Whitney McKnight

SCOTTSDALE, ARIZ. – The application of simple low-cost interventions and hands-on care, as well as enlisting the patient to participate in care for him or herself, can help vascular specialists achieve favorable outcomes when managing patients in an era of increased regulation.

That was the message of an expert panel assembled to deliver “clinically pertinent information in the midst of a regulatory system that is driving us down a [certain] pathway whether or not we want to go,” panelist Dr. Bruce H. Gray, a vascular surgeon at Greenville (S.C.) Health System, told the audience at this year’s annual meeting of the Southern Association for Vascular Surgery.

Whitney McKnight/Frontline Medical News

Under the Affordable Care Act, there has been “a shift from structure and process to now just outcomes,” according to panelist Dr. John W. Hallett Jr., a clinical professor of surgery at the Medical University of South Carolina and chief medical officer at the Roper St. Francis Vascular Care Center, both in Charleston.

Incentives now penalties

The Patient Quality Reporting System (formerly called the Physicians Quality Reporting Initiative) was the first national program designed by the Centers for Medicare & Medicaid Services to link the reporting of quality data to physician payment. There are six quality strategy domains in the PQRS: effective clinical care; patient safety; communication and care coordination; person- and caregiver-centered experience and outcomes; efficiency and cost reduction; and community and population health. Physicians must satisfy at least three of the six or risk penalties.

Initially intended as an incentive program when it was launched as part of the Tax Relief and Health Care Act of 2006, physicians who voluntarily reported their quality data were awarded a 2% bonus on their yearly CMS payment. Although still referred to by CMS as an incentive program, beginning this year, physician-reported quality data considered by the PQRS criteria as negative will be used to assess a penalty up to 1.5% against their expected CMS payment for that year. In 2016, the penalty is set to increase to 2% of the physician’s CMS payment. “They call the reporting voluntary but now there’s a penalty if you don’t report it,” said panelist Dr. Adam W. Beck, a vascular surgeon at the University of Florida.

Searching for evidence

However, much of the criteria used by the PRQS to evaluate a vascular surgeon’s performance, and thus what he or she will be paid, is not evidence based, according to Dr. Beck. For example, one CMS vascular surgery quality measure in place considers that open repair of a 6 cm or less nonruptured abdominal aortic aneurysm without major complications should result in the patient being discharged postoperatively on day 7.

“The idea is that this is a purely elective operation so in theory, that patient should not die, and should not have major complications, and so can go home on day 7,” Dr. Beck said. “But we don’t really know if that’s true. Some of us are working on figuring out if any of these [measures] are useful or not.”

Similarly, Dr. Gray said that, since its publication in 2005, the BASIL (Bypass vs. Angioplasty in Severe Ischemia of the Leg) trial, which supported surgery over balloon angioplasty for improved long-term outcomes in patients with peripheral artery disease, has been the de facto benchmark for predicting death in this patient cohort, a necessary consideration when choosing a treatment algorithm.

This, despite what he suggested were generalizations gleaned from the data that are not always appropriate, particularly when considering claudication. “Only 11% of those critical limb ischemia patients who were eligible for the trial were randomized to any of the study’s six sites. This trial cannot be extrapolated to our entire heterogeneous CLI population,” Dr. Gray said.

This was true, too, he said, not only because a minority of the patients had angioplasty at multiple levels, but because the patient assessment and mortality rate criteria in the study may not actually coincide with how other specialists assess their patients and predict mortality, as evidenced by a number of studies that have been published since BASIL, all of which relied on different criteria for determining two-year mortality rates.

“The BASIL trial recommendation that we should know the life expectancy of our patients has popped up in the literature more and more, and I have thought long and hard about how that impacts my clinical practice decision tree,” Dr. Gray said, concluding that ultimately, predicting mortality is beside the point. “Mortality is inevitable and sooner in CLI patients. The best care has less to do with predicting mortality, but requires ... the integrity to choose the right procedure for the right patient at the right time.”

Assessing how much muscle and functional mobility a patient has in order to help determine which treatment is best, and not overrelying on electronic health records can also impact outcomes. “You don’t need too many fancy tests to tell what a patient’s functional level is,” he said, adding “there is no substitute for putting your own eyes on the patient.”

Patient participation

Despite the pressure on physicians to perform well on the PQRS, there are many factors beyond their control, such as a patient’s choice to smoke. That’s why using “teachable moments” that remind patients of their own power to improve their chances for recovery is more important than ever, as is clear communication with the patient about what they can expect both pre- and post-surgery, according to Dr. Hallett. “The challenge of taking care of these patients is much more than our technical skill.”

Combining a medical tobacco-cessation program with teletherapeutic programs such as the federally funded 1-800-QUIT-NOW line can be of support to patients, as are phone-based counseling sessions to remind patients to fill their prescriptions and to take them once they do, said Dr. Hallett.

Motivating patients to participate in their recovery should not be left to others, however. Dr. Hallett said has found that leaning on his authority as the surgeon is more effective than leaving the role of adviser to “physician extenders.”

“I can do a teachable moment in less than 5 minutes,” he said in an interview. “For me to say to the patient, ‘Smoking is one of the reasons you have this bad leg. I would really like to help you with stopping. Are you interested?’ Coming from me, it’s much more powerful than from anyone else [on my staff].”

In addition, adhering to low- or no-cost postoperative protocols such as keeping patients warm, and administering both aspirin and a statin at discharge can help improve patient outcomes by as much as 20%, according to Dr. Hallett.

Above all else, Dr. Hallett urged vascular surgeons to focus on the long-term care of patients, or risk not only poor outcomes and lower reimbursements, but also loss of control over the patient’s care.

“If we don’t take care of them, they lose the integrated care they need,” Dr. Hallett said in an interview. “The primary care doctors are too frappin’ busy. I see 15-18 patients a day; they’ll see twice that.”

To that end, he recommended giving patients a thorough cardiovascular exam that includes a complete lipid profile and a review of their medications, particularly since the patient’s primary care doctors aren’t always as attentive to vascular concerns. “You are the long-term cardiovascular doc for these patients. You give the advice, you check their drugs, and you, the surgeon, needs to set their expectations, not someone else,” Dr. Hallett concluded.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – The application of simple low-cost interventions and hands-on care, as well as enlisting the patient to participate in care for him or herself, can help vascular specialists achieve favorable outcomes when managing patients in an era of increased regulation.

That was the message of an expert panel assembled to deliver “clinically pertinent information in the midst of a regulatory system that is driving us down a [certain] pathway whether or not we want to go,” panelist Dr. Bruce H. Gray, a vascular surgeon at Greenville (S.C.) Health System, told the audience at this year’s annual meeting of the Southern Association for Vascular Surgery.

Whitney McKnight/Frontline Medical News

Under the Affordable Care Act, there has been “a shift from structure and process to now just outcomes,” according to panelist Dr. John W. Hallett Jr., a clinical professor of surgery at the Medical University of South Carolina and chief medical officer at the Roper St. Francis Vascular Care Center, both in Charleston.

Incentives now penalties

The Patient Quality Reporting System (formerly called the Physicians Quality Reporting Initiative) was the first national program designed by the Centers for Medicare & Medicaid Services to link the reporting of quality data to physician payment. There are six quality strategy domains in the PQRS: effective clinical care; patient safety; communication and care coordination; person- and caregiver-centered experience and outcomes; efficiency and cost reduction; and community and population health. Physicians must satisfy at least three of the six or risk penalties.

Initially intended as an incentive program when it was launched as part of the Tax Relief and Health Care Act of 2006, physicians who voluntarily reported their quality data were awarded a 2% bonus on their yearly CMS payment. Although still referred to by CMS as an incentive program, beginning this year, physician-reported quality data considered by the PQRS criteria as negative will be used to assess a penalty up to 1.5% against their expected CMS payment for that year. In 2016, the penalty is set to increase to 2% of the physician’s CMS payment. “They call the reporting voluntary but now there’s a penalty if you don’t report it,” said panelist Dr. Adam W. Beck, a vascular surgeon at the University of Florida.

Searching for evidence

However, much of the criteria used by the PRQS to evaluate a vascular surgeon’s performance, and thus what he or she will be paid, is not evidence based, according to Dr. Beck. For example, one CMS vascular surgery quality measure in place considers that open repair of a 6 cm or less nonruptured abdominal aortic aneurysm without major complications should result in the patient being discharged postoperatively on day 7.

“The idea is that this is a purely elective operation so in theory, that patient should not die, and should not have major complications, and so can go home on day 7,” Dr. Beck said. “But we don’t really know if that’s true. Some of us are working on figuring out if any of these [measures] are useful or not.”

Similarly, Dr. Gray said that, since its publication in 2005, the BASIL (Bypass vs. Angioplasty in Severe Ischemia of the Leg) trial, which supported surgery over balloon angioplasty for improved long-term outcomes in patients with peripheral artery disease, has been the de facto benchmark for predicting death in this patient cohort, a necessary consideration when choosing a treatment algorithm.

This, despite what he suggested were generalizations gleaned from the data that are not always appropriate, particularly when considering claudication. “Only 11% of those critical limb ischemia patients who were eligible for the trial were randomized to any of the study’s six sites. This trial cannot be extrapolated to our entire heterogeneous CLI population,” Dr. Gray said.

This was true, too, he said, not only because a minority of the patients had angioplasty at multiple levels, but because the patient assessment and mortality rate criteria in the study may not actually coincide with how other specialists assess their patients and predict mortality, as evidenced by a number of studies that have been published since BASIL, all of which relied on different criteria for determining two-year mortality rates.

“The BASIL trial recommendation that we should know the life expectancy of our patients has popped up in the literature more and more, and I have thought long and hard about how that impacts my clinical practice decision tree,” Dr. Gray said, concluding that ultimately, predicting mortality is beside the point. “Mortality is inevitable and sooner in CLI patients. The best care has less to do with predicting mortality, but requires ... the integrity to choose the right procedure for the right patient at the right time.”

Assessing how much muscle and functional mobility a patient has in order to help determine which treatment is best, and not overrelying on electronic health records can also impact outcomes. “You don’t need too many fancy tests to tell what a patient’s functional level is,” he said, adding “there is no substitute for putting your own eyes on the patient.”

Patient participation

Despite the pressure on physicians to perform well on the PQRS, there are many factors beyond their control, such as a patient’s choice to smoke. That’s why using “teachable moments” that remind patients of their own power to improve their chances for recovery is more important than ever, as is clear communication with the patient about what they can expect both pre- and post-surgery, according to Dr. Hallett. “The challenge of taking care of these patients is much more than our technical skill.”

Combining a medical tobacco-cessation program with teletherapeutic programs such as the federally funded 1-800-QUIT-NOW line can be of support to patients, as are phone-based counseling sessions to remind patients to fill their prescriptions and to take them once they do, said Dr. Hallett.

Motivating patients to participate in their recovery should not be left to others, however. Dr. Hallett said has found that leaning on his authority as the surgeon is more effective than leaving the role of adviser to “physician extenders.”

“I can do a teachable moment in less than 5 minutes,” he said in an interview. “For me to say to the patient, ‘Smoking is one of the reasons you have this bad leg. I would really like to help you with stopping. Are you interested?’ Coming from me, it’s much more powerful than from anyone else [on my staff].”

In addition, adhering to low- or no-cost postoperative protocols such as keeping patients warm, and administering both aspirin and a statin at discharge can help improve patient outcomes by as much as 20%, according to Dr. Hallett.

Above all else, Dr. Hallett urged vascular surgeons to focus on the long-term care of patients, or risk not only poor outcomes and lower reimbursements, but also loss of control over the patient’s care.

“If we don’t take care of them, they lose the integrated care they need,” Dr. Hallett said in an interview. “The primary care doctors are too frappin’ busy. I see 15-18 patients a day; they’ll see twice that.”

To that end, he recommended giving patients a thorough cardiovascular exam that includes a complete lipid profile and a review of their medications, particularly since the patient’s primary care doctors aren’t always as attentive to vascular concerns. “You are the long-term cardiovascular doc for these patients. You give the advice, you check their drugs, and you, the surgeon, needs to set their expectations, not someone else,” Dr. Hallett concluded.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – The application of simple low-cost interventions and hands-on care, as well as enlisting the patient to participate in care for him or herself, can help vascular specialists achieve favorable outcomes when managing patients in an era of increased regulation.

That was the message of an expert panel assembled to deliver “clinically pertinent information in the midst of a regulatory system that is driving us down a [certain] pathway whether or not we want to go,” panelist Dr. Bruce H. Gray, a vascular surgeon at Greenville (S.C.) Health System, told the audience at this year’s annual meeting of the Southern Association for Vascular Surgery.

Whitney McKnight/Frontline Medical News

Under the Affordable Care Act, there has been “a shift from structure and process to now just outcomes,” according to panelist Dr. John W. Hallett Jr., a clinical professor of surgery at the Medical University of South Carolina and chief medical officer at the Roper St. Francis Vascular Care Center, both in Charleston.

Incentives now penalties

The Patient Quality Reporting System (formerly called the Physicians Quality Reporting Initiative) was the first national program designed by the Centers for Medicare & Medicaid Services to link the reporting of quality data to physician payment. There are six quality strategy domains in the PQRS: effective clinical care; patient safety; communication and care coordination; person- and caregiver-centered experience and outcomes; efficiency and cost reduction; and community and population health. Physicians must satisfy at least three of the six or risk penalties.

Initially intended as an incentive program when it was launched as part of the Tax Relief and Health Care Act of 2006, physicians who voluntarily reported their quality data were awarded a 2% bonus on their yearly CMS payment. Although still referred to by CMS as an incentive program, beginning this year, physician-reported quality data considered by the PQRS criteria as negative will be used to assess a penalty up to 1.5% against their expected CMS payment for that year. In 2016, the penalty is set to increase to 2% of the physician’s CMS payment. “They call the reporting voluntary but now there’s a penalty if you don’t report it,” said panelist Dr. Adam W. Beck, a vascular surgeon at the University of Florida.

Searching for evidence

However, much of the criteria used by the PRQS to evaluate a vascular surgeon’s performance, and thus what he or she will be paid, is not evidence based, according to Dr. Beck. For example, one CMS vascular surgery quality measure in place considers that open repair of a 6 cm or less nonruptured abdominal aortic aneurysm without major complications should result in the patient being discharged postoperatively on day 7.

“The idea is that this is a purely elective operation so in theory, that patient should not die, and should not have major complications, and so can go home on day 7,” Dr. Beck said. “But we don’t really know if that’s true. Some of us are working on figuring out if any of these [measures] are useful or not.”

Similarly, Dr. Gray said that, since its publication in 2005, the BASIL (Bypass vs. Angioplasty in Severe Ischemia of the Leg) trial, which supported surgery over balloon angioplasty for improved long-term outcomes in patients with peripheral artery disease, has been the de facto benchmark for predicting death in this patient cohort, a necessary consideration when choosing a treatment algorithm.

This, despite what he suggested were generalizations gleaned from the data that are not always appropriate, particularly when considering claudication. “Only 11% of those critical limb ischemia patients who were eligible for the trial were randomized to any of the study’s six sites. This trial cannot be extrapolated to our entire heterogeneous CLI population,” Dr. Gray said.

This was true, too, he said, not only because a minority of the patients had angioplasty at multiple levels, but because the patient assessment and mortality rate criteria in the study may not actually coincide with how other specialists assess their patients and predict mortality, as evidenced by a number of studies that have been published since BASIL, all of which relied on different criteria for determining two-year mortality rates.

“The BASIL trial recommendation that we should know the life expectancy of our patients has popped up in the literature more and more, and I have thought long and hard about how that impacts my clinical practice decision tree,” Dr. Gray said, concluding that ultimately, predicting mortality is beside the point. “Mortality is inevitable and sooner in CLI patients. The best care has less to do with predicting mortality, but requires ... the integrity to choose the right procedure for the right patient at the right time.”

Assessing how much muscle and functional mobility a patient has in order to help determine which treatment is best, and not overrelying on electronic health records can also impact outcomes. “You don’t need too many fancy tests to tell what a patient’s functional level is,” he said, adding “there is no substitute for putting your own eyes on the patient.”

Patient participation

Despite the pressure on physicians to perform well on the PQRS, there are many factors beyond their control, such as a patient’s choice to smoke. That’s why using “teachable moments” that remind patients of their own power to improve their chances for recovery is more important than ever, as is clear communication with the patient about what they can expect both pre- and post-surgery, according to Dr. Hallett. “The challenge of taking care of these patients is much more than our technical skill.”

