could not divest from them in a definitive time period. After advising Secretary Azar of both the status of the financial interests and the scope of her recusal, Dr. Fitzgerald tendered, and the Secretary accepted, her resignation. The Secretary thanks Dr. Brenda Fitzgerald for her service and wishes her the best in all her endeavors,” according to a report on CNBC.
 

rfranki@frontlinemedcom.com

Brenda Fitzgerald, MD, director of the Centers for Disease Control and Prevention, resigned Jan. 31 after reports surfaced on the public affairs website Politico that she purchased shares of Japan Tobacco about 1 month after becoming the agency’s director.

Dr. Fitzgerald, an ob.gyn., also bought stock in Merck & Co., Bayer, and Humana after joining the Trump Administration in July 2017, according to the report. Financial disclosure records confirm that she sold the tobacco stock in October and “all of her stock holdings above $1,000 by Nov. 21, more than 4 months after she became CDC director,” according to the Politico report.

According to a spokesperson for the Health and Human Services department, “This morning Secretary Azar accepted Dr. Brenda Fitzgerald’s resignation as Director of the Centers for Disease Control and Prevention.

“Dr. Fitzgerald owns certain complex financial interests that have imposed a broad recusal limiting her ability to complete all of her duties as the CDC Director. Due to the nature of these financial interests, Dr. Fitzgerald could not divest from them in a definitive time period. After advising Secretary Azar of both the status of the financial interests and the scope of her recusal, Dr. Fitzgerald tendered, and the Secretary accepted, her resignation. The Secretary thanks Dr. Brenda Fitzgerald for her service and wishes her the best in all her endeavors,” according to a report on CNBC.
 

rfranki@frontlinemedcom.com

Brenda Fitzgerald, MD, director of the Centers for Disease Control and Prevention, resigned Jan. 31 after reports surfaced on the public affairs website Politico that she purchased shares of Japan Tobacco about 1 month after becoming the agency’s director.

Dr. Fitzgerald, an ob.gyn., also bought stock in Merck & Co., Bayer, and Humana after joining the Trump Administration in July 2017, according to the report. Financial disclosure records confirm that she sold the tobacco stock in October and “all of her stock holdings above $1,000 by Nov. 21, more than 4 months after she became CDC director,” according to the Politico report.

According to a spokesperson for the Health and Human Services department, “This morning Secretary Azar accepted Dr. Brenda Fitzgerald’s resignation as Director of the Centers for Disease Control and Prevention.

“Dr. Fitzgerald owns certain complex financial interests that have imposed a broad recusal limiting her ability to complete all of her duties as the CDC Director. Due to the nature of these financial interests, Dr. Fitzgerald could not divest from them in a definitive time period. After advising Secretary Azar of both the status of the financial interests and the scope of her recusal, Dr. Fitzgerald tendered, and the Secretary accepted, her resignation. The Secretary thanks Dr. Brenda Fitzgerald for her service and wishes her the best in all her endeavors,” according to a report on CNBC.
 

rfranki@frontlinemedcom.com