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Australian apocalypse essentials and bacterial evolution stoppers
Irony 1, Council on Foreign Relations 0
It’s not a great time to be a business owner right now. People everywhere are feeling nervous, thanks to our old friend COVID-19, and it can be difficult to actually sell things when half the population is staying indoors hoarding toilet paper.
So if you are a business owner, you’re probably thinking: “Gee, it sure would be nice to meet up with my fellow business owners to come up with a plan on how to operate in a world dealing with a potential pandemic.” Right?
That’s the idea behind the Council on Foreign Relations’ roundtable discussion called “Doing Business Under Coronavirus,” scheduled for March 13, 2020, in New York. Or at least, it was the idea, because the conference has been canceled. And you’ll never guess why.
Okay, it was coronavirus. Uh, you probably did guess that. We’re not entirely sure what that means for business owners, but come on, there’s no need to worry, at least the infectious disease physicians had their meeting this past weekend ... oh wait. Hmm, maybe it’s time to start searching Amazon for some toilet paper.
Wipe away coronavirus fear
People now have smartphones to read the news while on the toilet, but at one point or another, having a newspaper to read in the john was probably pretty essential to combat boredom. Our friends down under, however, seem to have found another essential way to use a newspaper in the bathroom.
The coronavirus is slowly making its way around the world, and in Australia, people are stocking up on toilet paper. Toilet paper companies are working extra hard to keep a steady supply of toilet paper in supermarkets. A newspaper has tried to help by adding extra pages to its newspapers that could potentially be used as toilet paper. This seems like a good time to swap out your smartphone for one of these newspapers as it would not be wise to use your smartphone for toilet paper.
No one is sure why everyone in Australia is in a frenzy over toilet paper since it’s not a very big necessity in a large coronavirus outbreak. Are Aussies preparing to hide out in their homes just in case those affected by coronavirus turn into zombies, thus creating a zombie apocalypse? In that case, yeah, toilet paper, among other things, is probably essential.
Resistance meets resistance
As our planet moves from zombie apocalypse to coronapocalypse, even the business news has gone full COVID-19. So, it would be pointless for us to cover any other topic, right?
Well, welcome to the Bureau of Missing the Point. Ladies and gentleman, we give you [drum roll, please] bacteria.
That’s right, we said bacteria. In a world ruled by coronavirus, LOTME dares to bring you the latest edition of Bacteria vs. the World.
This week, we’re talking antibiotic resistance. The problem is that bacteria have the ability to pick up DNA from their surroundings to create resistance. That ability, known as competence, could be considered a form of evolution, and scientists are trying to stop it.
Investigators at the University of Groningen in the Netherlands and the Swiss University of Lausanne “developed a high-throughput assay to simultaneously test cells for competence and growth,” lead investigator Arnau Domenech, PhD, said in a written statement. Of the 1,366 approved drugs that they tested against Streptococcus pneumoniae, 46 blocked bacterial competence.
“When cells are under growth stress, for instance in the presence of antibiotics, they try to find a solution and become resistant to these drugs,” Dr. Domenech explained. “Importantly, we did not observe resistance to the drugs found here as they do not cause growth stress.”
The drug concentrations used to block competence may be too high to be safe for humans, but the results suggest that competence blockers are, indeed, anti-evolution drugs. As we go bacteria to the future, it seems, the ghost of Charles Darwin is working for the humans. Thanks, Chuck.
Oh, one more thing … CORONAVIRUS!
Irony 1, Council on Foreign Relations 0
It’s not a great time to be a business owner right now. People everywhere are feeling nervous, thanks to our old friend COVID-19, and it can be difficult to actually sell things when half the population is staying indoors hoarding toilet paper.
So if you are a business owner, you’re probably thinking: “Gee, it sure would be nice to meet up with my fellow business owners to come up with a plan on how to operate in a world dealing with a potential pandemic.” Right?
That’s the idea behind the Council on Foreign Relations’ roundtable discussion called “Doing Business Under Coronavirus,” scheduled for March 13, 2020, in New York. Or at least, it was the idea, because the conference has been canceled. And you’ll never guess why.
Okay, it was coronavirus. Uh, you probably did guess that. We’re not entirely sure what that means for business owners, but come on, there’s no need to worry, at least the infectious disease physicians had their meeting this past weekend ... oh wait. Hmm, maybe it’s time to start searching Amazon for some toilet paper.
Wipe away coronavirus fear
People now have smartphones to read the news while on the toilet, but at one point or another, having a newspaper to read in the john was probably pretty essential to combat boredom. Our friends down under, however, seem to have found another essential way to use a newspaper in the bathroom.
The coronavirus is slowly making its way around the world, and in Australia, people are stocking up on toilet paper. Toilet paper companies are working extra hard to keep a steady supply of toilet paper in supermarkets. A newspaper has tried to help by adding extra pages to its newspapers that could potentially be used as toilet paper. This seems like a good time to swap out your smartphone for one of these newspapers as it would not be wise to use your smartphone for toilet paper.