Combining a medical tobacco-cessation program with teletherapeutic programs such as the federally funded 1-800-QUIT-NOW line can be of support to patients, as are phone-based counseling sessions to remind patients to fill their prescriptions and to take them once they do, said Dr. Hallett.

Motivating patients to participate in their recovery should not be left to others, however. Dr. Hallett said has found that leaning on his authority as the surgeon is more effective than leaving the role of adviser to “physician extenders.”

“I can do a teachable moment in less than 5 minutes,” he said in an interview. “For me to say to the patient, ‘Smoking is one of the reasons you have this bad leg. I would really like to help you with stopping. Are you interested?’ Coming from me, it’s much more powerful than from anyone else [on my staff].”

In addition, adhering to low- or no-cost postoperative protocols such as keeping patients warm, and administering both aspirin and a statin at discharge can help improve patient outcomes by as much as 20%, according to Dr. Hallett.

Above all else, Dr. Hallett urged vascular surgeons to focus on the long-term care of patients, or risk not only poor outcomes and lower reimbursements, but also loss of control over the patient’s care.

“If we don’t take care of them, they lose the integrated care they need,” Dr. Hallett said in an interview. “The primary care doctors are too frappin’ busy. I see 15-18 patients a day; they’ll see twice that.”

To that end, he recommended giving patients a thorough cardiovascular exam that includes a complete lipid profile and a review of their medications, particularly since the patient’s primary care doctors aren’t always as attentive to vascular concerns. “You are the long-term cardiovascular doc for these patients. You give the advice, you check their drugs, and you, the surgeon, needs to set their expectations, not someone else,” Dr. Hallett concluded.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

LAS VEGAS – For many cannabis users who are trying to quit their habit, psychotherapy doesn’t seem to be enough, according to an expert.

“The addition of a pharmacological intervention might be helpful for [these people],” Dr. Frances R. Levin said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “There are some promising medications out there, but we’re just at the beginning of this whole era of research.”

Yet, while the literature is nascent, both the problem and complexity of cannabis use are growing.

According to the Substance Abuse and Mental Health Services Administration, in 1993, only 7% of those seeking treatment for substance abuse were addicted to marijuana. In 2011, just under one-fifth of all substance abuse treatment patients wanted help quitting their cannabis use. Meanwhile, in that same time period, people seeking treatment for alcohol abuse went from 57% to 39%.

Part of the rise is tied to more adolescents using the drug, said Dr. Levin, who is the Kennedy-Leavy Professor of Clinical Psychiatry at Columbia University, New York. “They are certainly overrepresented.”

With nearly 20 million Americans who say they’ve used cannabis in the past month, it is the most widely used illicit drug in the country, according to the National Survey on Drug Use and Health. However, because some states and the District of Columbia recently have legalized the use of cannabis for recreational or medical purposes, or both, Dr. Levin said the drug’s illicit status is conditional. “What’s interesting is that it’s a growing problem. Ten percent of first-time users, 17% of first-time adolescent users, and 50% of daily users will develop cannabis use disorder.”

Of particular concern are synthetic cannabinoids, said Dr. Levin, who explained that the manufactured drugs are dissolved in acetone or alcohol, and then sprayed “indiscriminately” over dried plant materials, making the concentration of THC, the main psychoactive component of cannabis, hard to gauge. In addition, the synthetic version of the drug is a full, not partial agonist. “This makes them quite dangerous,” Dr. Levin said.

Manufacturers of the synthetic drug products largely have managed to stay a step ahead of regulation by constantly creating compounds that have yet to be scheduled by the Food and Drug Administration. Although the products are often packaged and marketed as herbal incense with names like “Spice” or “K-2”, the contents of the packages typically are smoked by adolescents and by those seeking to avoid failing drug tests since, according to Dr. Levin, synthetic cannabinoids also are undetectable on THC-based drug tests.

“Even though they are called ‘cannabinoid,’ these are a very different drug,” Dr. Levin said. Episodes of paranoia, anxiety, and tachycardia that sometimes last for months have been reported in case studies. “It’s very different from what happens from smoking marijuana,” she said.

Meanwhile, over the past few decades, marijuana proper also has undergone a transformation, in large part because of advances in the way in which growers can manipulate the various cannabinoids in the different plant strains. For example, Dr. Levin said that in Colorado, where the drug is legal, it is possible to purchase marijuana with specific cannabinoids at different concentration levels, developed to “reportedly induce certain types of psychoactive effects.”

Regardless of whether users choose the more designer drug options, Dr. Levin said that compared with the 1970s when the concentration of THC in marijuana that was smoked was typically 1%-3%, now “all bets are off,” because the potency and effects are much higher. “Kids getting into smoking marijuana today could be getting concentrations of 10, 20, maybe even 40%. We have a very different drug today that these kids, as well as the adults, are being exposed to.”

When the drug is ingested orally, such as in baked goods, the concentrations absorbed by the body can be even more, although the highs are less predictable and can last as much as three times longer as when it is smoked.

Currently, the only therapies available to those who want to quit are psychotherapies. Whether pharmacologic treatments can keep pace with the spread of the disorder is in question. “I want to be optimistic, but at the moment, we just have signals,” said Dr. Levin, who said the most promising pharmacotherapeutic approaches in humans to date include gabapentin, which has been used successfully to treat alcohol dependence, and N-acetylcysteine (NAC).

Data are encouraging on the efficacy of gabapentin in adults with cannabis use disorder from a 12-week, randomized double-blind trial of 50 adults given either placebo or 1,200 mg of gabapentin divided into three daily doses (Neuropsychopharmacology 2012;37:689-98). Although the study group did not suffer severe withdrawal and did decrease their overall cannabis use, the group did not necessarily achieve complete abstinence. However, the overall executive functions scores of the study group did improve. A puzzling drawback to the trial, said Dr. Levin, was the study’s notable attrition rate. “Only 36% made it to the end of the trial. We need to find out why there was such a high dropout rate.”

NAC is another potential avenue of efficacious pharmaceutical cannabis use treatment, based on several studies, including one in 116 adolescents given either 1,200 mg of NAC or placebo twice daily (Am. J. Psychiatry 2012;169:805-12). These treatments were combined with 10 minutes of talk therapy for the 8-week duration of the trial. In this trial, there was only a 40% attrition rate, and the study group was twice as likely as controls to turn in cannabinoid-free urine each week. The results have led to a multicenter National Institute on Drug Abuse–sponsored trial of 300 people and NAC along with paid urine tests, although Dr. Levin said she was curious how NAC would perform without the contingency management of having to pay for the urine. “That would have to be another study,” she noted.

Perhaps seeing partial cessation as a viable endpoint also might improve outcomes. It’s a larger question that has already come up for debate in studies of alcohol abuse where abject abstinence is not always the required outcome. It’s a point worth considering for cannabis use, said Dr. Levin, particularly when it can take weeks for cannabinoids to leave the urine. “Maybe continuous abstinence is too high a bar,” Dr. Levin said. “You talk to people who want to go from using all the time to maybe just smoking a joint at night. Who is to say that is the wrong outcome measure?”

Dr. Levin said she has received financial support from U.S. World Meds and GW Pharmaceuticals.

wmcknight@frontlinemedcom.com                                                                     On Twitter @whitneymcknight

LAS VEGAS – For many cannabis users who are trying to quit their habit, psychotherapy doesn’t seem to be enough, according to an expert.

“The addition of a pharmacological intervention might be helpful for [these people],” Dr. Frances R. Levin said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “There are some promising medications out there, but we’re just at the beginning of this whole era of research.”

Yet, while the literature is nascent, both the problem and complexity of cannabis use are growing.

According to the Substance Abuse and Mental Health Services Administration, in 1993, only 7% of those seeking treatment for substance abuse were addicted to marijuana. In 2011, just under one-fifth of all substance abuse treatment patients wanted help quitting their cannabis use. Meanwhile, in that same time period, people seeking treatment for alcohol abuse went from 57% to 39%.

Part of the rise is tied to more adolescents using the drug, said Dr. Levin, who is the Kennedy-Leavy Professor of Clinical Psychiatry at Columbia University, New York. “They are certainly overrepresented.”

With nearly 20 million Americans who say they’ve used cannabis in the past month, it is the most widely used illicit drug in the country, according to the National Survey on Drug Use and Health. However, because some states and the District of Columbia recently have legalized the use of cannabis for recreational or medical purposes, or both, Dr. Levin said the drug’s illicit status is conditional. “What’s interesting is that it’s a growing problem. Ten percent of first-time users, 17% of first-time adolescent users, and 50% of daily users will develop cannabis use disorder.”

Of particular concern are synthetic cannabinoids, said Dr. Levin, who explained that the manufactured drugs are dissolved in acetone or alcohol, and then sprayed “indiscriminately” over dried plant materials, making the concentration of THC, the main psychoactive component of cannabis, hard to gauge. In addition, the synthetic version of the drug is a full, not partial agonist. “This makes them quite dangerous,” Dr. Levin said.

Manufacturers of the synthetic drug products largely have managed to stay a step ahead of regulation by constantly creating compounds that have yet to be scheduled by the Food and Drug Administration. Although the products are often packaged and marketed as herbal incense with names like “Spice” or “K-2”, the contents of the packages typically are smoked by adolescents and by those seeking to avoid failing drug tests since, according to Dr. Levin, synthetic cannabinoids also are undetectable on THC-based drug tests.

“Even though they are called ‘cannabinoid,’ these are a very different drug,” Dr. Levin said. Episodes of paranoia, anxiety, and tachycardia that sometimes last for months have been reported in case studies. “It’s very different from what happens from smoking marijuana,” she said.

Meanwhile, over the past few decades, marijuana proper also has undergone a transformation, in large part because of advances in the way in which growers can manipulate the various cannabinoids in the different plant strains. For example, Dr. Levin said that in Colorado, where the drug is legal, it is possible to purchase marijuana with specific cannabinoids at different concentration levels, developed to “reportedly induce certain types of psychoactive effects.”

Regardless of whether users choose the more designer drug options, Dr. Levin said that compared with the 1970s when the concentration of THC in marijuana that was smoked was typically 1%-3%, now “all bets are off,” because the potency and effects are much higher. “Kids getting into smoking marijuana today could be getting concentrations of 10, 20, maybe even 40%. We have a very different drug today that these kids, as well as the adults, are being exposed to.”

When the drug is ingested orally, such as in baked goods, the concentrations absorbed by the body can be even more, although the highs are less predictable and can last as much as three times longer as when it is smoked.

Currently, the only therapies available to those who want to quit are psychotherapies. Whether pharmacologic treatments can keep pace with the spread of the disorder is in question. “I want to be optimistic, but at the moment, we just have signals,” said Dr. Levin, who said the most promising pharmacotherapeutic approaches in humans to date include gabapentin, which has been used successfully to treat alcohol dependence, and N-acetylcysteine (NAC).

Data are encouraging on the efficacy of gabapentin in adults with cannabis use disorder from a 12-week, randomized double-blind trial of 50 adults given either placebo or 1,200 mg of gabapentin divided into three daily doses (Neuropsychopharmacology 2012;37:689-98). Although the study group did not suffer severe withdrawal and did decrease their overall cannabis use, the group did not necessarily achieve complete abstinence. However, the overall executive functions scores of the study group did improve. A puzzling drawback to the trial, said Dr. Levin, was the study’s notable attrition rate. “Only 36% made it to the end of the trial. We need to find out why there was such a high dropout rate.”

NAC is another potential avenue of efficacious pharmaceutical cannabis use treatment, based on several studies, including one in 116 adolescents given either 1,200 mg of NAC or placebo twice daily (Am. J. Psychiatry 2012;169:805-12). These treatments were combined with 10 minutes of talk therapy for the 8-week duration of the trial. In this trial, there was only a 40% attrition rate, and the study group was twice as likely as controls to turn in cannabinoid-free urine each week. The results have led to a multicenter National Institute on Drug Abuse–sponsored trial of 300 people and NAC along with paid urine tests, although Dr. Levin said she was curious how NAC would perform without the contingency management of having to pay for the urine. “That would have to be another study,” she noted.

Perhaps seeing partial cessation as a viable endpoint also might improve outcomes. It’s a larger question that has already come up for debate in studies of alcohol abuse where abject abstinence is not always the required outcome. It’s a point worth considering for cannabis use, said Dr. Levin, particularly when it can take weeks for cannabinoids to leave the urine. “Maybe continuous abstinence is too high a bar,” Dr. Levin said. “You talk to people who want to go from using all the time to maybe just smoking a joint at night. Who is to say that is the wrong outcome measure?”

Dr. Levin said she has received financial support from U.S. World Meds and GW Pharmaceuticals.

wmcknight@frontlinemedcom.com                                                                     On Twitter @whitneymcknight

LAS VEGAS – For many cannabis users who are trying to quit their habit, psychotherapy doesn’t seem to be enough, according to an expert.

“The addition of a pharmacological intervention might be helpful for [these people],” Dr. Frances R. Levin said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “There are some promising medications out there, but we’re just at the beginning of this whole era of research.”

Yet, while the literature is nascent, both the problem and complexity of cannabis use are growing.

According to the Substance Abuse and Mental Health Services Administration, in 1993, only 7% of those seeking treatment for substance abuse were addicted to marijuana. In 2011, just under one-fifth of all substance abuse treatment patients wanted help quitting their cannabis use. Meanwhile, in that same time period, people seeking treatment for alcohol abuse went from 57% to 39%.

Part of the rise is tied to more adolescents using the drug, said Dr. Levin, who is the Kennedy-Leavy Professor of Clinical Psychiatry at Columbia University, New York. “They are certainly overrepresented.”

With nearly 20 million Americans who say they’ve used cannabis in the past month, it is the most widely used illicit drug in the country, according to the National Survey on Drug Use and Health. However, because some states and the District of Columbia recently have legalized the use of cannabis for recreational or medical purposes, or both, Dr. Levin said the drug’s illicit status is conditional. “What’s interesting is that it’s a growing problem. Ten percent of first-time users, 17% of first-time adolescent users, and 50% of daily users will develop cannabis use disorder.”

Of particular concern are synthetic cannabinoids, said Dr. Levin, who explained that the manufactured drugs are dissolved in acetone or alcohol, and then sprayed “indiscriminately” over dried plant materials, making the concentration of THC, the main psychoactive component of cannabis, hard to gauge. In addition, the synthetic version of the drug is a full, not partial agonist. “This makes them quite dangerous,” Dr. Levin said.

Manufacturers of the synthetic drug products largely have managed to stay a step ahead of regulation by constantly creating compounds that have yet to be scheduled by the Food and Drug Administration. Although the products are often packaged and marketed as herbal incense with names like “Spice” or “K-2”, the contents of the packages typically are smoked by adolescents and by those seeking to avoid failing drug tests since, according to Dr. Levin, synthetic cannabinoids also are undetectable on THC-based drug tests.

“Even though they are called ‘cannabinoid,’ these are a very different drug,” Dr. Levin said. Episodes of paranoia, anxiety, and tachycardia that sometimes last for months have been reported in case studies. “It’s very different from what happens from smoking marijuana,” she said.

Meanwhile, over the past few decades, marijuana proper also has undergone a transformation, in large part because of advances in the way in which growers can manipulate the various cannabinoids in the different plant strains. For example, Dr. Levin said that in Colorado, where the drug is legal, it is possible to purchase marijuana with specific cannabinoids at different concentration levels, developed to “reportedly induce certain types of psychoactive effects.”

Regardless of whether users choose the more designer drug options, Dr. Levin said that compared with the 1970s when the concentration of THC in marijuana that was smoked was typically 1%-3%, now “all bets are off,” because the potency and effects are much higher. “Kids getting into smoking marijuana today could be getting concentrations of 10, 20, maybe even 40%. We have a very different drug today that these kids, as well as the adults, are being exposed to.”

When the drug is ingested orally, such as in baked goods, the concentrations absorbed by the body can be even more, although the highs are less predictable and can last as much as three times longer as when it is smoked.

Currently, the only therapies available to those who want to quit are psychotherapies. Whether pharmacologic treatments can keep pace with the spread of the disorder is in question. “I want to be optimistic, but at the moment, we just have signals,” said Dr. Levin, who said the most promising pharmacotherapeutic approaches in humans to date include gabapentin, which has been used successfully to treat alcohol dependence, and N-acetylcysteine (NAC).

Data are encouraging on the efficacy of gabapentin in adults with cannabis use disorder from a 12-week, randomized double-blind trial of 50 adults given either placebo or 1,200 mg of gabapentin divided into three daily doses (Neuropsychopharmacology 2012;37:689-98). Although the study group did not suffer severe withdrawal and did decrease their overall cannabis use, the group did not necessarily achieve complete abstinence. However, the overall executive functions scores of the study group did improve. A puzzling drawback to the trial, said Dr. Levin, was the study’s notable attrition rate. “Only 36% made it to the end of the trial. We need to find out why there was such a high dropout rate.”

NAC is another potential avenue of efficacious pharmaceutical cannabis use treatment, based on several studies, including one in 116 adolescents given either 1,200 mg of NAC or placebo twice daily (Am. J. Psychiatry 2012;169:805-12). These treatments were combined with 10 minutes of talk therapy for the 8-week duration of the trial. In this trial, there was only a 40% attrition rate, and the study group was twice as likely as controls to turn in cannabinoid-free urine each week. The results have led to a multicenter National Institute on Drug Abuse–sponsored trial of 300 people and NAC along with paid urine tests, although Dr. Levin said she was curious how NAC would perform without the contingency management of having to pay for the urine. “That would have to be another study,” she noted.

Perhaps seeing partial cessation as a viable endpoint also might improve outcomes. It’s a larger question that has already come up for debate in studies of alcohol abuse where abject abstinence is not always the required outcome. It’s a point worth considering for cannabis use, said Dr. Levin, particularly when it can take weeks for cannabinoids to leave the urine. “Maybe continuous abstinence is too high a bar,” Dr. Levin said. “You talk to people who want to go from using all the time to maybe just smoking a joint at night. Who is to say that is the wrong outcome measure?”

Dr. Levin said she has received financial support from U.S. World Meds and GW Pharmaceuticals.

wmcknight@frontlinemedcom.com                                                                     On Twitter @whitneymcknight

LAS VEGAS – By ignoring schizophrenia’s symptomatology and focusing instead on its biomarkers and other implicated factors, researchers are homing in on treatments and interventions for the disease, according to an expert.

“The developmental model of schizophrenia suggests ... the field is now moving toward treatments better targeted to causes,” Dr. Matcheri S. Keshavan said at the annual psychopharmacology update held by the Nevada Psychiatric Association.

Whitney McKnight/Frontline Medical News

Clinicians need to understand that the disease is not homogeneous but more like a syndrome that can present in a variety of ways, according to Dr. Keshavan, Stanley Cobb Professor of Psychiatry at Harvard Medical School, Boston.

The stars emerging in the constellation many researchers are now using to chart the disease’s etiology range from neurobiologic disruptions, to drug use, to genetics, and several other possible factors. Reductions in stress, preventing drug use, and proactive cognitive support, as well as the development of targeted pharmacologic interventions are all currently being explored as ways to mitigate the disease.

‘Pathophysiological hits’

Whereas an excess of dopamine and hypersensitive dopamine receptors in the limbic region of the brain previously were thought to increase the risk for schizophrenia, Dr. Keshavan said the latest thinking is that there also might be cortical dopamine deficits, leading to a variety of symptoms, including psychosis. “Too little cortical dopamine might account for cognitive impairments and medical symptoms, whereas too much limbic dopamine might account for psychosis,” Dr. Keshavan said.

Beyond dopamine dysfunction, Dr. Keshavan said he and others have observed that higher levels of brain glutamate in adolescents correlate with more schizotypal symptoms, leading him to consider that there might be a problem with cortical glutaminergic regulation.

The pathophysiology of these changes is still uncertain, but Dr. Keshavan said several novel pharmacologic intervention trials are now underway, including some intended to reverse cognitive deficits by targeting GABA allosteric modulators to help correct glutaminergic dysfunction.

Also occurring in adolescence, both preceding and during schizophrenia’s prodromal phase, is a depletion of gray matter in the brain, particularly in boys. Also, a decrease in the brain’s plasticity because of exaggerated synaptic pruning by the adolescent brain, an otherwise normal function, has been cited as a risk factor for schizophrenia. Additionally, research into disruptions of the adolescent’s maturing stress response system has shown that for some, prolonged periods of stress can lead to an imbalance of cortical cognitive control.

Such brain imbalances often are thought to be related to a series of “pathophysiological hits” as Dr. Keshavan called them.

“It’s possible that in the premorbid phase, there is already a failure in brain development which is followed by a steep decline [in its integrity] due to excessive pruning, and there might be a post-illness onset of decline as well. That might be related to neuroinflammation, excitotoxicity, oxidative stress, and antipsychotic effects.”

Inflammation and genetics

If these so-called hits are implicated, Dr. Keshavan said it might be possible to remediate high levels of oxidative stress that otherwise can lead to toxicity, damaging neurons and mitochondria, and contributing to functional decline after the onset of illness.

Finding ways to reduce brain inflammation also could lead to treatment. “There is an increasing amount of evidence that shows proinflammatory cytokines like [interleukin-6] and tumor necrosis factor–alpha are increased in people who are psychotic or in the prodromal phase of the illness,” Dr. Keshavan said. “As they get better, their inflammation is reduced. Therefore, I think working with anti-inflammatory hormones could have value.”

The highly heritable nature of schizophrenia is long established, but recent genetic research has helped identify multiple etiologic factors, particularly when it comes to the implication of more common genes that have a small impact and rarer ones that have a greater effect. These discoveries have shown how several mental illnesses such as autism, bipolar disorder, and ADHD overlap, but the way in which they manifest is determined by how one’s genes are either triggered or influenced by the environment or by neurochemical influences. “The picture is becoming more and more clear that schizophrenia is not one disease,” Dr. Keshavan said. “It’s a combination of a lot of physiological processes.”

Predictors for the development of psychosis include a family history of psychosis, cognitive impairment, schizotypal symptoms, childhood trauma, and cannabis use, Dr. Keshavan said.

 Prevention may not be complicated

As the various etiologies of this disease are being mapped, so too are new approaches that combine existing and emerging therapies. For primary prevention and secondary interventions, Dr. Keshavan said that, particularly in those in whom a risk for the illness already has been identified, reducing stress, enhancing cognitive abilities, and preventing drug use was key. In the near future, he anticipates that these kinds of behavioral interventions will be combined with cognitive-behavioral therapies, along with dopamine blockers, neuroprotective agents, and glutaminergic modulation, and perhaps even fish oil for its omega-3 fatty acids, as well as common anti-inflammatory agents such as aspirin.

By seeing schizophrenia not as “one disease but one of heterogeneity, we can better classify, stratify, and divide and conquer it,” Dr. Keshavan said.

Dr. Keshavan disclosed he has financial relationships with Sunovion and Otsuka.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

LAS VEGAS – By ignoring schizophrenia’s symptomatology and focusing instead on its biomarkers and other implicated factors, researchers are homing in on treatments and interventions for the disease, according to an expert.

“The developmental model of schizophrenia suggests ... the field is now moving toward treatments better targeted to causes,” Dr. Matcheri S. Keshavan said at the annual psychopharmacology update held by the Nevada Psychiatric Association.

Whitney McKnight/Frontline Medical News

Clinicians need to understand that the disease is not homogeneous but more like a syndrome that can present in a variety of ways, according to Dr. Keshavan, Stanley Cobb Professor of Psychiatry at Harvard Medical School, Boston.

The stars emerging in the constellation many researchers are now using to chart the disease’s etiology range from neurobiologic disruptions, to drug use, to genetics, and several other possible factors. Reductions in stress, preventing drug use, and proactive cognitive support, as well as the development of targeted pharmacologic interventions are all currently being explored as ways to mitigate the disease.

‘Pathophysiological hits’

Whereas an excess of dopamine and hypersensitive dopamine receptors in the limbic region of the brain previously were thought to increase the risk for schizophrenia, Dr. Keshavan said the latest thinking is that there also might be cortical dopamine deficits, leading to a variety of symptoms, including psychosis. “Too little cortical dopamine might account for cognitive impairments and medical symptoms, whereas too much limbic dopamine might account for psychosis,” Dr. Keshavan said.

Beyond dopamine dysfunction, Dr. Keshavan said he and others have observed that higher levels of brain glutamate in adolescents correlate with more schizotypal symptoms, leading him to consider that there might be a problem with cortical glutaminergic regulation.

The pathophysiology of these changes is still uncertain, but Dr. Keshavan said several novel pharmacologic intervention trials are now underway, including some intended to reverse cognitive deficits by targeting GABA allosteric modulators to help correct glutaminergic dysfunction.

Also occurring in adolescence, both preceding and during schizophrenia’s prodromal phase, is a depletion of gray matter in the brain, particularly in boys. Also, a decrease in the brain’s plasticity because of exaggerated synaptic pruning by the adolescent brain, an otherwise normal function, has been cited as a risk factor for schizophrenia. Additionally, research into disruptions of the adolescent’s maturing stress response system has shown that for some, prolonged periods of stress can lead to an imbalance of cortical cognitive control.

Such brain imbalances often are thought to be related to a series of “pathophysiological hits” as Dr. Keshavan called them.

“It’s possible that in the premorbid phase, there is already a failure in brain development which is followed by a steep decline [in its integrity] due to excessive pruning, and there might be a post-illness onset of decline as well. That might be related to neuroinflammation, excitotoxicity, oxidative stress, and antipsychotic effects.”

Inflammation and genetics

If these so-called hits are implicated, Dr. Keshavan said it might be possible to remediate high levels of oxidative stress that otherwise can lead to toxicity, damaging neurons and mitochondria, and contributing to functional decline after the onset of illness.

Finding ways to reduce brain inflammation also could lead to treatment. “There is an increasing amount of evidence that shows proinflammatory cytokines like [interleukin-6] and tumor necrosis factor–alpha are increased in people who are psychotic or in the prodromal phase of the illness,” Dr. Keshavan said. “As they get better, their inflammation is reduced. Therefore, I think working with anti-inflammatory hormones could have value.”

The highly heritable nature of schizophrenia is long established, but recent genetic research has helped identify multiple etiologic factors, particularly when it comes to the implication of more common genes that have a small impact and rarer ones that have a greater effect. These discoveries have shown how several mental illnesses such as autism, bipolar disorder, and ADHD overlap, but the way in which they manifest is determined by how one’s genes are either triggered or influenced by the environment or by neurochemical influences. “The picture is becoming more and more clear that schizophrenia is not one disease,” Dr. Keshavan said. “It’s a combination of a lot of physiological processes.”

Predictors for the development of psychosis include a family history of psychosis, cognitive impairment, schizotypal symptoms, childhood trauma, and cannabis use, Dr. Keshavan said.

 Prevention may not be complicated

As the various etiologies of this disease are being mapped, so too are new approaches that combine existing and emerging therapies. For primary prevention and secondary interventions, Dr. Keshavan said that, particularly in those in whom a risk for the illness already has been identified, reducing stress, enhancing cognitive abilities, and preventing drug use was key. In the near future, he anticipates that these kinds of behavioral interventions will be combined with cognitive-behavioral therapies, along with dopamine blockers, neuroprotective agents, and glutaminergic modulation, and perhaps even fish oil for its omega-3 fatty acids, as well as common anti-inflammatory agents such as aspirin.

By seeing schizophrenia not as “one disease but one of heterogeneity, we can better classify, stratify, and divide and conquer it,” Dr. Keshavan said.

Dr. Keshavan disclosed he has financial relationships with Sunovion and Otsuka.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

LAS VEGAS – By ignoring schizophrenia’s symptomatology and focusing instead on its biomarkers and other implicated factors, researchers are homing in on treatments and interventions for the disease, according to an expert.

“The developmental model of schizophrenia suggests ... the field is now moving toward treatments better targeted to causes,” Dr. Matcheri S. Keshavan said at the annual psychopharmacology update held by the Nevada Psychiatric Association.

Whitney McKnight/Frontline Medical News

Clinicians need to understand that the disease is not homogeneous but more like a syndrome that can present in a variety of ways, according to Dr. Keshavan, Stanley Cobb Professor of Psychiatry at Harvard Medical School, Boston.

The stars emerging in the constellation many researchers are now using to chart the disease’s etiology range from neurobiologic disruptions, to drug use, to genetics, and several other possible factors. Reductions in stress, preventing drug use, and proactive cognitive support, as well as the development of targeted pharmacologic interventions are all currently being explored as ways to mitigate the disease.

‘Pathophysiological hits’

Whereas an excess of dopamine and hypersensitive dopamine receptors in the limbic region of the brain previously were thought to increase the risk for schizophrenia, Dr. Keshavan said the latest thinking is that there also might be cortical dopamine deficits, leading to a variety of symptoms, including psychosis. “Too little cortical dopamine might account for cognitive impairments and medical symptoms, whereas too much limbic dopamine might account for psychosis,” Dr. Keshavan said.

Beyond dopamine dysfunction, Dr. Keshavan said he and others have observed that higher levels of brain glutamate in adolescents correlate with more schizotypal symptoms, leading him to consider that there might be a problem with cortical glutaminergic regulation.

The pathophysiology of these changes is still uncertain, but Dr. Keshavan said several novel pharmacologic intervention trials are now underway, including some intended to reverse cognitive deficits by targeting GABA allosteric modulators to help correct glutaminergic dysfunction.

Also occurring in adolescence, both preceding and during schizophrenia’s prodromal phase, is a depletion of gray matter in the brain, particularly in boys. Also, a decrease in the brain’s plasticity because of exaggerated synaptic pruning by the adolescent brain, an otherwise normal function, has been cited as a risk factor for schizophrenia. Additionally, research into disruptions of the adolescent’s maturing stress response system has shown that for some, prolonged periods of stress can lead to an imbalance of cortical cognitive control.

Such brain imbalances often are thought to be related to a series of “pathophysiological hits” as Dr. Keshavan called them.

“It’s possible that in the premorbid phase, there is already a failure in brain development which is followed by a steep decline [in its integrity] due to excessive pruning, and there might be a post-illness onset of decline as well. That might be related to neuroinflammation, excitotoxicity, oxidative stress, and antipsychotic effects.”

Inflammation and genetics

If these so-called hits are implicated, Dr. Keshavan said it might be possible to remediate high levels of oxidative stress that otherwise can lead to toxicity, damaging neurons and mitochondria, and contributing to functional decline after the onset of illness.

Finding ways to reduce brain inflammation also could lead to treatment. “There is an increasing amount of evidence that shows proinflammatory cytokines like [interleukin-6] and tumor necrosis factor–alpha are increased in people who are psychotic or in the prodromal phase of the illness,” Dr. Keshavan said. “As they get better, their inflammation is reduced. Therefore, I think working with anti-inflammatory hormones could have value.”

The highly heritable nature of schizophrenia is long established, but recent genetic research has helped identify multiple etiologic factors, particularly when it comes to the implication of more common genes that have a small impact and rarer ones that have a greater effect. These discoveries have shown how several mental illnesses such as autism, bipolar disorder, and ADHD overlap, but the way in which they manifest is determined by how one’s genes are either triggered or influenced by the environment or by neurochemical influences. “The picture is becoming more and more clear that schizophrenia is not one disease,” Dr. Keshavan said. “It’s a combination of a lot of physiological processes.”

Predictors for the development of psychosis include a family history of psychosis, cognitive impairment, schizotypal symptoms, childhood trauma, and cannabis use, Dr. Keshavan said.

 Prevention may not be complicated

As the various etiologies of this disease are being mapped, so too are new approaches that combine existing and emerging therapies. For primary prevention and secondary interventions, Dr. Keshavan said that, particularly in those in whom a risk for the illness already has been identified, reducing stress, enhancing cognitive abilities, and preventing drug use was key. In the near future, he anticipates that these kinds of behavioral interventions will be combined with cognitive-behavioral therapies, along with dopamine blockers, neuroprotective agents, and glutaminergic modulation, and perhaps even fish oil for its omega-3 fatty acids, as well as common anti-inflammatory agents such as aspirin.

By seeing schizophrenia not as “one disease but one of heterogeneity, we can better classify, stratify, and divide and conquer it,” Dr. Keshavan said.

Dr. Keshavan disclosed he has financial relationships with Sunovion and Otsuka.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

ORLANDO– Independent investigators eager to author studies that have notable impact on the field of inflammatory bowel disease have plenty of important paths to pursue, according to Dr. Jean-Frederic Colombel, a professor of gastroenterology at Mt. Sinai Hospital in New York.