No one is sure why everyone in Australia is in a frenzy over toilet paper since it’s not a very big necessity in a large coronavirus outbreak. Are Aussies preparing to hide out in their homes just in case those affected by coronavirus turn into zombies, thus creating a zombie apocalypse? In that case, yeah, toilet paper, among other things, is probably essential.
Resistance meets resistance
As our planet moves from zombie apocalypse to coronapocalypse, even the business news has gone full COVID-19. So, it would be pointless for us to cover any other topic, right?
Well, welcome to the Bureau of Missing the Point. Ladies and gentleman, we give you [drum roll, please] bacteria.
That’s right, we said bacteria. In a world ruled by coronavirus, LOTME dares to bring you the latest edition of Bacteria vs. the World.
This week, we’re talking antibiotic resistance. The problem is that bacteria have the ability to pick up DNA from their surroundings to create resistance. That ability, known as competence, could be considered a form of evolution, and scientists are trying to stop it.
Investigators at the University of Groningen in the Netherlands and the Swiss University of Lausanne “developed a high-throughput assay to simultaneously test cells for competence and growth,” lead investigator Arnau Domenech, PhD, said in a written statement. Of the 1,366 approved drugs that they tested against Streptococcus pneumoniae, 46 blocked bacterial competence.
“When cells are under growth stress, for instance in the presence of antibiotics, they try to find a solution and become resistant to these drugs,” Dr. Domenech explained. “Importantly, we did not observe resistance to the drugs found here as they do not cause growth stress.”
The drug concentrations used to block competence may be too high to be safe for humans, but the results suggest that competence blockers are, indeed, anti-evolution drugs. As we go bacteria to the future, it seems, the ghost of Charles Darwin is working for the humans. Thanks, Chuck.
Oh, one more thing … CORONAVIRUS!
Irony 1, Council on Foreign Relations 0
It’s not a great time to be a business owner right now. People everywhere are feeling nervous, thanks to our old friend COVID-19, and it can be difficult to actually sell things when half the population is staying indoors hoarding toilet paper.
So if you are a business owner, you’re probably thinking: “Gee, it sure would be nice to meet up with my fellow business owners to come up with a plan on how to operate in a world dealing with a potential pandemic.” Right?
That’s the idea behind the Council on Foreign Relations’ roundtable discussion called “Doing Business Under Coronavirus,” scheduled for March 13, 2020, in New York. Or at least, it was the idea, because the conference has been canceled. And you’ll never guess why.
Okay, it was coronavirus. Uh, you probably did guess that. We’re not entirely sure what that means for business owners, but come on, there’s no need to worry, at least the infectious disease physicians had their meeting this past weekend ... oh wait. Hmm, maybe it’s time to start searching Amazon for some toilet paper.
Wipe away coronavirus fear
People now have smartphones to read the news while on the toilet, but at one point or another, having a newspaper to read in the john was probably pretty essential to combat boredom. Our friends down under, however, seem to have found another essential way to use a newspaper in the bathroom.
The coronavirus is slowly making its way around the world, and in Australia, people are stocking up on toilet paper. Toilet paper companies are working extra hard to keep a steady supply of toilet paper in supermarkets. A newspaper has tried to help by adding extra pages to its newspapers that could potentially be used as toilet paper. This seems like a good time to swap out your smartphone for one of these newspapers as it would not be wise to use your smartphone for toilet paper.
No one is sure why everyone in Australia is in a frenzy over toilet paper since it’s not a very big necessity in a large coronavirus outbreak. Are Aussies preparing to hide out in their homes just in case those affected by coronavirus turn into zombies, thus creating a zombie apocalypse? In that case, yeah, toilet paper, among other things, is probably essential.
Resistance meets resistance
As our planet moves from zombie apocalypse to coronapocalypse, even the business news has gone full COVID-19. So, it would be pointless for us to cover any other topic, right?
Well, welcome to the Bureau of Missing the Point. Ladies and gentleman, we give you [drum roll, please] bacteria.
That’s right, we said bacteria. In a world ruled by coronavirus, LOTME dares to bring you the latest edition of Bacteria vs. the World.
This week, we’re talking antibiotic resistance. The problem is that bacteria have the ability to pick up DNA from their surroundings to create resistance. That ability, known as competence, could be considered a form of evolution, and scientists are trying to stop it.
Investigators at the University of Groningen in the Netherlands and the Swiss University of Lausanne “developed a high-throughput assay to simultaneously test cells for competence and growth,” lead investigator Arnau Domenech, PhD, said in a written statement. Of the 1,366 approved drugs that they tested against Streptococcus pneumoniae, 46 blocked bacterial competence.
“When cells are under growth stress, for instance in the presence of antibiotics, they try to find a solution and become resistant to these drugs,” Dr. Domenech explained. “Importantly, we did not observe resistance to the drugs found here as they do not cause growth stress.”
The drug concentrations used to block competence may be too high to be safe for humans, but the results suggest that competence blockers are, indeed, anti-evolution drugs. As we go bacteria to the future, it seems, the ghost of Charles Darwin is working for the humans. Thanks, Chuck.
Oh, one more thing … CORONAVIRUS!
Largest meeting on cancer research canceled: AACR
The biggest cancer research meeting of the year has been canceled as a reaction to the novel coronavirus (COVID-19) outbreak, which has also led to many other medical conferences being canceled or postponed.
The annual meeting of the American Association for Cancer Research (AACR) was due to take place April 24-29 in San Diego, California. More than 24,000 delegates from 80 countries and more than 500 exhibitors were expected to attend.
There are plans to reschedule it for later this year.
This has been a “difficult decision,” said the AACR board of directors, but “we believe that the decision to postpone the meeting is absolutely the correct one to safeguard our meeting participants from further potential exposure to the coronavirus.”
The board goes on to explain that “this evidence-based decision was made after a thorough review and discussion of all factors impacting the annual meeting, including the US government’s enforcement of restrictions on international travelers to enter the US; the imposition of travel restrictions issued by US government agencies, cancer centers, academic institutions, and pharmaceutical and biotech companies; and the counsel of infectious disease experts. It is clear that all of these elements significantly affect the ability of delegates, speakers, presenters of proffered papers, and exhibitors to participate fully in the annual meeting.”
Other cancer conferences that were planned for March and that have been canceled include the following:
- European Breast Cancer Conference (EBCC), Barcelona, Spain, which was to have taken place March 18-20. This conference has been postponed and will now take place September 30 to October 2 at the same venue. Abstracts that have been accepted for the initial conference will remain in the program, and organizers will reopen abstract submissions in May.
- National Comprehensive Cancer Network (NCCN), Orlando, Florida, was scheduled for March 19-22. This conference has been postponed. No new dates have been provided, but the society notes that “NCCN staff is working as quickly as possible to notify all conference registrants about the postponement and further information regarding the refund process.”
- European Association of Urology (EAU), Amsterdam, the Netherlands, at which there is always new research presented on prostate, kidney, and bladder cancer, was due to take place March 20-24. This conference has been postponed to July 2020.
- Society of Gynecologic Oncology (SGO), in Toronto, Canada, which was scheduled for March 28-31. SGO is “exploring alternatives for delivering the science and education.”
Overall, the move to cancel medical conferences over the next few months is a good idea, commented F. Perry Wilson, MD, MSCE, associate professor of medicine and director of Yale’s Program of Applied Translational Research, in a Medscape Medical News commentary.
“There’s a pretty straightforward case here,” he argued. “Medical professionals are at higher risk for exposure to coronavirus because we come into contact with lots and lots of patients. Gathering a large group of medical professionals in a single place increases the risk for exposure further. Factor in airplane flights to and from the conferences, and the chance that infection is spread is significant.”
This article first appeared on Medscape.com.
The biggest cancer research meeting of the year has been canceled as a reaction to the novel coronavirus (COVID-19) outbreak, which has also led to many other medical conferences being canceled or postponed.
The annual meeting of the American Association for Cancer Research (AACR) was due to take place April 24-29 in San Diego, California. More than 24,000 delegates from 80 countries and more than 500 exhibitors were expected to attend.
There are plans to reschedule it for later this year.
This has been a “difficult decision,” said the AACR board of directors, but “we believe that the decision to postpone the meeting is absolutely the correct one to safeguard our meeting participants from further potential exposure to the coronavirus.”
The board goes on to explain that “this evidence-based decision was made after a thorough review and discussion of all factors impacting the annual meeting, including the US government’s enforcement of restrictions on international travelers to enter the US; the imposition of travel restrictions issued by US government agencies, cancer centers, academic institutions, and pharmaceutical and biotech companies; and the counsel of infectious disease experts. It is clear that all of these elements significantly affect the ability of delegates, speakers, presenters of proffered papers, and exhibitors to participate fully in the annual meeting.”
Other cancer conferences that were planned for March and that have been canceled include the following:
- European Breast Cancer Conference (EBCC), Barcelona, Spain, which was to have taken place March 18-20. This conference has been postponed and will now take place September 30 to October 2 at the same venue. Abstracts that have been accepted for the initial conference will remain in the program, and organizers will reopen abstract submissions in May.
- National Comprehensive Cancer Network (NCCN), Orlando, Florida, was scheduled for March 19-22. This conference has been postponed. No new dates have been provided, but the society notes that “NCCN staff is working as quickly as possible to notify all conference registrants about the postponement and further information regarding the refund process.”
- European Association of Urology (EAU), Amsterdam, the Netherlands, at which there is always new research presented on prostate, kidney, and bladder cancer, was due to take place March 20-24. This conference has been postponed to July 2020.
- Society of Gynecologic Oncology (SGO), in Toronto, Canada, which was scheduled for March 28-31. SGO is “exploring alternatives for delivering the science and education.”
Overall, the move to cancel medical conferences over the next few months is a good idea, commented F. Perry Wilson, MD, MSCE, associate professor of medicine and director of Yale’s Program of Applied Translational Research, in a Medscape Medical News commentary.
“There’s a pretty straightforward case here,” he argued. “Medical professionals are at higher risk for exposure to coronavirus because we come into contact with lots and lots of patients. Gathering a large group of medical professionals in a single place increases the risk for exposure further. Factor in airplane flights to and from the conferences, and the chance that infection is spread is significant.”