“Over the next 3-5 years, we will have a lot of new drugs, which is nice, but we don’t yet know how to use them, or which ones to use,” Dr. Colombel said during a presentation on the future of the field at this year’s meeting of the annual Advances in Inflammatory Bowel Disease, sponsored by the Crohn’s and Colitis Foundation of America and endorsed by the American Gastroenterological Association.

Whitney McKnight/Frontline Medical Media

A host of biologics including vedolizumab, recently indicated by the U.S. Food and Drug Administration for ulcerative colitis and Crohn’s disease, and ustekinumab, currently in phase III studies for Crohn’s disease, are set to revolutionize treatment at a time when the field is already undergoing great change, according to Dr. Colombel. The result, he says, is that despite “formidable” challenges in recruitment and funding, “huge opportunities” exist for investigators willing to collaborate and be creative.

Studies that elucidate the natural history of Crohn’s disease and colitis offer insight into the efficacy of various treatment strategies, help determine whether to target symptoms or biomarkers, and answer whether combination therapies are safe and effective in certain patients are what Dr. Colombel says he hopes will help improve the field as the drug pipeline continues to grow.

He stipulated a caveat, however, “I strongly believe we need some new study designs.” Although he noted that trials needn’t be complicated, they should be long enough to collect sorely needed prospective data. “These can only be done in investigator-initiated trials because of the time frames,” Dr. Colombel urged the audience of young investigators.

A fieldwide shift in thinking about ulcerative colitis and Crohn’s disease as chronic, progressive diseases, rather than intermittent afflictions has already helped generate new study endpoints such as the Lémann Score, an index of progressive bowel damage that allows researchers to better track the history of IBD in patients, and thus provide a window of opportunity for interventions, said Dr. Colombel.

To wit, the CURE study, conducted by the French IBD society GITAID, is a 5-year, prospective study of patients whose early Crohn’s disease is treated with the biologic adalimumab. The Lémann Score is used to screen patients at the end of each successive year, in order to adjust their treatment to reach the final endpoint of deep remission by year 5 when several indicators are measured, including bowel image, level of disability, and whether there was the need for surgery. Dr. Colombel said the novel design of the study, which has already recruited 60 patients, shows it is “feasible” to collect longitudinal data.

The field also has a responsibility to conduct randomly assigned controlled trials to demonstrate the comparative effectiveness, safety, immunogenicity, and cost benefits of the rapidly emerging spate of biosimilars, particularly since there is not global agreement about their use, according to Dr. Colombel. Their approval for IBD in Europe is “highly disputable.... I think this could be a very nice topic for an investigator-initiated trial, in Canada and the U.S.”

Head-to-head trials that are well designed will help answer “very important questions” about which treatment strategies have the best outcomes, but doing so requires fortitude, according to Dr. Colombel. “The Dutch have the guts to conduct the LIRIC trial,” he said. In it, patients with Crohn’s disease in the terminal ileum, who have failed steroids or immune therapy, will be assigned randomly to either laparoscopic ileocolic resection or infliximab, the first available biosimilar. Sixty participants have enrolled to date, he said.

These types of studies could also help delineate how best to employ combination therapies. “What I propose for this kind of study is an intensive therapy combining biologics very early in patients with bad prognoses, and looking at the long-term outcome using bowel image,” Dr. Colombel said. These data, and others indicating the most appropriate length of treatment in patients with varying states of disease, are Dr. Colombel’s personal “top choice” for investigation. The excitement that personalized medicine has engendered across the specialities has so far not resulted in specific, validated treatments for IBD patients. However, the question of how to use personal characteristics and serologic and genetic markers to create predictive models for which patients will need either step-up or top-down therapies, accounting for their individual risk of complication, is what he said is among the most “important [question] we need to answer because the choice of early therapy will depend on this predictor,” according to Dr. Colombel.

The question of which treatment targets are best remains unclear but is important to decipher, according to Dr. Colombel, who said simple studies comparing outcomes when patients are treated to symptoms vs. treated to biomarker measurements are needed, as well as the importance of mucosal healing vs. symptom improvement. “This is important because there is discordance between endoscopy and histology,” said Dr. Colombel. “Persistent histologic inflammation is frequently associated with bad outcomes.”

However, endoscopic scoring itself is another area Dr. Colombel said is worth investigating, especially when it comes to validating endpoints such as those in the Crohn’s Disease Index of Severity (CDEIS), and Simple Endoscopic Score for Crohn’s Disease (SES-CD), which will help determine remission cutoffs. Also, endoscopic scoring in comparison with live video and imaging still need standardized approaches. “When you see how it is done in the U.S., it is generally very poor,” Dr. Colombel said.

The biggest obstacles of all when it comes to independent investigation in the United States, according to Frenchman Dr. Colombel, is heavy regulation and cost. “In France, [conducting trials] was considered part of my job. I was not compensated. It is different here.”

Dr. Colombel has numerous financial ties to the pharmaceutical industry, including AB Science, Amgen, Baxter, Bristol-Meyers Squibb, and Merck, among several others.

wmcknight@frontlinemedcom.com


On Twitter @whitneymcknight

ORLANDO– Independent investigators eager to author studies that have notable impact on the field of inflammatory bowel disease have plenty of important paths to pursue, according to Dr. Jean-Frederic Colombel, a professor of gastroenterology at Mt. Sinai Hospital in New York.

“Over the next 3-5 years, we will have a lot of new drugs, which is nice, but we don’t yet know how to use them, or which ones to use,” Dr. Colombel said during a presentation on the future of the field at this year’s meeting of the annual Advances in Inflammatory Bowel Disease, sponsored by the Crohn’s and Colitis Foundation of America and endorsed by the American Gastroenterological Association.

Whitney McKnight/Frontline Medical Media

A host of biologics including vedolizumab, recently indicated by the U.S. Food and Drug Administration for ulcerative colitis and Crohn’s disease, and ustekinumab, currently in phase III studies for Crohn’s disease, are set to revolutionize treatment at a time when the field is already undergoing great change, according to Dr. Colombel. The result, he says, is that despite “formidable” challenges in recruitment and funding, “huge opportunities” exist for investigators willing to collaborate and be creative.

Studies that elucidate the natural history of Crohn’s disease and colitis offer insight into the efficacy of various treatment strategies, help determine whether to target symptoms or biomarkers, and answer whether combination therapies are safe and effective in certain patients are what Dr. Colombel says he hopes will help improve the field as the drug pipeline continues to grow.

He stipulated a caveat, however, “I strongly believe we need some new study designs.” Although he noted that trials needn’t be complicated, they should be long enough to collect sorely needed prospective data. “These can only be done in investigator-initiated trials because of the time frames,” Dr. Colombel urged the audience of young investigators.

A fieldwide shift in thinking about ulcerative colitis and Crohn’s disease as chronic, progressive diseases, rather than intermittent afflictions has already helped generate new study endpoints such as the Lémann Score, an index of progressive bowel damage that allows researchers to better track the history of IBD in patients, and thus provide a window of opportunity for interventions, said Dr. Colombel.

To wit, the CURE study, conducted by the French IBD society GITAID, is a 5-year, prospective study of patients whose early Crohn’s disease is treated with the biologic adalimumab. The Lémann Score is used to screen patients at the end of each successive year, in order to adjust their treatment to reach the final endpoint of deep remission by year 5 when several indicators are measured, including bowel image, level of disability, and whether there was the need for surgery. Dr. Colombel said the novel design of the study, which has already recruited 60 patients, shows it is “feasible” to collect longitudinal data.

The field also has a responsibility to conduct randomly assigned controlled trials to demonstrate the comparative effectiveness, safety, immunogenicity, and cost benefits of the rapidly emerging spate of biosimilars, particularly since there is not global agreement about their use, according to Dr. Colombel. Their approval for IBD in Europe is “highly disputable.... I think this could be a very nice topic for an investigator-initiated trial, in Canada and the U.S.”

Head-to-head trials that are well designed will help answer “very important questions” about which treatment strategies have the best outcomes, but doing so requires fortitude, according to Dr. Colombel. “The Dutch have the guts to conduct the LIRIC trial,” he said. In it, patients with Crohn’s disease in the terminal ileum, who have failed steroids or immune therapy, will be assigned randomly to either laparoscopic ileocolic resection or infliximab, the first available biosimilar. Sixty participants have enrolled to date, he said.

These types of studies could also help delineate how best to employ combination therapies. “What I propose for this kind of study is an intensive therapy combining biologics very early in patients with bad prognoses, and looking at the long-term outcome using bowel image,” Dr. Colombel said. These data, and others indicating the most appropriate length of treatment in patients with varying states of disease, are Dr. Colombel’s personal “top choice” for investigation. The excitement that personalized medicine has engendered across the specialities has so far not resulted in specific, validated treatments for IBD patients. However, the question of how to use personal characteristics and serologic and genetic markers to create predictive models for which patients will need either step-up or top-down therapies, accounting for their individual risk of complication, is what he said is among the most “important [question] we need to answer because the choice of early therapy will depend on this predictor,” according to Dr. Colombel.

The question of which treatment targets are best remains unclear but is important to decipher, according to Dr. Colombel, who said simple studies comparing outcomes when patients are treated to symptoms vs. treated to biomarker measurements are needed, as well as the importance of mucosal healing vs. symptom improvement. “This is important because there is discordance between endoscopy and histology,” said Dr. Colombel. “Persistent histologic inflammation is frequently associated with bad outcomes.”

However, endoscopic scoring itself is another area Dr. Colombel said is worth investigating, especially when it comes to validating endpoints such as those in the Crohn’s Disease Index of Severity (CDEIS), and Simple Endoscopic Score for Crohn’s Disease (SES-CD), which will help determine remission cutoffs. Also, endoscopic scoring in comparison with live video and imaging still need standardized approaches. “When you see how it is done in the U.S., it is generally very poor,” Dr. Colombel said.

The biggest obstacles of all when it comes to independent investigation in the United States, according to Frenchman Dr. Colombel, is heavy regulation and cost. “In France, [conducting trials] was considered part of my job. I was not compensated. It is different here.”

Dr. Colombel has numerous financial ties to the pharmaceutical industry, including AB Science, Amgen, Baxter, Bristol-Meyers Squibb, and Merck, among several others.

wmcknight@frontlinemedcom.com


On Twitter @whitneymcknight

ORLANDO– Independent investigators eager to author studies that have notable impact on the field of inflammatory bowel disease have plenty of important paths to pursue, according to Dr. Jean-Frederic Colombel, a professor of gastroenterology at Mt. Sinai Hospital in New York.

“Over the next 3-5 years, we will have a lot of new drugs, which is nice, but we don’t yet know how to use them, or which ones to use,” Dr. Colombel said during a presentation on the future of the field at this year’s meeting of the annual Advances in Inflammatory Bowel Disease, sponsored by the Crohn’s and Colitis Foundation of America and endorsed by the American Gastroenterological Association.

Whitney McKnight/Frontline Medical Media

A host of biologics including vedolizumab, recently indicated by the U.S. Food and Drug Administration for ulcerative colitis and Crohn’s disease, and ustekinumab, currently in phase III studies for Crohn’s disease, are set to revolutionize treatment at a time when the field is already undergoing great change, according to Dr. Colombel. The result, he says, is that despite “formidable” challenges in recruitment and funding, “huge opportunities” exist for investigators willing to collaborate and be creative.

Studies that elucidate the natural history of Crohn’s disease and colitis offer insight into the efficacy of various treatment strategies, help determine whether to target symptoms or biomarkers, and answer whether combination therapies are safe and effective in certain patients are what Dr. Colombel says he hopes will help improve the field as the drug pipeline continues to grow.

He stipulated a caveat, however, “I strongly believe we need some new study designs.” Although he noted that trials needn’t be complicated, they should be long enough to collect sorely needed prospective data. “These can only be done in investigator-initiated trials because of the time frames,” Dr. Colombel urged the audience of young investigators.

A fieldwide shift in thinking about ulcerative colitis and Crohn’s disease as chronic, progressive diseases, rather than intermittent afflictions has already helped generate new study endpoints such as the Lémann Score, an index of progressive bowel damage that allows researchers to better track the history of IBD in patients, and thus provide a window of opportunity for interventions, said Dr. Colombel.

To wit, the CURE study, conducted by the French IBD society GITAID, is a 5-year, prospective study of patients whose early Crohn’s disease is treated with the biologic adalimumab. The Lémann Score is used to screen patients at the end of each successive year, in order to adjust their treatment to reach the final endpoint of deep remission by year 5 when several indicators are measured, including bowel image, level of disability, and whether there was the need for surgery. Dr. Colombel said the novel design of the study, which has already recruited 60 patients, shows it is “feasible” to collect longitudinal data.

The field also has a responsibility to conduct randomly assigned controlled trials to demonstrate the comparative effectiveness, safety, immunogenicity, and cost benefits of the rapidly emerging spate of biosimilars, particularly since there is not global agreement about their use, according to Dr. Colombel. Their approval for IBD in Europe is “highly disputable.... I think this could be a very nice topic for an investigator-initiated trial, in Canada and the U.S.”

Head-to-head trials that are well designed will help answer “very important questions” about which treatment strategies have the best outcomes, but doing so requires fortitude, according to Dr. Colombel. “The Dutch have the guts to conduct the LIRIC trial,” he said. In it, patients with Crohn’s disease in the terminal ileum, who have failed steroids or immune therapy, will be assigned randomly to either laparoscopic ileocolic resection or infliximab, the first available biosimilar. Sixty participants have enrolled to date, he said.

These types of studies could also help delineate how best to employ combination therapies. “What I propose for this kind of study is an intensive therapy combining biologics very early in patients with bad prognoses, and looking at the long-term outcome using bowel image,” Dr. Colombel said. These data, and others indicating the most appropriate length of treatment in patients with varying states of disease, are Dr. Colombel’s personal “top choice” for investigation. The excitement that personalized medicine has engendered across the specialities has so far not resulted in specific, validated treatments for IBD patients. However, the question of how to use personal characteristics and serologic and genetic markers to create predictive models for which patients will need either step-up or top-down therapies, accounting for their individual risk of complication, is what he said is among the most “important [question] we need to answer because the choice of early therapy will depend on this predictor,” according to Dr. Colombel.

The question of which treatment targets are best remains unclear but is important to decipher, according to Dr. Colombel, who said simple studies comparing outcomes when patients are treated to symptoms vs. treated to biomarker measurements are needed, as well as the importance of mucosal healing vs. symptom improvement. “This is important because there is discordance between endoscopy and histology,” said Dr. Colombel. “Persistent histologic inflammation is frequently associated with bad outcomes.”

However, endoscopic scoring itself is another area Dr. Colombel said is worth investigating, especially when it comes to validating endpoints such as those in the Crohn’s Disease Index of Severity (CDEIS), and Simple Endoscopic Score for Crohn’s Disease (SES-CD), which will help determine remission cutoffs. Also, endoscopic scoring in comparison with live video and imaging still need standardized approaches. “When you see how it is done in the U.S., it is generally very poor,” Dr. Colombel said.

The biggest obstacles of all when it comes to independent investigation in the United States, according to Frenchman Dr. Colombel, is heavy regulation and cost. “In France, [conducting trials] was considered part of my job. I was not compensated. It is different here.”

Dr. Colombel has numerous financial ties to the pharmaceutical industry, including AB Science, Amgen, Baxter, Bristol-Meyers Squibb, and Merck, among several others.

wmcknight@frontlinemedcom.com


On Twitter @whitneymcknight

In just 1 year, 34 out of about 5,000 patients seen at the inflammatory bowel disease center at the University of Pittsburgh Medical Center cost more than $10 million to treat.

“Our health plan said, ‘You have to fix this,’” recalled Dr. Miguel Regueiro, codirector of the IBD center.

So, in addition to asking the insurer for ideas, Dr. Regueiro did the most cost conscious thing he could think of: He asked for ideas from his colleague, Dr. Eva Szigethy, a psychiatrist specializing in the treatment of pain and psychosocial issues faced by IBD patients.

“Nearly half of our patient population has some behavioral, stress, or mental health component that is driving their disease, [leading] to high health care utilization,” Dr. Regueiro said.

Dr. Szigethy’s work of late, both on her own and with others such as Dr. Douglas Drossman, an emeritus psychiatrist and gastroenterologist at the University of North Carolina at Chapel Hill, has focused on the so-called brain-gut axis and includes the impact of narcotics on the gastrointestinal tract, the correlation between inflammation and depression, the effectiveness of cognitive-behavioral therapy in IBD, and the use of self-hypnosis to manage chronic pain.

“The vast majority of IBD patients have mood disorders, depression, reactive adjustment disorder, anxiety both [before and after] their diagnosis, and chronic pain,” Dr. Szigethy said in an interview.

In practical terms, this means patients benefit from the partnership between Dr. Regueiro, who brings a deep medical knowledge of IBD, and Dr. Szigethy, who combines her research with her psychiatric skill for asking the kinds of questions that evoke the patient’s larger story. Together, said Dr. Szigethy, they assess patients as a whole, directly accounting for the emotional complexity inherent in IBD, with an eye toward helping patients regain control of their lives, often made chaotic by the unpredictable indignities that are the hallmarks of the disease.

“Often, if we listen in the lines and between the lines, our patients tell us exactly what other factors are involved: why their disease is not getting better, why they are getting headaches, why they have such continued suffering,” Dr. Szigethy said.

“You don’t need to know the basic science to understand the stress these patients feel,” Dr. Regueiro recounted to an audience at a recent Advances in IBD meeting in Orlando, sponsored by the Crohn’s and Colitis Foundation of America.

He shared with his audience the story of 45-year-old Anne, a Crohn’s disease sufferer treated at his center. Anne is not the patient’s real name. Despite her disease being inactive, Anne was hospitalized 23 times, and given 19 CT scans and seven endoscopic procedures in one calendar year alone, qualifying her as one of the center’s top 34 “health care frequent fliers.”

Empowering patients like Anne, whose costly care Dr. Szigethy and Dr. Regueiro recognized was attributable more to her psychosocial rather than medical IBD needs, not only improves their quality of life, it saves the system money.

This is why the same health plan representatives who told Dr. Regueiro they’d like to see cost reductions have partnered with him and Dr. Szigethy to develop a specialty care medical home pilot program that combines specialty, primary, and mental health care in one location. The program officially opened in mid-January of this year.

In the mid-1990s, the UPMC Health Plan was conceived by the medical center as a “strategic move to combine the intellectual capital of the provider system with that of the payer system,” according to Sandy McAnallen, UPMC Health Plan’s senior vice president for clinical affairs and quality performance.

The result, she said in an interview, is greater flexibility when it comes to what care is provided and how it is delivered. “The physicians are setting the evidence-based pathways on the kind of care that patients need to receive, and we have the ability to be very proactive with [how we pay for that] with this kind of relationship.”

Over the course of 2 years, Dr. Regueiro and Ms. McAnallen met several times to parse data on more effective ways to address the fractured way IBD patients, particularly those with undiagnosed psychosocial concerns, were seeking and receiving treatment. The pair also honed in on ways to cut the high cost of surgeries and pharmaceuticals with the overall goal being to create a healthier IBD patient population who perceived their care to be the best possible.

To develop their specialty medical home model, Dr. Regueiro, Dr. Szigethy, Ms. McAnallen, and other key UPMC hospital system and health plan administrators, as well as other IBD specialists, met many times over the course of 2 years to plan what Ms. McAnallen calls their proof of concept.

The program is offered automatically to those covered by the UPMC Health Plan, although anyone is welcome to opt out if they choose. Participants are asked, but not required, to submit to genetic sampling for IBD research purposes, and other data also are gathered with consent at the center. Those not covered by UPMC insurance also are welcome to participate. “The center is payer-agnostic,” Ms. McAnallen said.

Dr. Regueiro and his colleagues will be the primary doctors for all patients who want to be seen at the IBD center for their chronic condition, while episodic illnesses such as colds, flus, and rashes are treated by a newly added advance practice nurse. All patients are now offered behavioral and psychosocial support, depending on the concern, either from Dr. Szigethy, a psychologist, or a social worker who was added to the team for the pilot project.

“Part of what we are defining [with this project] is when a psychiatrist is needed, and what can be done by a less expensive, but well-trained behavioral health, medically trained person like a social worker,” said Dr. Szigethy, who is also a member of the department of psychiatry.

A new patient peer group offers patients the chance to discuss their IBD-related struggles with others who can empathize directly, and a nutritionist and pharmacist both specializing in IBD needs have been added to the payroll. A 24/7 call center also has been established.

“We want patients to be in the habit of calling one place where their entire history is known,” said Ms. McAnallen. “Whether they need primary care or specialty care, we want these patients to go to the specialty medical home.”

It’s a patient-centered, rather than an institution-based model, where the referrals are controlled by the payer, “but the system is value based not volume based,” said Dr. Regueiro.

To that end, Dr. Regueiro said he hopes the center will expand its use of telemedicine to further accommodate patients, who often find it difficult to take time off from work or school, find and afford child care, and travel long distances to their doctor appointments. “Right now, some patients have to drive hours to see us, but a lot of what we do for these patients is cognitive care,” he said.

The IBD center’s additional personnel have been paid for by the health plan, in order to cover the cost of adequately serving the approximately 725 IBD patients the insurer determined were the most expensive to treat out of the more than 5,000 IBD patients, a notably high number according to Dr. Szigethy, that the center serves.

In exchange for underwriting the cost of a portion of the staff, the health plan expects Dr. Regueiro and his team to cut treatment costs for this cohort. “If we save a certain amount on patients each year, the health plan will give that back to us,” Dr. Regueiro said.

One way Ms. McAnallen said the program is projected to save is by reducing the number of times frequent fliers of UPMC’s emergency department arrive with an IBD complaint.

“The ED specializes in all acute medical issues, but for IBD we need to focus in a different way,” said Ms. McAnallen.

To wit, in her health care high-utilization heyday, Anne’s treatment typically began in the emergency department, where she arrived seeking narcotics for her condition.

“She said she hated that the people in the ED treated her like a drug addict, but she hated the pain even more,” Dr. Regueiro told his Orlando audience.

This was particularly troublesome for Anne, since Dr. Szigethy determined she was a potential sufferer of narcotic bowel syndrome.

Although at present, much of the research into this phenomenon is still bench science, Dr. Szigethy said a growing body of evidence provided in part by advanced neuroimaging techniques indicates that chronic narcotic use changes opioid receptors in some human adults from creating an analgesic effect, to a hyperanalgesic one instead, where the narcotics themselves start to create pain and exacerbate any existing bowel issues.

“In Anne’s case, she was going up and up in her opiates, but her pain was getting worse,” Dr. Szigethy said.

Dr. Szigethy obtained permission from Anne’s insurer, which happened to be UPMC Health Plan, to give her a 5-day inpatient medical hospitalization during which time Anne was weaned from her narcotics. For 6 months prior to her detoxification from the opiates, Anne learned self-hypnosis techniques from Dr. Szigethy and her colleagues, which she used to support her withdrawal from the pain medication. Anne’s self-reported favorite technique was that whenever the pain would start, she would visualize filling a balloon with it, and then letting the balloon drift away until it eventually evaporated into the air.

“I know it sounds corny, but guess what? Last year, Anne had zero hospitalizations,” Dr. Regueiro said.

According to Dr. Szigethy, Anne still has occasional pain, “But she can deal with it.”The exact savings UPMC Health Plan expects to realize by way of reimbursing the IBD center for treatment models created in response to emerging research such as that of Dr. Szigethy is still unknown. But Ms. McAnallen is optimistic the program will meet its broader targets.

“We are at a point where costs are becoming out of control and the consumer can’t afford health care. You have to be in a position where you can rely on your physicians to develop evidence-based pathways for treatment of acute and chronic disease, which Eva and Miguel are doing, and to do be able to do so in a laboratory where you have the premium to support that,” Ms. McAnallen said, adding that had Dr. Regueiro approached an outside payer to help him create the medical home model, she doubted it would have come to fruition.

“Because we’re part of an integrated system, we’re all aligned with the same goals, which include improving the health status of our community and decreasing the cost of care so it’s affordable.”

Analysis of data collected on total cost and quality of care, and patient perception of care, will begin within the next 6 months, said Ms. McAnallen, who did not offer specific margins but noted that if gains are made, UPMC would look at how to apply this integrated approach to treating other chronic diseases such as rheumatoid arthritis and multiple sclerosis.

One central question the pilot program is expected to answer is whether it is feasible to do away with fee-for-service provider reimbursements, which Ms. McAnallen said are, in her opinion, at the crux of the current national health care crisis.

“You go to your physician, they do something, they submit a claim, they get a check. We haven’t put in a system that makes providers, whether hospitals or physicians, step back and say, ‘Let’s do this differently. I’m on a treadmill of fee for service. The more I produce, the more I get paid.’ This IBD pilot program is to really help us transform that payment structure.”

Intangible factors such as how much of a specialty medical home’s success is predicated on the verve of its leadership will also be evaluated. “If you don’t have a physician who will be the [medical home’s] champion, it will be very hard to replicate,” Ms. McAnallen said. Attracting ambitious specialists with the opportunity to create such an integrated care model could become a recruitment tool for UPMC, she added.

If the concept of a one-stop-doc-shop sounds slightly “what was old is new again,” harkening back to the days when physicians were called doctors, never “providers,” and largely were thought of as family friends who made house calls, said Dr. Szigethy, it’s because it is that model, amplified by modern means.

“We can’t go to patients’ homes because they’re even more widespread than they were back in the day of the village, but what we can do is provide care through the ancillary team members who are extraordinarily well trained, and can provide education on nutrition and medication. Whether it’s by telemedicine or face to face, patients are getting treated in an integrated way, and we’re doing it as efficaciously as possible. That is brand new.”

Dr. Regueiro said in an interview at least one other insurance company has expressed interest in learning more about the IBD center’s integrated approach, causing him to reassess the payer’s role in health care’s revolution. “There is more common ground between us than I once thought. Insurers are not the devil. They are central to improving value.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

In just 1 year, 34 out of about 5,000 patients seen at the inflammatory bowel disease center at the University of Pittsburgh Medical Center cost more than $10 million to treat.

“Our health plan said, ‘You have to fix this,’” recalled Dr. Miguel Regueiro, codirector of the IBD center.

So, in addition to asking the insurer for ideas, Dr. Regueiro did the most cost conscious thing he could think of: He asked for ideas from his colleague, Dr. Eva Szigethy, a psychiatrist specializing in the treatment of pain and psychosocial issues faced by IBD patients.

“Nearly half of our patient population has some behavioral, stress, or mental health component that is driving their disease, [leading] to high health care utilization,” Dr. Regueiro said.

Dr. Szigethy’s work of late, both on her own and with others such as Dr. Douglas Drossman, an emeritus psychiatrist and gastroenterologist at the University of North Carolina at Chapel Hill, has focused on the so-called brain-gut axis and includes the impact of narcotics on the gastrointestinal tract, the correlation between inflammation and depression, the effectiveness of cognitive-behavioral therapy in IBD, and the use of self-hypnosis to manage chronic pain.

“The vast majority of IBD patients have mood disorders, depression, reactive adjustment disorder, anxiety both [before and after] their diagnosis, and chronic pain,” Dr. Szigethy said in an interview.

In practical terms, this means patients benefit from the partnership between Dr. Regueiro, who brings a deep medical knowledge of IBD, and Dr. Szigethy, who combines her research with her psychiatric skill for asking the kinds of questions that evoke the patient’s larger story. Together, said Dr. Szigethy, they assess patients as a whole, directly accounting for the emotional complexity inherent in IBD, with an eye toward helping patients regain control of their lives, often made chaotic by the unpredictable indignities that are the hallmarks of the disease.

“Often, if we listen in the lines and between the lines, our patients tell us exactly what other factors are involved: why their disease is not getting better, why they are getting headaches, why they have such continued suffering,” Dr. Szigethy said.

“You don’t need to know the basic science to understand the stress these patients feel,” Dr. Regueiro recounted to an audience at a recent Advances in IBD meeting in Orlando, sponsored by the Crohn’s and Colitis Foundation of America.

He shared with his audience the story of 45-year-old Anne, a Crohn’s disease sufferer treated at his center. Anne is not the patient’s real name. Despite her disease being inactive, Anne was hospitalized 23 times, and given 19 CT scans and seven endoscopic procedures in one calendar year alone, qualifying her as one of the center’s top 34 “health care frequent fliers.”

Empowering patients like Anne, whose costly care Dr. Szigethy and Dr. Regueiro recognized was attributable more to her psychosocial rather than medical IBD needs, not only improves their quality of life, it saves the system money.

This is why the same health plan representatives who told Dr. Regueiro they’d like to see cost reductions have partnered with him and Dr. Szigethy to develop a specialty care medical home pilot program that combines specialty, primary, and mental health care in one location. The program officially opened in mid-January of this year.

In the mid-1990s, the UPMC Health Plan was conceived by the medical center as a “strategic move to combine the intellectual capital of the provider system with that of the payer system,” according to Sandy McAnallen, UPMC Health Plan’s senior vice president for clinical affairs and quality performance.

The result, she said in an interview, is greater flexibility when it comes to what care is provided and how it is delivered. “The physicians are setting the evidence-based pathways on the kind of care that patients need to receive, and we have the ability to be very proactive with [how we pay for that] with this kind of relationship.”

Over the course of 2 years, Dr. Regueiro and Ms. McAnallen met several times to parse data on more effective ways to address the fractured way IBD patients, particularly those with undiagnosed psychosocial concerns, were seeking and receiving treatment. The pair also honed in on ways to cut the high cost of surgeries and pharmaceuticals with the overall goal being to create a healthier IBD patient population who perceived their care to be the best possible.

To develop their specialty medical home model, Dr. Regueiro, Dr. Szigethy, Ms. McAnallen, and other key UPMC hospital system and health plan administrators, as well as other IBD specialists, met many times over the course of 2 years to plan what Ms. McAnallen calls their proof of concept.

The program is offered automatically to those covered by the UPMC Health Plan, although anyone is welcome to opt out if they choose. Participants are asked, but not required, to submit to genetic sampling for IBD research purposes, and other data also are gathered with consent at the center. Those not covered by UPMC insurance also are welcome to participate. “The center is payer-agnostic,” Ms. McAnallen said.

Dr. Regueiro and his colleagues will be the primary doctors for all patients who want to be seen at the IBD center for their chronic condition, while episodic illnesses such as colds, flus, and rashes are treated by a newly added advance practice nurse. All patients are now offered behavioral and psychosocial support, depending on the concern, either from Dr. Szigethy, a psychologist, or a social worker who was added to the team for the pilot project.

“Part of what we are defining [with this project] is when a psychiatrist is needed, and what can be done by a less expensive, but well-trained behavioral health, medically trained person like a social worker,” said Dr. Szigethy, who is also a member of the department of psychiatry.

A new patient peer group offers patients the chance to discuss their IBD-related struggles with others who can empathize directly, and a nutritionist and pharmacist both specializing in IBD needs have been added to the payroll. A 24/7 call center also has been established.

“We want patients to be in the habit of calling one place where their entire history is known,” said Ms. McAnallen. “Whether they need primary care or specialty care, we want these patients to go to the specialty medical home.”

It’s a patient-centered, rather than an institution-based model, where the referrals are controlled by the payer, “but the system is value based not volume based,” said Dr. Regueiro.

To that end, Dr. Regueiro said he hopes the center will expand its use of telemedicine to further accommodate patients, who often find it difficult to take time off from work or school, find and afford child care, and travel long distances to their doctor appointments. “Right now, some patients have to drive hours to see us, but a lot of what we do for these patients is cognitive care,” he said.

The IBD center’s additional personnel have been paid for by the health plan, in order to cover the cost of adequately serving the approximately 725 IBD patients the insurer determined were the most expensive to treat out of the more than 5,000 IBD patients, a notably high number according to Dr. Szigethy, that the center serves.

In exchange for underwriting the cost of a portion of the staff, the health plan expects Dr. Regueiro and his team to cut treatment costs for this cohort. “If we save a certain amount on patients each year, the health plan will give that back to us,” Dr. Regueiro said.

One way Ms. McAnallen said the program is projected to save is by reducing the number of times frequent fliers of UPMC’s emergency department arrive with an IBD complaint.

“The ED specializes in all acute medical issues, but for IBD we need to focus in a different way,” said Ms. McAnallen.

To wit, in her health care high-utilization heyday, Anne’s treatment typically began in the emergency department, where she arrived seeking narcotics for her condition.

“She said she hated that the people in the ED treated her like a drug addict, but she hated the pain even more,” Dr. Regueiro told his Orlando audience.

This was particularly troublesome for Anne, since Dr. Szigethy determined she was a potential sufferer of narcotic bowel syndrome.