This article first appeared on Medscape.com.
The biggest cancer research meeting of the year has been canceled as a reaction to the novel coronavirus (COVID-19) outbreak, which has also led to many other medical conferences being canceled or postponed.
The annual meeting of the American Association for Cancer Research (AACR) was due to take place April 24-29 in San Diego, California. More than 24,000 delegates from 80 countries and more than 500 exhibitors were expected to attend.
There are plans to reschedule it for later this year.
This has been a “difficult decision,” said the AACR board of directors, but “we believe that the decision to postpone the meeting is absolutely the correct one to safeguard our meeting participants from further potential exposure to the coronavirus.”
The board goes on to explain that “this evidence-based decision was made after a thorough review and discussion of all factors impacting the annual meeting, including the US government’s enforcement of restrictions on international travelers to enter the US; the imposition of travel restrictions issued by US government agencies, cancer centers, academic institutions, and pharmaceutical and biotech companies; and the counsel of infectious disease experts. It is clear that all of these elements significantly affect the ability of delegates, speakers, presenters of proffered papers, and exhibitors to participate fully in the annual meeting.”
Other cancer conferences that were planned for March and that have been canceled include the following:
- European Breast Cancer Conference (EBCC), Barcelona, Spain, which was to have taken place March 18-20. This conference has been postponed and will now take place September 30 to October 2 at the same venue. Abstracts that have been accepted for the initial conference will remain in the program, and organizers will reopen abstract submissions in May.
- National Comprehensive Cancer Network (NCCN), Orlando, Florida, was scheduled for March 19-22. This conference has been postponed. No new dates have been provided, but the society notes that “NCCN staff is working as quickly as possible to notify all conference registrants about the postponement and further information regarding the refund process.”
- European Association of Urology (EAU), Amsterdam, the Netherlands, at which there is always new research presented on prostate, kidney, and bladder cancer, was due to take place March 20-24. This conference has been postponed to July 2020.
- Society of Gynecologic Oncology (SGO), in Toronto, Canada, which was scheduled for March 28-31. SGO is “exploring alternatives for delivering the science and education.”
Overall, the move to cancel medical conferences over the next few months is a good idea, commented F. Perry Wilson, MD, MSCE, associate professor of medicine and director of Yale’s Program of Applied Translational Research, in a Medscape Medical News commentary.
“There’s a pretty straightforward case here,” he argued. “Medical professionals are at higher risk for exposure to coronavirus because we come into contact with lots and lots of patients. Gathering a large group of medical professionals in a single place increases the risk for exposure further. Factor in airplane flights to and from the conferences, and the chance that infection is spread is significant.”
This article first appeared on Medscape.com.
Manual dexterity may decline more rapidly in pediatric-onset MS
WEST PALM BEACH, FLA. – (AOMS), according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.
When MS onset occurs before the patient is age 18 years, the patient is considered to have POMS. Compared with AOMS, POMS is less prevalent and has distinct features. To determine whether changes in physical performance differ between POMS and AOMS, Sarah M. Planchon, PhD, a project scientist at the Mellen Center for MS at the Cleveland Clinic, and colleagues analyzed data cut 9 from the MS PATHS (MS Partners Advancing Technology and Health Solutions) initiative. As part of this initiative, which is sponsored by Biogen, investigators collect MS performance measures longitudinally at each patient visit. Among these measures are the manual dexterity test (MDT), an iPad version of the Nine-Hole Peg Test, and the walking speed test (WST), which is the iPad version of the Timed 25-Foot Walk.
Dr. Planchon and colleagues matched each patient with POMS to five patients with AOMS according to disease duration. They calculated descriptive statistics for the sample and performed Tukey’s honestly significant difference test to compare patient groups on several categorical variables.
Overall, function was better in POMS than in AOMS
The investigators included 3 years’ worth of data from 6,457 patients in their analysis. The average age was approximately 50 years for patients with AOMS and 31 years for patients with POMS. The time elapsed since diagnosis was approximately 14 years in the AOMS group and 17 years in the POMS group. The proportion of female patients was about 74% in the AOMS group and 73% in the POMS group. Compared with the AOMS group, the POMS group had higher proportions of patients who were Asian (0.5% vs 2.6%), black (9.3% vs 11.5%), and other race (2.8% vs 9.3%).
Overall, patients with POMS performed better than patients with AOMS by 1.39 seconds on the MDT and by 0.79 seconds on the WST. Regression analyses indicated that with increasing age, patients with AOMS declined more quickly on the MDT and the WST than patients with POMS did. When the investigators stratified the results by disease duration, however, patients with POMS declined more rapidly on the MDT than did patients with AOMS. There was no significant difference between groups in WST in this analysis. When Dr. Planchon and colleagues performed linear regression and adjusted for variables such as age, sex, race, education, insurance, employment, MS phenotype, disease duration, number of relapses, and Patient-Determined Disease Steps (PDDS), the MS onset type did not significantly affect outcomes. Age, sex, PDDS, and MS type were significant covariates for both tests.
The role of occupational and physical therapy
“POMS patients tend to have a greater dysfunction of the cerebellar and brainstem regions of the brain, both of which may impact motor skills to a greater degree than other regions of the brain,” said Dr. Planchon. The increased rate of manual impairment in POMS, compared with AOMS, does not necessarily indicate more severe disease, she added. Getting a true picture of disease severity would require consideration of factors such as ambulation, cognitive functioning, vision, fatigue, and depression.
“We would recommend introducing POMS patients to occupational and physical therapy early in their disease course, before significant deficits accrue,” said Dr. Planchon. “Early familiarity with rehabilitation services should help the patient and family optimize what exercises are being done to improve and maintain function.”
The optimal pharmacologic treatment for POMS is unknown. One therapy (i.e., fingolimod) has Food and Drug Administration approval, and clinical trials of other treatments are ongoing. Some MS treatments not indicated for a pediatric population are used off label in children.
“We plan to delve deeper into the data set, including using regression modeling to try to better define differences between individuals with POMS and AOMS that may lead to the functional outcome changes we have already observed,” said Dr. Planchon. “We also plan to investigate further the impact of POMS on cognition and quality of life measures and to better understand disease-modifying therapy prescribing patterns and benefits in individuals with POMS. We will look for associations in the MRI imaging findings and various biomarkers to help us understand the disease process in this special population of MS.”
Dr. Planchon has received research support from the Guthy-Jackson Charitable Foundation. Her coinvestigators received funding from Biogen, Genentech, Genzyme, MedImmune, Novartis, Serono, and Teva.
SOURCE: Planchon SM et al. ACTRIMS 2020. Abstract P043.
WEST PALM BEACH, FLA. – (AOMS), according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.
When MS onset occurs before the patient is age 18 years, the patient is considered to have POMS. Compared with AOMS, POMS is less prevalent and has distinct features. To determine whether changes in physical performance differ between POMS and AOMS, Sarah M. Planchon, PhD, a project scientist at the Mellen Center for MS at the Cleveland Clinic, and colleagues analyzed data cut 9 from the MS PATHS (MS Partners Advancing Technology and Health Solutions) initiative. As part of this initiative, which is sponsored by Biogen, investigators collect MS performance measures longitudinally at each patient visit. Among these measures are the manual dexterity test (MDT), an iPad version of the Nine-Hole Peg Test, and the walking speed test (WST), which is the iPad version of the Timed 25-Foot Walk.
Dr. Planchon and colleagues matched each patient with POMS to five patients with AOMS according to disease duration. They calculated descriptive statistics for the sample and performed Tukey’s honestly significant difference test to compare patient groups on several categorical variables.
Overall, function was better in POMS than in AOMS
The investigators included 3 years’ worth of data from 6,457 patients in their analysis. The average age was approximately 50 years for patients with AOMS and 31 years for patients with POMS. The time elapsed since diagnosis was approximately 14 years in the AOMS group and 17 years in the POMS group. The proportion of female patients was about 74% in the AOMS group and 73% in the POMS group. Compared with the AOMS group, the POMS group had higher proportions of patients who were Asian (0.5% vs 2.6%), black (9.3% vs 11.5%), and other race (2.8% vs 9.3%).
Overall, patients with POMS performed better than patients with AOMS by 1.39 seconds on the MDT and by 0.79 seconds on the WST. Regression analyses indicated that with increasing age, patients with AOMS declined more quickly on the MDT and the WST than patients with POMS did. When the investigators stratified the results by disease duration, however, patients with POMS declined more rapidly on the MDT than did patients with AOMS. There was no significant difference between groups in WST in this analysis. When Dr. Planchon and colleagues performed linear regression and adjusted for variables such as age, sex, race, education, insurance, employment, MS phenotype, disease duration, number of relapses, and Patient-Determined Disease Steps (PDDS), the MS onset type did not significantly affect outcomes. Age, sex, PDDS, and MS type were significant covariates for both tests.
The role of occupational and physical therapy
“POMS patients tend to have a greater dysfunction of the cerebellar and brainstem regions of the brain, both of which may impact motor skills to a greater degree than other regions of the brain,” said Dr. Planchon. The increased rate of manual impairment in POMS, compared with AOMS, does not necessarily indicate more severe disease, she added. Getting a true picture of disease severity would require consideration of factors such as ambulation, cognitive functioning, vision, fatigue, and depression.
“We would recommend introducing POMS patients to occupational and physical therapy early in their disease course, before significant deficits accrue,” said Dr. Planchon. “Early familiarity with rehabilitation services should help the patient and family optimize what exercises are being done to improve and maintain function.”
The optimal pharmacologic treatment for POMS is unknown. One therapy (i.e., fingolimod) has Food and Drug Administration approval, and clinical trials of other treatments are ongoing. Some MS treatments not indicated for a pediatric population are used off label in children.
“We plan to delve deeper into the data set, including using regression modeling to try to better define differences between individuals with POMS and AOMS that may lead to the functional outcome changes we have already observed,” said Dr. Planchon. “We also plan to investigate further the impact of POMS on cognition and quality of life measures and to better understand disease-modifying therapy prescribing patterns and benefits in individuals with POMS. We will look for associations in the MRI imaging findings and various biomarkers to help us understand the disease process in this special population of MS.”