Although at present, much of the research into this phenomenon is still bench science, Dr. Szigethy said a growing body of evidence provided in part by advanced neuroimaging techniques indicates that chronic narcotic use changes opioid receptors in some human adults from creating an analgesic effect, to a hyperanalgesic one instead, where the narcotics themselves start to create pain and exacerbate any existing bowel issues.

“In Anne’s case, she was going up and up in her opiates, but her pain was getting worse,” Dr. Szigethy said.

Dr. Szigethy obtained permission from Anne’s insurer, which happened to be UPMC Health Plan, to give her a 5-day inpatient medical hospitalization during which time Anne was weaned from her narcotics. For 6 months prior to her detoxification from the opiates, Anne learned self-hypnosis techniques from Dr. Szigethy and her colleagues, which she used to support her withdrawal from the pain medication. Anne’s self-reported favorite technique was that whenever the pain would start, she would visualize filling a balloon with it, and then letting the balloon drift away until it eventually evaporated into the air.

“I know it sounds corny, but guess what? Last year, Anne had zero hospitalizations,” Dr. Regueiro said.

According to Dr. Szigethy, Anne still has occasional pain, “But she can deal with it.”The exact savings UPMC Health Plan expects to realize by way of reimbursing the IBD center for treatment models created in response to emerging research such as that of Dr. Szigethy is still unknown. But Ms. McAnallen is optimistic the program will meet its broader targets.

“We are at a point where costs are becoming out of control and the consumer can’t afford health care. You have to be in a position where you can rely on your physicians to develop evidence-based pathways for treatment of acute and chronic disease, which Eva and Miguel are doing, and to do be able to do so in a laboratory where you have the premium to support that,” Ms. McAnallen said, adding that had Dr. Regueiro approached an outside payer to help him create the medical home model, she doubted it would have come to fruition.

“Because we’re part of an integrated system, we’re all aligned with the same goals, which include improving the health status of our community and decreasing the cost of care so it’s affordable.”

Analysis of data collected on total cost and quality of care, and patient perception of care, will begin within the next 6 months, said Ms. McAnallen, who did not offer specific margins but noted that if gains are made, UPMC would look at how to apply this integrated approach to treating other chronic diseases such as rheumatoid arthritis and multiple sclerosis.

One central question the pilot program is expected to answer is whether it is feasible to do away with fee-for-service provider reimbursements, which Ms. McAnallen said are, in her opinion, at the crux of the current national health care crisis.

“You go to your physician, they do something, they submit a claim, they get a check. We haven’t put in a system that makes providers, whether hospitals or physicians, step back and say, ‘Let’s do this differently. I’m on a treadmill of fee for service. The more I produce, the more I get paid.’ This IBD pilot program is to really help us transform that payment structure.”

Intangible factors such as how much of a specialty medical home’s success is predicated on the verve of its leadership will also be evaluated. “If you don’t have a physician who will be the [medical home’s] champion, it will be very hard to replicate,” Ms. McAnallen said. Attracting ambitious specialists with the opportunity to create such an integrated care model could become a recruitment tool for UPMC, she added.

If the concept of a one-stop-doc-shop sounds slightly “what was old is new again,” harkening back to the days when physicians were called doctors, never “providers,” and largely were thought of as family friends who made house calls, said Dr. Szigethy, it’s because it is that model, amplified by modern means.

“We can’t go to patients’ homes because they’re even more widespread than they were back in the day of the village, but what we can do is provide care through the ancillary team members who are extraordinarily well trained, and can provide education on nutrition and medication. Whether it’s by telemedicine or face to face, patients are getting treated in an integrated way, and we’re doing it as efficaciously as possible. That is brand new.”

Dr. Regueiro said in an interview at least one other insurance company has expressed interest in learning more about the IBD center’s integrated approach, causing him to reassess the payer’s role in health care’s revolution. “There is more common ground between us than I once thought. Insurers are not the devil. They are central to improving value.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

In just 1 year, 34 out of about 5,000 patients seen at the inflammatory bowel disease center at the University of Pittsburgh Medical Center cost more than $10 million to treat.

“Our health plan said, ‘You have to fix this,’” recalled Dr. Miguel Regueiro, codirector of the IBD center.

So, in addition to asking the insurer for ideas, Dr. Regueiro did the most cost conscious thing he could think of: He asked for ideas from his colleague, Dr. Eva Szigethy, a psychiatrist specializing in the treatment of pain and psychosocial issues faced by IBD patients.

“Nearly half of our patient population has some behavioral, stress, or mental health component that is driving their disease, [leading] to high health care utilization,” Dr. Regueiro said.

Dr. Szigethy’s work of late, both on her own and with others such as Dr. Douglas Drossman, an emeritus psychiatrist and gastroenterologist at the University of North Carolina at Chapel Hill, has focused on the so-called brain-gut axis and includes the impact of narcotics on the gastrointestinal tract, the correlation between inflammation and depression, the effectiveness of cognitive-behavioral therapy in IBD, and the use of self-hypnosis to manage chronic pain.

“The vast majority of IBD patients have mood disorders, depression, reactive adjustment disorder, anxiety both [before and after] their diagnosis, and chronic pain,” Dr. Szigethy said in an interview.

In practical terms, this means patients benefit from the partnership between Dr. Regueiro, who brings a deep medical knowledge of IBD, and Dr. Szigethy, who combines her research with her psychiatric skill for asking the kinds of questions that evoke the patient’s larger story. Together, said Dr. Szigethy, they assess patients as a whole, directly accounting for the emotional complexity inherent in IBD, with an eye toward helping patients regain control of their lives, often made chaotic by the unpredictable indignities that are the hallmarks of the disease.

“Often, if we listen in the lines and between the lines, our patients tell us exactly what other factors are involved: why their disease is not getting better, why they are getting headaches, why they have such continued suffering,” Dr. Szigethy said.

“You don’t need to know the basic science to understand the stress these patients feel,” Dr. Regueiro recounted to an audience at a recent Advances in IBD meeting in Orlando, sponsored by the Crohn’s and Colitis Foundation of America.

He shared with his audience the story of 45-year-old Anne, a Crohn’s disease sufferer treated at his center. Anne is not the patient’s real name. Despite her disease being inactive, Anne was hospitalized 23 times, and given 19 CT scans and seven endoscopic procedures in one calendar year alone, qualifying her as one of the center’s top 34 “health care frequent fliers.”

Empowering patients like Anne, whose costly care Dr. Szigethy and Dr. Regueiro recognized was attributable more to her psychosocial rather than medical IBD needs, not only improves their quality of life, it saves the system money.

This is why the same health plan representatives who told Dr. Regueiro they’d like to see cost reductions have partnered with him and Dr. Szigethy to develop a specialty care medical home pilot program that combines specialty, primary, and mental health care in one location. The program officially opened in mid-January of this year.

In the mid-1990s, the UPMC Health Plan was conceived by the medical center as a “strategic move to combine the intellectual capital of the provider system with that of the payer system,” according to Sandy McAnallen, UPMC Health Plan’s senior vice president for clinical affairs and quality performance.

The result, she said in an interview, is greater flexibility when it comes to what care is provided and how it is delivered. “The physicians are setting the evidence-based pathways on the kind of care that patients need to receive, and we have the ability to be very proactive with [how we pay for that] with this kind of relationship.”

Over the course of 2 years, Dr. Regueiro and Ms. McAnallen met several times to parse data on more effective ways to address the fractured way IBD patients, particularly those with undiagnosed psychosocial concerns, were seeking and receiving treatment. The pair also honed in on ways to cut the high cost of surgeries and pharmaceuticals with the overall goal being to create a healthier IBD patient population who perceived their care to be the best possible.

To develop their specialty medical home model, Dr. Regueiro, Dr. Szigethy, Ms. McAnallen, and other key UPMC hospital system and health plan administrators, as well as other IBD specialists, met many times over the course of 2 years to plan what Ms. McAnallen calls their proof of concept.

The program is offered automatically to those covered by the UPMC Health Plan, although anyone is welcome to opt out if they choose. Participants are asked, but not required, to submit to genetic sampling for IBD research purposes, and other data also are gathered with consent at the center. Those not covered by UPMC insurance also are welcome to participate. “The center is payer-agnostic,” Ms. McAnallen said.

Dr. Regueiro and his colleagues will be the primary doctors for all patients who want to be seen at the IBD center for their chronic condition, while episodic illnesses such as colds, flus, and rashes are treated by a newly added advance practice nurse. All patients are now offered behavioral and psychosocial support, depending on the concern, either from Dr. Szigethy, a psychologist, or a social worker who was added to the team for the pilot project.

“Part of what we are defining [with this project] is when a psychiatrist is needed, and what can be done by a less expensive, but well-trained behavioral health, medically trained person like a social worker,” said Dr. Szigethy, who is also a member of the department of psychiatry.

A new patient peer group offers patients the chance to discuss their IBD-related struggles with others who can empathize directly, and a nutritionist and pharmacist both specializing in IBD needs have been added to the payroll. A 24/7 call center also has been established.

“We want patients to be in the habit of calling one place where their entire history is known,” said Ms. McAnallen. “Whether they need primary care or specialty care, we want these patients to go to the specialty medical home.”

It’s a patient-centered, rather than an institution-based model, where the referrals are controlled by the payer, “but the system is value based not volume based,” said Dr. Regueiro.

To that end, Dr. Regueiro said he hopes the center will expand its use of telemedicine to further accommodate patients, who often find it difficult to take time off from work or school, find and afford child care, and travel long distances to their doctor appointments. “Right now, some patients have to drive hours to see us, but a lot of what we do for these patients is cognitive care,” he said.

The IBD center’s additional personnel have been paid for by the health plan, in order to cover the cost of adequately serving the approximately 725 IBD patients the insurer determined were the most expensive to treat out of the more than 5,000 IBD patients, a notably high number according to Dr. Szigethy, that the center serves.

In exchange for underwriting the cost of a portion of the staff, the health plan expects Dr. Regueiro and his team to cut treatment costs for this cohort. “If we save a certain amount on patients each year, the health plan will give that back to us,” Dr. Regueiro said.

One way Ms. McAnallen said the program is projected to save is by reducing the number of times frequent fliers of UPMC’s emergency department arrive with an IBD complaint.

“The ED specializes in all acute medical issues, but for IBD we need to focus in a different way,” said Ms. McAnallen.

To wit, in her health care high-utilization heyday, Anne’s treatment typically began in the emergency department, where she arrived seeking narcotics for her condition.

“She said she hated that the people in the ED treated her like a drug addict, but she hated the pain even more,” Dr. Regueiro told his Orlando audience.

This was particularly troublesome for Anne, since Dr. Szigethy determined she was a potential sufferer of narcotic bowel syndrome.

Although at present, much of the research into this phenomenon is still bench science, Dr. Szigethy said a growing body of evidence provided in part by advanced neuroimaging techniques indicates that chronic narcotic use changes opioid receptors in some human adults from creating an analgesic effect, to a hyperanalgesic one instead, where the narcotics themselves start to create pain and exacerbate any existing bowel issues.

“In Anne’s case, she was going up and up in her opiates, but her pain was getting worse,” Dr. Szigethy said.

Dr. Szigethy obtained permission from Anne’s insurer, which happened to be UPMC Health Plan, to give her a 5-day inpatient medical hospitalization during which time Anne was weaned from her narcotics. For 6 months prior to her detoxification from the opiates, Anne learned self-hypnosis techniques from Dr. Szigethy and her colleagues, which she used to support her withdrawal from the pain medication. Anne’s self-reported favorite technique was that whenever the pain would start, she would visualize filling a balloon with it, and then letting the balloon drift away until it eventually evaporated into the air.

“I know it sounds corny, but guess what? Last year, Anne had zero hospitalizations,” Dr. Regueiro said.

According to Dr. Szigethy, Anne still has occasional pain, “But she can deal with it.”The exact savings UPMC Health Plan expects to realize by way of reimbursing the IBD center for treatment models created in response to emerging research such as that of Dr. Szigethy is still unknown. But Ms. McAnallen is optimistic the program will meet its broader targets.

“We are at a point where costs are becoming out of control and the consumer can’t afford health care. You have to be in a position where you can rely on your physicians to develop evidence-based pathways for treatment of acute and chronic disease, which Eva and Miguel are doing, and to do be able to do so in a laboratory where you have the premium to support that,” Ms. McAnallen said, adding that had Dr. Regueiro approached an outside payer to help him create the medical home model, she doubted it would have come to fruition.

“Because we’re part of an integrated system, we’re all aligned with the same goals, which include improving the health status of our community and decreasing the cost of care so it’s affordable.”

Analysis of data collected on total cost and quality of care, and patient perception of care, will begin within the next 6 months, said Ms. McAnallen, who did not offer specific margins but noted that if gains are made, UPMC would look at how to apply this integrated approach to treating other chronic diseases such as rheumatoid arthritis and multiple sclerosis.

One central question the pilot program is expected to answer is whether it is feasible to do away with fee-for-service provider reimbursements, which Ms. McAnallen said are, in her opinion, at the crux of the current national health care crisis.

“You go to your physician, they do something, they submit a claim, they get a check. We haven’t put in a system that makes providers, whether hospitals or physicians, step back and say, ‘Let’s do this differently. I’m on a treadmill of fee for service. The more I produce, the more I get paid.’ This IBD pilot program is to really help us transform that payment structure.”

Intangible factors such as how much of a specialty medical home’s success is predicated on the verve of its leadership will also be evaluated. “If you don’t have a physician who will be the [medical home’s] champion, it will be very hard to replicate,” Ms. McAnallen said. Attracting ambitious specialists with the opportunity to create such an integrated care model could become a recruitment tool for UPMC, she added.

If the concept of a one-stop-doc-shop sounds slightly “what was old is new again,” harkening back to the days when physicians were called doctors, never “providers,” and largely were thought of as family friends who made house calls, said Dr. Szigethy, it’s because it is that model, amplified by modern means.

“We can’t go to patients’ homes because they’re even more widespread than they were back in the day of the village, but what we can do is provide care through the ancillary team members who are extraordinarily well trained, and can provide education on nutrition and medication. Whether it’s by telemedicine or face to face, patients are getting treated in an integrated way, and we’re doing it as efficaciously as possible. That is brand new.”

Dr. Regueiro said in an interview at least one other insurance company has expressed interest in learning more about the IBD center’s integrated approach, causing him to reassess the payer’s role in health care’s revolution. “There is more common ground between us than I once thought. Insurers are not the devil. They are central to improving value.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – “It’s surprising to me today, when I go proctor or watch a case, how people don’t understand the impact of radiation,” Dr. Mark A. Farber, professor of surgery and radiology at the University of North Carolina, Chapel Hill, said at the Southern Association for Vascular Surgery annual meeting. “Many times, I see people’s hands underneath and on the fluoroscopy machine.”

This flouting of the so-called ALARA principle (as low as reasonably achievable) happens in part because the number of complex procedures performed by vascular surgeons is increasing, despite what presenter Dr. Melissa Kirkwood, a vascular surgeon at the University of Texas Southwestern Medical Center, Dallas, told the audience is a lack of training in radiation dose terminology and basic safety principals.

Yet, practicing excellent radiation safety protocols is “paramount” according to Dr. Farber who, along with Dr. Kirkwood, shared insights on how to minimize dose to both patients and vascular specialists, whether it be from primary, leakage, or scatter radiation.

Table up, top down

Minimizing the air gap by as little as 100 mm – from 700 mm to 600 mm, for example – can reduce the dose of radiation from 17% to 29%, whereas a 10-cm increase in the air gap can result in as much as a 20%-38% increase in the radiation skin dose. This is essentially the application of the inverse square law, according to Dr. Kirkwood.

Although Dr. Farber said that some of the newer, more advanced machines have sensors that automatically detect where the collector should be in relation to the patient, he cautioned that, if your machine doesn’t have these “bells and whistles … remember that the skin dose decreases as the air gap decreases.”

Slow the frame rate

Another advantage to using new imaging systems, according to Dr. Farber, is that they allow the use of pulsed fluoroscopy for as few as 2 or 3 pulses/sec. The selected pulse rate determines the number of fluoroscopic image frames that are generated by the machine per second. This is significant when the dose savings are essential or for when performing simpler procedures, he said. “If you go from 7.5 frames down to 3 frames/sec, you can decrease the exposure for both you and your patient.”

Use between 15 and 30 pulses/sec for critical procedures where precision is crucial, but reducing the rate to 7.5 pulses/sec may result is as much as 70% less of a skin dose.

Add barriers

Don’t just assume that the lead shielding is doing the job. “It’s important that you keep up on this and have it tested regularly,” said Dr. Farber, who recently discovered his thyroid shield was cracked and needed to be replaced.