Dr. Planchon has received research support from the Guthy-Jackson Charitable Foundation. Her coinvestigators received funding from Biogen, Genentech, Genzyme, MedImmune, Novartis, Serono, and Teva.
SOURCE: Planchon SM et al. ACTRIMS 2020. Abstract P043.
WEST PALM BEACH, FLA. – (AOMS), according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.
When MS onset occurs before the patient is age 18 years, the patient is considered to have POMS. Compared with AOMS, POMS is less prevalent and has distinct features. To determine whether changes in physical performance differ between POMS and AOMS, Sarah M. Planchon, PhD, a project scientist at the Mellen Center for MS at the Cleveland Clinic, and colleagues analyzed data cut 9 from the MS PATHS (MS Partners Advancing Technology and Health Solutions) initiative. As part of this initiative, which is sponsored by Biogen, investigators collect MS performance measures longitudinally at each patient visit. Among these measures are the manual dexterity test (MDT), an iPad version of the Nine-Hole Peg Test, and the walking speed test (WST), which is the iPad version of the Timed 25-Foot Walk.
Dr. Planchon and colleagues matched each patient with POMS to five patients with AOMS according to disease duration. They calculated descriptive statistics for the sample and performed Tukey’s honestly significant difference test to compare patient groups on several categorical variables.
Overall, function was better in POMS than in AOMS
The investigators included 3 years’ worth of data from 6,457 patients in their analysis. The average age was approximately 50 years for patients with AOMS and 31 years for patients with POMS. The time elapsed since diagnosis was approximately 14 years in the AOMS group and 17 years in the POMS group. The proportion of female patients was about 74% in the AOMS group and 73% in the POMS group. Compared with the AOMS group, the POMS group had higher proportions of patients who were Asian (0.5% vs 2.6%), black (9.3% vs 11.5%), and other race (2.8% vs 9.3%).
Overall, patients with POMS performed better than patients with AOMS by 1.39 seconds on the MDT and by 0.79 seconds on the WST. Regression analyses indicated that with increasing age, patients with AOMS declined more quickly on the MDT and the WST than patients with POMS did. When the investigators stratified the results by disease duration, however, patients with POMS declined more rapidly on the MDT than did patients with AOMS. There was no significant difference between groups in WST in this analysis. When Dr. Planchon and colleagues performed linear regression and adjusted for variables such as age, sex, race, education, insurance, employment, MS phenotype, disease duration, number of relapses, and Patient-Determined Disease Steps (PDDS), the MS onset type did not significantly affect outcomes. Age, sex, PDDS, and MS type were significant covariates for both tests.
The role of occupational and physical therapy
“POMS patients tend to have a greater dysfunction of the cerebellar and brainstem regions of the brain, both of which may impact motor skills to a greater degree than other regions of the brain,” said Dr. Planchon. The increased rate of manual impairment in POMS, compared with AOMS, does not necessarily indicate more severe disease, she added. Getting a true picture of disease severity would require consideration of factors such as ambulation, cognitive functioning, vision, fatigue, and depression.
“We would recommend introducing POMS patients to occupational and physical therapy early in their disease course, before significant deficits accrue,” said Dr. Planchon. “Early familiarity with rehabilitation services should help the patient and family optimize what exercises are being done to improve and maintain function.”
The optimal pharmacologic treatment for POMS is unknown. One therapy (i.e., fingolimod) has Food and Drug Administration approval, and clinical trials of other treatments are ongoing. Some MS treatments not indicated for a pediatric population are used off label in children.
“We plan to delve deeper into the data set, including using regression modeling to try to better define differences between individuals with POMS and AOMS that may lead to the functional outcome changes we have already observed,” said Dr. Planchon. “We also plan to investigate further the impact of POMS on cognition and quality of life measures and to better understand disease-modifying therapy prescribing patterns and benefits in individuals with POMS. We will look for associations in the MRI imaging findings and various biomarkers to help us understand the disease process in this special population of MS.”
Dr. Planchon has received research support from the Guthy-Jackson Charitable Foundation. Her coinvestigators received funding from Biogen, Genentech, Genzyme, MedImmune, Novartis, Serono, and Teva.
SOURCE: Planchon SM et al. ACTRIMS 2020. Abstract P043.
REPORTING FROM ACTRIMS FORUM 2020
Managing children’s fear, anxiety in the age of COVID-19
With coronavirus disease (COVID-19) reaching epidemic proportions, many US children are growing increasingly anxious about what this means for their own health and safety and that of their friends and family.
The constantly changing numbers of people affected by the virus and the evolving situation mean daily life for many children is affected in some way, with school trips, sports tournaments, and family vacations being postponed or canceled.
All children may have a heightened level of worry, and some who are normally anxious might be obsessing more about handwashing or getting sick.
Experts say there are ways to manage this fear to help children feel safe and appropriately informed.
Clinicians and other adults should provide children with honest and accurate information geared to their age and developmental level, said David Fassler, MD, clinical professor of psychiatry, University of Vermont Larner College of Medicine, Burlington, and member of the Consumer Issues Committee of the American Academy of Child and Adolescent Psychiatry.
That said, it’s also acceptable to let children know that some questions can’t be answered, said Fassler.
Be truthful, calm
“This is partly because the information keeps changing as we learn more about how the virus spreads, how to best protect communities, and how to treat people who get sick,” he added.
Clinicians and parents should remind children “that there are a lot of adults who are working very hard to keep them safe,” said Eli R. Lebowitz, PhD, associate professor in the Child Study Center, Yale School of Medicine, New Haven, Connecticut, who directs a program for anxiety.
It’s important for adults to pay attention not only to what they say to children but also how they say it, said Lebowitz. He highlighted the importance of talking about the virus “in a calm and matter-of-fact way” rather than in an anxious way.
“If you look scared or tense or your voice is conveying that you’re really scared, the child is going to absorb that and feel anxious as well,” he noted.
This advice also applies when adults are discussing the issue among themselves. They should be aware that “children are listening” and are picking up any anxiety or panic adults are expressing.
Children are soaking up information about this virus from the Internet, the media, friends, teachers, and elsewhere. Lebowitz suggests asking children what they have already heard, which provides an opportunity to correct rumors and inaccurate information.
“A child might have a very inflated sense of what the actual risk is. For example, they may think that anyone who gets the virus dies,” he said.
Myth busting
Adults should let children know that not everything they hear from friends or on the Internet “is necessarily correct,” he added.
Some children who have experienced serious illness or losses may be particularly vulnerable to experiencing intense reactions to graphic news reports or images of illness or death and may need extra support, said Fassler.
Adults could use the “framework of knowledge” that children already have, said Lebowitz. He noted that all children are aware of sickness.
“They know people get sick, and they themselves have probably been sick, so you can tell them that this is a sickness like a bad flu,” he said.
Children should be encouraged to approach adults they trust, such as their pediatrician, a parent, or a teacher, with their questions, said Lebowitz. “Those are the people who are able to give them the most accurate information.”
Fassler noted that accurate, up-to-date information is available via fact sheets developed by the Centers for Disease Control and Prevention and the World Health Organization.
Although it’s helpful and appropriate to be reassuring, Fassler advises not to make unrealistic promises.
“It’s fine to tell kids that you’ll deal with whatever happens, even if it means altering travel plans or work schedules, but you can’t promise that no one in your state or community will get sick,” he said.
Maintain healthy habits
Physicians and other adults can tell children “in an age-appropriate way” how the virus is transmitted and what the symptoms are, but it’s important to emphasize that most people who are sick don’t have COVID-19, said Lebowitz.
“I would emphasize that the people who are the sickest are the elderly who are already sick, rather than healthy younger people,” he said.
Lebowitz recommends continuing to follow guidelines on staying healthy, including coughing into a sleeve instead of your hand and regular handwashing.
It’s also important at this time for children to maintain healthy habits – getting enough physical activity and sleep, eating well, and being outside – because this regime will go a long way toward reducing anxiety, said Lebowitz. Deep breathing and muscle-relaxing exercises can also help, he said.
Lebowitz also suggests maintaining a supportive attitude and showing “some acceptance and validation of what children are feeling, as well as some confidence that they can cope and tolerate feeling uncomfortable sometimes, that they can handle some anxiety.”
While accepting that the child could be anxious, it’s important not to encourage excessive avoidance or unhealthy coping strategies. Fassler and Lebowitz agree that children who are overly anxious or preoccupied with concerns about the coronavirus should be evaluated by a trained, qualified mental health professional.
Signs that a child may need additional help include ongoing sleep difficulties, intrusive thoughts or worries, obsessive-compulsive behaviors, or reluctance or refusal to go to school, said Fassler.
The good news is that most children are resilient, said Fassler. “They’ll adjust, adapt, and go on with their lives.”
This article first appeared on Medscape.com.
With coronavirus disease (COVID-19) reaching epidemic proportions, many US children are growing increasingly anxious about what this means for their own health and safety and that of their friends and family.
The constantly changing numbers of people affected by the virus and the evolving situation mean daily life for many children is affected in some way, with school trips, sports tournaments, and family vacations being postponed or canceled.
All children may have a heightened level of worry, and some who are normally anxious might be obsessing more about handwashing or getting sick.
Experts say there are ways to manage this fear to help children feel safe and appropriately informed.
Clinicians and other adults should provide children with honest and accurate information geared to their age and developmental level, said David Fassler, MD, clinical professor of psychiatry, University of Vermont Larner College of Medicine, Burlington, and member of the Consumer Issues Committee of the American Academy of Child and Adolescent Psychiatry.
That said, it’s also acceptable to let children know that some questions can’t be answered, said Fassler.
Be truthful, calm
“This is partly because the information keeps changing as we learn more about how the virus spreads, how to best protect communities, and how to treat people who get sick,” he added.