Additionally, consider the lead shielding of your staff, which, even if it is not used as frequently as the physician’s, can suffer from improper handling. “They fold it or crinkle it up and drop it on the floor. This can lead to problems,” he said. And be sure to remember leaded glasses, lead drapes for the sides of the table, and leaded ceiling-mounted or standing shields.

For extra protection, Dr. Farber recommended the use of disposable protective drapes with cut-outs that allow access to the patient while helping to reduce the amount of scatter radiation exposure to the operator’s limbs. At a tally of anywhere from 1 to 10 mGy/hour, scatter radiation emanating from the patient is a particular risk to the operator’s legs from the knees down, said Dr. Kirkwood, “depending on how tall you are.”

Using the disposable drapes also can result in a 12-fold decrease in the amount of scatter on the eyes, a 25-fold decrease in thyroid exposure to scatter, and a 29-fold decrease in the hands being exposed.

“They can be cumbersome at times, I admit,” Dr. Farber said. “But there can be no substitute for using protective drapes.”

Leaded aprons also can help cut radiation transmission rates, even if they are not foolproof. Wearing two-piece leaded apron systems can help cut down the body strain from the weight of the aprons; however, Dr. Farber said that, at his institution, they now use a suspended body shield system operated by a boom so there is no physical stress on the clinician.

Because the weightless system also provides additional protection for the specialist’s head and limbs, Dr. Farber said that the hefty price tag (approximately $50,000) is justified.

“The way I sold it to the hospital was I told them I could stop doing procedures, or they could get me one of these systems so I could do more procedures,” he said, adding he has had a weightless system installed on each side of the table. “They’ll get their money’s worth by the fact that you’re not over your exposure limit.”

And finally, don’t forget to protect the anesthesiologist! A standing shield that gives broad coverage area should suffice, Dr. Farber said.

Vary the technique

Altering the angle can help ensure that one area of the patient’s body isn’t being overexposed to radiation. Since previously irradiated skin reacts abnormally when re-exposed to radiation because the regeneration and repair of the dermis can take up to several weeks after the initial insult, the timing of the intervals between exposures is critical, said Dr. Kirkwood, adding that the Joint Commission recently recommended that all doses of fluoroscopically guided interventions performed within the past 6-12 months should be considered when assessing potential skin injury risk.

Change the collimation

Making it tighter, for example, can help improve image quality and reduce the radiation dose to both the patient and the operator, as can varying the acquisition rates.

Exit the room during DSA

During digital subtraction angiography, Dr. Farber said to “get away from the table if you can! It’s a huge dose you don’t need to be exposed to if you don’t need to be right next to the machine.” Dr. Kirkwood agreed: “Angiography is 10-100 times more dose than fluoroscopy.”

De-mag

Using a larger monitor allows the operator to see more detail without increasing the magnification, which also increases the dose in the amount of the diameter over the diameter squared. “By not magnifying up [from a field of view of 14 to 28] you will save yourself a factor of at least 4,” Dr. Farber said. “And the actual dose may be even less.”

Optimize imaging

Today’s advanced imaging systems mean that it’s easy to produce many high-quality images – CT scans and ultrasounds – that allow a deeper, more complete picture.

Having the number of images it is now possible to have on screen at once is “practice changing” because it can help clinicians see more possibilities for “how to do the case,” said Dr. Farber. “I’ve never heard anyone say, ’Well, I wish I didn’t have that extra imaging next to me.’ ”

Save images

But once you get it, don’t forget to keep it. “Many times you do an acquisition, you move the machine, and you realize you forget to save the image and now you’ve got to go back and do it all over again,” Dr. Farber lamented. But by once again making technology your friend, with functions that allow auto-return to previous positions, among other auto-commands, you can save the needed information and reduce any unnecessary dose exposure for both yourself and the patient, he said.

Protect your eyes

Cataracts are still all too common in the field, according to Dr. Farber. “It’s important that you have side shields on your glasses to cut down on the amount of radiation that comes in and around the glasses.” Eschew glasses that don’t overtly hug your face, he said.

Know your geometry

Don’t forget that, if you’re standing on the side of the imaging source, the scattering effect will be greater than if you’re on the side of the image receptor. Once again, an understanding of the inverse square law can be protective, according to Dr. Kirkwood: “As x-rays exit the source, there is an exponential decrease in the number of x-rays per unit area as the distance from the source increases.”

“It’s simple stuff,” concluded Dr. Farber. “If you get in the habit of doing these things you will cut down your radiation exposure.”

Neither Dr. Farber nor Dr. Kirkwood had any relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – “It’s surprising to me today, when I go proctor or watch a case, how people don’t understand the impact of radiation,” Dr. Mark A. Farber, professor of surgery and radiology at the University of North Carolina, Chapel Hill, said at the Southern Association for Vascular Surgery annual meeting. “Many times, I see people’s hands underneath and on the fluoroscopy machine.”

This flouting of the so-called ALARA principle (as low as reasonably achievable) happens in part because the number of complex procedures performed by vascular surgeons is increasing, despite what presenter Dr. Melissa Kirkwood, a vascular surgeon at the University of Texas Southwestern Medical Center, Dallas, told the audience is a lack of training in radiation dose terminology and basic safety principals.

Yet, practicing excellent radiation safety protocols is “paramount” according to Dr. Farber who, along with Dr. Kirkwood, shared insights on how to minimize dose to both patients and vascular specialists, whether it be from primary, leakage, or scatter radiation.

Table up, top down

Minimizing the air gap by as little as 100 mm – from 700 mm to 600 mm, for example – can reduce the dose of radiation from 17% to 29%, whereas a 10-cm increase in the air gap can result in as much as a 20%-38% increase in the radiation skin dose. This is essentially the application of the inverse square law, according to Dr. Kirkwood.

Although Dr. Farber said that some of the newer, more advanced machines have sensors that automatically detect where the collector should be in relation to the patient, he cautioned that, if your machine doesn’t have these “bells and whistles … remember that the skin dose decreases as the air gap decreases.”

Slow the frame rate

Another advantage to using new imaging systems, according to Dr. Farber, is that they allow the use of pulsed fluoroscopy for as few as 2 or 3 pulses/sec. The selected pulse rate determines the number of fluoroscopic image frames that are generated by the machine per second. This is significant when the dose savings are essential or for when performing simpler procedures, he said. “If you go from 7.5 frames down to 3 frames/sec, you can decrease the exposure for both you and your patient.”

Use between 15 and 30 pulses/sec for critical procedures where precision is crucial, but reducing the rate to 7.5 pulses/sec may result is as much as 70% less of a skin dose.

Add barriers

Don’t just assume that the lead shielding is doing the job. “It’s important that you keep up on this and have it tested regularly,” said Dr. Farber, who recently discovered his thyroid shield was cracked and needed to be replaced.

Additionally, consider the lead shielding of your staff, which, even if it is not used as frequently as the physician’s, can suffer from improper handling. “They fold it or crinkle it up and drop it on the floor. This can lead to problems,” he said. And be sure to remember leaded glasses, lead drapes for the sides of the table, and leaded ceiling-mounted or standing shields.

For extra protection, Dr. Farber recommended the use of disposable protective drapes with cut-outs that allow access to the patient while helping to reduce the amount of scatter radiation exposure to the operator’s limbs. At a tally of anywhere from 1 to 10 mGy/hour, scatter radiation emanating from the patient is a particular risk to the operator’s legs from the knees down, said Dr. Kirkwood, “depending on how tall you are.”

Using the disposable drapes also can result in a 12-fold decrease in the amount of scatter on the eyes, a 25-fold decrease in thyroid exposure to scatter, and a 29-fold decrease in the hands being exposed.

“They can be cumbersome at times, I admit,” Dr. Farber said. “But there can be no substitute for using protective drapes.”

Leaded aprons also can help cut radiation transmission rates, even if they are not foolproof. Wearing two-piece leaded apron systems can help cut down the body strain from the weight of the aprons; however, Dr. Farber said that, at his institution, they now use a suspended body shield system operated by a boom so there is no physical stress on the clinician.

Because the weightless system also provides additional protection for the specialist’s head and limbs, Dr. Farber said that the hefty price tag (approximately $50,000) is justified.

“The way I sold it to the hospital was I told them I could stop doing procedures, or they could get me one of these systems so I could do more procedures,” he said, adding he has had a weightless system installed on each side of the table. “They’ll get their money’s worth by the fact that you’re not over your exposure limit.”

And finally, don’t forget to protect the anesthesiologist! A standing shield that gives broad coverage area should suffice, Dr. Farber said.

Vary the technique

Altering the angle can help ensure that one area of the patient’s body isn’t being overexposed to radiation. Since previously irradiated skin reacts abnormally when re-exposed to radiation because the regeneration and repair of the dermis can take up to several weeks after the initial insult, the timing of the intervals between exposures is critical, said Dr. Kirkwood, adding that the Joint Commission recently recommended that all doses of fluoroscopically guided interventions performed within the past 6-12 months should be considered when assessing potential skin injury risk.

Change the collimation

Making it tighter, for example, can help improve image quality and reduce the radiation dose to both the patient and the operator, as can varying the acquisition rates.

Exit the room during DSA

During digital subtraction angiography, Dr. Farber said to “get away from the table if you can! It’s a huge dose you don’t need to be exposed to if you don’t need to be right next to the machine.” Dr. Kirkwood agreed: “Angiography is 10-100 times more dose than fluoroscopy.”

De-mag

Using a larger monitor allows the operator to see more detail without increasing the magnification, which also increases the dose in the amount of the diameter over the diameter squared. “By not magnifying up [from a field of view of 14 to 28] you will save yourself a factor of at least 4,” Dr. Farber said. “And the actual dose may be even less.”

Optimize imaging

Today’s advanced imaging systems mean that it’s easy to produce many high-quality images – CT scans and ultrasounds – that allow a deeper, more complete picture.

Having the number of images it is now possible to have on screen at once is “practice changing” because it can help clinicians see more possibilities for “how to do the case,” said Dr. Farber. “I’ve never heard anyone say, ’Well, I wish I didn’t have that extra imaging next to me.’ ”

Save images

But once you get it, don’t forget to keep it. “Many times you do an acquisition, you move the machine, and you realize you forget to save the image and now you’ve got to go back and do it all over again,” Dr. Farber lamented. But by once again making technology your friend, with functions that allow auto-return to previous positions, among other auto-commands, you can save the needed information and reduce any unnecessary dose exposure for both yourself and the patient, he said.

Protect your eyes

Cataracts are still all too common in the field, according to Dr. Farber. “It’s important that you have side shields on your glasses to cut down on the amount of radiation that comes in and around the glasses.” Eschew glasses that don’t overtly hug your face, he said.

Know your geometry

Don’t forget that, if you’re standing on the side of the imaging source, the scattering effect will be greater than if you’re on the side of the image receptor. Once again, an understanding of the inverse square law can be protective, according to Dr. Kirkwood: “As x-rays exit the source, there is an exponential decrease in the number of x-rays per unit area as the distance from the source increases.”

“It’s simple stuff,” concluded Dr. Farber. “If you get in the habit of doing these things you will cut down your radiation exposure.”

Neither Dr. Farber nor Dr. Kirkwood had any relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – “It’s surprising to me today, when I go proctor or watch a case, how people don’t understand the impact of radiation,” Dr. Mark A. Farber, professor of surgery and radiology at the University of North Carolina, Chapel Hill, said at the Southern Association for Vascular Surgery annual meeting. “Many times, I see people’s hands underneath and on the fluoroscopy machine.”

This flouting of the so-called ALARA principle (as low as reasonably achievable) happens in part because the number of complex procedures performed by vascular surgeons is increasing, despite what presenter Dr. Melissa Kirkwood, a vascular surgeon at the University of Texas Southwestern Medical Center, Dallas, told the audience is a lack of training in radiation dose terminology and basic safety principals.

Yet, practicing excellent radiation safety protocols is “paramount” according to Dr. Farber who, along with Dr. Kirkwood, shared insights on how to minimize dose to both patients and vascular specialists, whether it be from primary, leakage, or scatter radiation.

Table up, top down

Minimizing the air gap by as little as 100 mm – from 700 mm to 600 mm, for example – can reduce the dose of radiation from 17% to 29%, whereas a 10-cm increase in the air gap can result in as much as a 20%-38% increase in the radiation skin dose. This is essentially the application of the inverse square law, according to Dr. Kirkwood.

Although Dr. Farber said that some of the newer, more advanced machines have sensors that automatically detect where the collector should be in relation to the patient, he cautioned that, if your machine doesn’t have these “bells and whistles … remember that the skin dose decreases as the air gap decreases.”

Slow the frame rate

Another advantage to using new imaging systems, according to Dr. Farber, is that they allow the use of pulsed fluoroscopy for as few as 2 or 3 pulses/sec. The selected pulse rate determines the number of fluoroscopic image frames that are generated by the machine per second. This is significant when the dose savings are essential or for when performing simpler procedures, he said. “If you go from 7.5 frames down to 3 frames/sec, you can decrease the exposure for both you and your patient.”

Use between 15 and 30 pulses/sec for critical procedures where precision is crucial, but reducing the rate to 7.5 pulses/sec may result is as much as 70% less of a skin dose.

Add barriers

Don’t just assume that the lead shielding is doing the job. “It’s important that you keep up on this and have it tested regularly,” said Dr. Farber, who recently discovered his thyroid shield was cracked and needed to be replaced.

Additionally, consider the lead shielding of your staff, which, even if it is not used as frequently as the physician’s, can suffer from improper handling. “They fold it or crinkle it up and drop it on the floor. This can lead to problems,” he said. And be sure to remember leaded glasses, lead drapes for the sides of the table, and leaded ceiling-mounted or standing shields.

For extra protection, Dr. Farber recommended the use of disposable protective drapes with cut-outs that allow access to the patient while helping to reduce the amount of scatter radiation exposure to the operator’s limbs. At a tally of anywhere from 1 to 10 mGy/hour, scatter radiation emanating from the patient is a particular risk to the operator’s legs from the knees down, said Dr. Kirkwood, “depending on how tall you are.”

Using the disposable drapes also can result in a 12-fold decrease in the amount of scatter on the eyes, a 25-fold decrease in thyroid exposure to scatter, and a 29-fold decrease in the hands being exposed.

“They can be cumbersome at times, I admit,” Dr. Farber said. “But there can be no substitute for using protective drapes.”

Leaded aprons also can help cut radiation transmission rates, even if they are not foolproof. Wearing two-piece leaded apron systems can help cut down the body strain from the weight of the aprons; however, Dr. Farber said that, at his institution, they now use a suspended body shield system operated by a boom so there is no physical stress on the clinician.

Because the weightless system also provides additional protection for the specialist’s head and limbs, Dr. Farber said that the hefty price tag (approximately $50,000) is justified.

“The way I sold it to the hospital was I told them I could stop doing procedures, or they could get me one of these systems so I could do more procedures,” he said, adding he has had a weightless system installed on each side of the table. “They’ll get their money’s worth by the fact that you’re not over your exposure limit.”

And finally, don’t forget to protect the anesthesiologist! A standing shield that gives broad coverage area should suffice, Dr. Farber said.

Vary the technique

Altering the angle can help ensure that one area of the patient’s body isn’t being overexposed to radiation. Since previously irradiated skin reacts abnormally when re-exposed to radiation because the regeneration and repair of the dermis can take up to several weeks after the initial insult, the timing of the intervals between exposures is critical, said Dr. Kirkwood, adding that the Joint Commission recently recommended that all doses of fluoroscopically guided interventions performed within the past 6-12 months should be considered when assessing potential skin injury risk.

Change the collimation

Making it tighter, for example, can help improve image quality and reduce the radiation dose to both the patient and the operator, as can varying the acquisition rates.

Exit the room during DSA

During digital subtraction angiography, Dr. Farber said to “get away from the table if you can! It’s a huge dose you don’t need to be exposed to if you don’t need to be right next to the machine.” Dr. Kirkwood agreed: “Angiography is 10-100 times more dose than fluoroscopy.”

De-mag

Using a larger monitor allows the operator to see more detail without increasing the magnification, which also increases the dose in the amount of the diameter over the diameter squared. “By not magnifying up [from a field of view of 14 to 28] you will save yourself a factor of at least 4,” Dr. Farber said. “And the actual dose may be even less.”

Optimize imaging

Today’s advanced imaging systems mean that it’s easy to produce many high-quality images – CT scans and ultrasounds – that allow a deeper, more complete picture.

Having the number of images it is now possible to have on screen at once is “practice changing” because it can help clinicians see more possibilities for “how to do the case,” said Dr. Farber. “I’ve never heard anyone say, ’Well, I wish I didn’t have that extra imaging next to me.’ ”

Save images

But once you get it, don’t forget to keep it. “Many times you do an acquisition, you move the machine, and you realize you forget to save the image and now you’ve got to go back and do it all over again,” Dr. Farber lamented. But by once again making technology your friend, with functions that allow auto-return to previous positions, among other auto-commands, you can save the needed information and reduce any unnecessary dose exposure for both yourself and the patient, he said.

Protect your eyes

Cataracts are still all too common in the field, according to Dr. Farber. “It’s important that you have side shields on your glasses to cut down on the amount of radiation that comes in and around the glasses.” Eschew glasses that don’t overtly hug your face, he said.

Know your geometry

Don’t forget that, if you’re standing on the side of the imaging source, the scattering effect will be greater than if you’re on the side of the image receptor. Once again, an understanding of the inverse square law can be protective, according to Dr. Kirkwood: “As x-rays exit the source, there is an exponential decrease in the number of x-rays per unit area as the distance from the source increases.”

“It’s simple stuff,” concluded Dr. Farber. “If you get in the habit of doing these things you will cut down your radiation exposure.”

Neither Dr. Farber nor Dr. Kirkwood had any relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

PHOENIX – Pneumonia, dehydration, and septicemia topped the list of risk factors associated with the need for cardiopulmonary resuscitation during hospitalization for a major surgical procedure in 1 in 500 patients, a retrospective analysis found.

The large sample studied shows that having emergency rather than elective surgery, being older, being African American, and lacking health insurance were also associated with greater odds of needing CPR in this cohort, Dr. Ashima Das of Rainbow Children’s Hospital in Cleveland reported.

© KatarzynaBialasiewicz/Thinkstock

A review of 12,631,502 patient records found in the 2009 and 2010 National Inpatient Sample showed that 0.2% of all major surgery patients between 18 and 64 years went into cardiac arrest during their surgical hospitalization. Patients with postoperative pneumonia were at 3.05 (95% confidence interval = 2.75-3.39, P < .0001) times higher risk for needing CPR; meanwhile, major surgery patients with postoperative dehydration or other fluid and electrolyte disruptions faced an increased risk of 3.50 (95% CI = 3.18-3.85, P < .0001), Dr. Das reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Septicemia posed a 2.60 greater risk (95% CI = 2.34-2.86, P < .0001). The odds ratio of needing CPR for patients with coagulopathy was 2.54 (95% CI = 2.30-2.81, P < .0001).

Dr. Das and her colleagues found that 80% of the 23,858 surgical procedures performed in patients who also needed CPR were emergent rather than elective. Patients’ risk of cardiac arrest increased by 1.02 ( 95% CI = 1.01-1.03, P < .0001) with every year of age, while African Americans had a slightly higher risk of needing CPR, compared with whites (OR, 1.51; 95% CI = 1.35-1.68; P < .0001), as did the uninsured, compared with the insured (P < .0001).

The authors of this study said they had no relevant financial disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

PHOENIX – Pneumonia, dehydration, and septicemia topped the list of risk factors associated with the need for cardiopulmonary resuscitation during hospitalization for a major surgical procedure in 1 in 500 patients, a retrospective analysis found.

The large sample studied shows that having emergency rather than elective surgery, being older, being African American, and lacking health insurance were also associated with greater odds of needing CPR in this cohort, Dr. Ashima Das of Rainbow Children’s Hospital in Cleveland reported.

© KatarzynaBialasiewicz/Thinkstock

A review of 12,631,502 patient records found in the 2009 and 2010 National Inpatient Sample showed that 0.2% of all major surgery patients between 18 and 64 years went into cardiac arrest during their surgical hospitalization. Patients with postoperative pneumonia were at 3.05 (95% confidence interval = 2.75-3.39, P < .0001) times higher risk for needing CPR; meanwhile, major surgery patients with postoperative dehydration or other fluid and electrolyte disruptions faced an increased risk of 3.50 (95% CI = 3.18-3.85, P < .0001), Dr. Das reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Septicemia posed a 2.60 greater risk (95% CI = 2.34-2.86, P < .0001). The odds ratio of needing CPR for patients with coagulopathy was 2.54 (95% CI = 2.30-2.81, P < .0001).

Dr. Das and her colleagues found that 80% of the 23,858 surgical procedures performed in patients who also needed CPR were emergent rather than elective. Patients’ risk of cardiac arrest increased by 1.02 ( 95% CI = 1.01-1.03, P < .0001) with every year of age, while African Americans had a slightly higher risk of needing CPR, compared with whites (OR, 1.51; 95% CI = 1.35-1.68; P < .0001), as did the uninsured, compared with the insured (P < .0001).

The authors of this study said they had no relevant financial disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

PHOENIX – Pneumonia, dehydration, and septicemia topped the list of risk factors associated with the need for cardiopulmonary resuscitation during hospitalization for a major surgical procedure in 1 in 500 patients, a retrospective analysis found.

The large sample studied shows that having emergency rather than elective surgery, being older, being African American, and lacking health insurance were also associated with greater odds of needing CPR in this cohort, Dr. Ashima Das of Rainbow Children’s Hospital in Cleveland reported.

© KatarzynaBialasiewicz/Thinkstock

A review of 12,631,502 patient records found in the 2009 and 2010 National Inpatient Sample showed that 0.2% of all major surgery patients between 18 and 64 years went into cardiac arrest during their surgical hospitalization. Patients with postoperative pneumonia were at 3.05 (95% confidence interval = 2.75-3.39, P < .0001) times higher risk for needing CPR; meanwhile, major surgery patients with postoperative dehydration or other fluid and electrolyte disruptions faced an increased risk of 3.50 (95% CI = 3.18-3.85, P < .0001), Dr. Das reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Septicemia posed a 2.60 greater risk (95% CI = 2.34-2.86, P < .0001). The odds ratio of needing CPR for patients with coagulopathy was 2.54 (95% CI = 2.30-2.81, P < .0001).

Dr. Das and her colleagues found that 80% of the 23,858 surgical procedures performed in patients who also needed CPR were emergent rather than elective. Patients’ risk of cardiac arrest increased by 1.02 ( 95% CI = 1.01-1.03, P < .0001) with every year of age, while African Americans had a slightly higher risk of needing CPR, compared with whites (OR, 1.51; 95% CI = 1.35-1.68; P < .0001), as did the uninsured, compared with the insured (P < .0001).

The authors of this study said they had no relevant financial disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

Physicians should have a high degree of suspicion for measles when a patient presents with fever, rash, and other measles-related symptoms, CDC officials advised Jan. 29.

“I’m urging all health care professionals to think ‘measles’ when they’re evaluating patients with fever, rash, and other measles-related symptoms,” Dr. Anne Schuchat, the U.S. assistant surgeon general, and the director of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases, said during a press conference. “Health care professionals need to know the guidelines for infection control and reporting measles cases, and they should work to ensure that patients are getting the best protection possible against measles, which is on-time MMR [measles, mumps, and rubella] vaccination, to protect them whether at home or abroad.” 

Early symptoms include cough, runny nose and red, light-sensitive eyes. Two to four days later, a fine rash of red spots develops on the face and then gradually spreads down over the entire body. Fever, which can reach 103-105° F, comes with the rash. White spots, called Koplik spots, may appear on the inside of the cheeks. 

Measles is more contagious than almost any other disease. The virus that causes measles lives in the nose and throat of infected people and is sprayed into the air when an infected person sneezes, coughs or talks, and can stay in the air for up to 2 hours. People with measles can spread the disease starting 4 days before the rash begins until 4 days after it appears.

Courtesy CDC/NIP/Barbara Rice

At least 84 people across 14 states have been diagnosed recently with measles, including at least 67 who are thought to have been infected in mid- to late December while visiting Disneyland in Anaheim, Calif., Dr. Schuchat said. “We believe someone got infected [with measles] overseas, visited the Disneyland park, and spread the disease to others.” Those people went on to expose others in a variety of settings, including schools, day care centers, outpatient clinics, and airplanes, she added.

“This is not a problem of the measles vaccine not working, this is a problem of the measles vaccine not being used,” Dr. Schuchat said.

The CDC’s Advisory Committee on Immunization Practices recommends that children between 6 months and 12 months of age be vaccinated, particularly if they will be traveling, since many countries still experience measles on a much larger scale than in the United States.

For parents who balk at this, Dr Schuchat said, “The reason that MMR is recommended at 12 months routinely is because babies are exquisitely vulnerable to measles and the complications from measles.”

The CDC does not recommend the vaccine for children younger than 6 months and urged physicians to remind parents to have their children vaccinated with the recommended two additional doses after their children reach 12 months. “Between 6 and 12 months, it will protect, but it won’t last that long.”

The CDC is also urging adults to be sure of their vaccination status. Adults who are unsure whether they are immune to the virus, either through vaccination or from having had the disease, should get vaccinated or at the least discuss it with their physician. “There is no harm in getting another MMR vaccine if you’ve already been vaccinated,” Dr. Schuchat said.

The majority of measles cases over the past few years, she said, have been in persons who were unvaccinated, primarily because of personal beliefs. Others, however, were unvaccinated because of a missed opportunity.

“People were at the doctor’s office and didn’t get their vaccine because they had an illness, but we recommend you get vaccinated when you are there,” she said.

Already in January 2015, the United States has seen more than the median number of measles cases typically recorded annually since the virus was eliminated as a native disease. In 2014, a record number of 644 cases from 27 states reported to CDC’s National Center for Immunization and Respiratory Diseases.

“This is a wake-up call to make sure that we keep measles from gaining a foothold in our country,” Dr. Schuchat said.

The recommended vaccination schedules for children and adults can be found on the CDC website.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

*Updated on 1/30/15

Physicians should have a high degree of suspicion for measles when a patient presents with fever, rash, and other measles-related symptoms, CDC officials advised Jan. 29.

“I’m urging all health care professionals to think ‘measles’ when they’re evaluating patients with fever, rash, and other measles-related symptoms,” Dr. Anne Schuchat, the U.S. assistant surgeon general, and the director of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases, said during a press conference. “Health care professionals need to know the guidelines for infection control and reporting measles cases, and they should work to ensure that patients are getting the best protection possible against measles, which is on-time MMR [measles, mumps, and rubella] vaccination, to protect them whether at home or abroad.” 

Early symptoms include cough, runny nose and red, light-sensitive eyes. Two to four days later, a fine rash of red spots develops on the face and then gradually spreads down over the entire body. Fever, which can reach 103-105° F, comes with the rash. White spots, called Koplik spots, may appear on the inside of the cheeks. 

Measles is more contagious than almost any other disease. The virus that causes measles lives in the nose and throat of infected people and is sprayed into the air when an infected person sneezes, coughs or talks, and can stay in the air for up to 2 hours. People with measles can spread the disease starting 4 days before the rash begins until 4 days after it appears.

Courtesy CDC/NIP/Barbara Rice

At least 84 people across 14 states have been diagnosed recently with measles, including at least 67 who are thought to have been infected in mid- to late December while visiting Disneyland in Anaheim, Calif., Dr. Schuchat said. “We believe someone got infected [with measles] overseas, visited the Disneyland park, and spread the disease to others.” Those people went on to expose others in a variety of settings, including schools, day care centers, outpatient clinics, and airplanes, she added.

“This is not a problem of the measles vaccine not working, this is a problem of the measles vaccine not being used,” Dr. Schuchat said.

The CDC’s Advisory Committee on Immunization Practices recommends that children between 6 months and 12 months of age be vaccinated, particularly if they will be traveling, since many countries still experience measles on a much larger scale than in the United States.

For parents who balk at this, Dr Schuchat said, “The reason that MMR is recommended at 12 months routinely is because babies are exquisitely vulnerable to measles and the complications from measles.”

The CDC does not recommend the vaccine for children younger than 6 months and urged physicians to remind parents to have their children vaccinated with the recommended two additional doses after their children reach 12 months. “Between 6 and 12 months, it will protect, but it won’t last that long.”

The CDC is also urging adults to be sure of their vaccination status. Adults who are unsure whether they are immune to the virus, either through vaccination or from having had the disease, should get vaccinated or at the least discuss it with their physician. “There is no harm in getting another MMR vaccine if you’ve already been vaccinated,” Dr. Schuchat said.

The majority of measles cases over the past few years, she said, have been in persons who were unvaccinated, primarily because of personal beliefs. Others, however, were unvaccinated because of a missed opportunity.

“People were at the doctor’s office and didn’t get their vaccine because they had an illness, but we recommend you get vaccinated when you are there,” she said.

Already in January 2015, the United States has seen more than the median number of measles cases typically recorded annually since the virus was eliminated as a native disease. In 2014, a record number of 644 cases from 27 states reported to CDC’s National Center for Immunization and Respiratory Diseases.

“This is a wake-up call to make sure that we keep measles from gaining a foothold in our country,” Dr. Schuchat said.

The recommended vaccination schedules for children and adults can be found on the CDC website.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

*Updated on 1/30/15

Physicians should have a high degree of suspicion for measles when a patient presents with fever, rash, and other measles-related symptoms, CDC officials advised Jan. 29.

“I’m urging all health care professionals to think ‘measles’ when they’re evaluating patients with fever, rash, and other measles-related symptoms,” Dr. Anne Schuchat, the U.S. assistant surgeon general, and the director of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases, said during a press conference. “Health care professionals need to know the guidelines for infection control and reporting measles cases, and they should work to ensure that patients are getting the best protection possible against measles, which is on-time MMR [measles, mumps, and rubella] vaccination, to protect them whether at home or abroad.” 

Early symptoms include cough, runny nose and red, light-sensitive eyes. Two to four days later, a fine rash of red spots develops on the face and then gradually spreads down over the entire body. Fever, which can reach 103-105° F, comes with the rash. White spots, called Koplik spots, may appear on the inside of the cheeks. 

Measles is more contagious than almost any other disease. The virus that causes measles lives in the nose and throat of infected people and is sprayed into the air when an infected person sneezes, coughs or talks, and can stay in the air for up to 2 hours. People with measles can spread the disease starting 4 days before the rash begins until 4 days after it appears.

Courtesy CDC/NIP/Barbara Rice

At least 84 people across 14 states have been diagnosed recently with measles, including at least 67 who are thought to have been infected in mid- to late December while visiting Disneyland in Anaheim, Calif., Dr. Schuchat said. “We believe someone got infected [with measles] overseas, visited the Disneyland park, and spread the disease to others.” Those people went on to expose others in a variety of settings, including schools, day care centers, outpatient clinics, and airplanes, she added.

“This is not a problem of the measles vaccine not working, this is a problem of the measles vaccine not being used,” Dr. Schuchat said.

The CDC’s Advisory Committee on Immunization Practices recommends that children between 6 months and 12 months of age be vaccinated, particularly if they will be traveling, since many countries still experience measles on a much larger scale than in the United States.

For parents who balk at this, Dr Schuchat said, “The reason that MMR is recommended at 12 months routinely is because babies are exquisitely vulnerable to measles and the complications from measles.”

The CDC does not recommend the vaccine for children younger than 6 months and urged physicians to remind parents to have their children vaccinated with the recommended two additional doses after their children reach 12 months. “Between 6 and 12 months, it will protect, but it won’t last that long.”

The CDC is also urging adults to be sure of their vaccination status. Adults who are unsure whether they are immune to the virus, either through vaccination or from having had the disease, should get vaccinated or at the least discuss it with their physician. “There is no harm in getting another MMR vaccine if you’ve already been vaccinated,” Dr. Schuchat said.

The majority of measles cases over the past few years, she said, have been in persons who were unvaccinated, primarily because of personal beliefs. Others, however, were unvaccinated because of a missed opportunity.

“People were at the doctor’s office and didn’t get their vaccine because they had an illness, but we recommend you get vaccinated when you are there,” she said.

Already in January 2015, the United States has seen more than the median number of measles cases typically recorded annually since the virus was eliminated as a native disease. In 2014, a record number of 644 cases from 27 states reported to CDC’s National Center for Immunization and Respiratory Diseases.

“This is a wake-up call to make sure that we keep measles from gaining a foothold in our country,” Dr. Schuchat said.

The recommended vaccination schedules for children and adults can be found on the CDC website.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

*Updated on 1/30/15