Clinicians and parents should remind children “that there are a lot of adults who are working very hard to keep them safe,” said Eli R. Lebowitz, PhD, associate professor in the Child Study Center, Yale School of Medicine, New Haven, Connecticut, who directs a program for anxiety.
It’s important for adults to pay attention not only to what they say to children but also how they say it, said Lebowitz. He highlighted the importance of talking about the virus “in a calm and matter-of-fact way” rather than in an anxious way.
“If you look scared or tense or your voice is conveying that you’re really scared, the child is going to absorb that and feel anxious as well,” he noted.
This advice also applies when adults are discussing the issue among themselves. They should be aware that “children are listening” and are picking up any anxiety or panic adults are expressing.
Children are soaking up information about this virus from the Internet, the media, friends, teachers, and elsewhere. Lebowitz suggests asking children what they have already heard, which provides an opportunity to correct rumors and inaccurate information.
“A child might have a very inflated sense of what the actual risk is. For example, they may think that anyone who gets the virus dies,” he said.
Myth busting
Adults should let children know that not everything they hear from friends or on the Internet “is necessarily correct,” he added.
Some children who have experienced serious illness or losses may be particularly vulnerable to experiencing intense reactions to graphic news reports or images of illness or death and may need extra support, said Fassler.
Adults could use the “framework of knowledge” that children already have, said Lebowitz. He noted that all children are aware of sickness.
“They know people get sick, and they themselves have probably been sick, so you can tell them that this is a sickness like a bad flu,” he said.
Children should be encouraged to approach adults they trust, such as their pediatrician, a parent, or a teacher, with their questions, said Lebowitz. “Those are the people who are able to give them the most accurate information.”
Fassler noted that accurate, up-to-date information is available via fact sheets developed by the Centers for Disease Control and Prevention and the World Health Organization.
Although it’s helpful and appropriate to be reassuring, Fassler advises not to make unrealistic promises.
“It’s fine to tell kids that you’ll deal with whatever happens, even if it means altering travel plans or work schedules, but you can’t promise that no one in your state or community will get sick,” he said.
Maintain healthy habits
Physicians and other adults can tell children “in an age-appropriate way” how the virus is transmitted and what the symptoms are, but it’s important to emphasize that most people who are sick don’t have COVID-19, said Lebowitz.
“I would emphasize that the people who are the sickest are the elderly who are already sick, rather than healthy younger people,” he said.
Lebowitz recommends continuing to follow guidelines on staying healthy, including coughing into a sleeve instead of your hand and regular handwashing.
It’s also important at this time for children to maintain healthy habits – getting enough physical activity and sleep, eating well, and being outside – because this regime will go a long way toward reducing anxiety, said Lebowitz. Deep breathing and muscle-relaxing exercises can also help, he said.
Lebowitz also suggests maintaining a supportive attitude and showing “some acceptance and validation of what children are feeling, as well as some confidence that they can cope and tolerate feeling uncomfortable sometimes, that they can handle some anxiety.”
While accepting that the child could be anxious, it’s important not to encourage excessive avoidance or unhealthy coping strategies. Fassler and Lebowitz agree that children who are overly anxious or preoccupied with concerns about the coronavirus should be evaluated by a trained, qualified mental health professional.
Signs that a child may need additional help include ongoing sleep difficulties, intrusive thoughts or worries, obsessive-compulsive behaviors, or reluctance or refusal to go to school, said Fassler.
The good news is that most children are resilient, said Fassler. “They’ll adjust, adapt, and go on with their lives.”
This article first appeared on Medscape.com.
With coronavirus disease (COVID-19) reaching epidemic proportions, many US children are growing increasingly anxious about what this means for their own health and safety and that of their friends and family.
The constantly changing numbers of people affected by the virus and the evolving situation mean daily life for many children is affected in some way, with school trips, sports tournaments, and family vacations being postponed or canceled.
All children may have a heightened level of worry, and some who are normally anxious might be obsessing more about handwashing or getting sick.
Experts say there are ways to manage this fear to help children feel safe and appropriately informed.
Clinicians and other adults should provide children with honest and accurate information geared to their age and developmental level, said David Fassler, MD, clinical professor of psychiatry, University of Vermont Larner College of Medicine, Burlington, and member of the Consumer Issues Committee of the American Academy of Child and Adolescent Psychiatry.
That said, it’s also acceptable to let children know that some questions can’t be answered, said Fassler.
Be truthful, calm
“This is partly because the information keeps changing as we learn more about how the virus spreads, how to best protect communities, and how to treat people who get sick,” he added.
Clinicians and parents should remind children “that there are a lot of adults who are working very hard to keep them safe,” said Eli R. Lebowitz, PhD, associate professor in the Child Study Center, Yale School of Medicine, New Haven, Connecticut, who directs a program for anxiety.
It’s important for adults to pay attention not only to what they say to children but also how they say it, said Lebowitz. He highlighted the importance of talking about the virus “in a calm and matter-of-fact way” rather than in an anxious way.
“If you look scared or tense or your voice is conveying that you’re really scared, the child is going to absorb that and feel anxious as well,” he noted.
This advice also applies when adults are discussing the issue among themselves. They should be aware that “children are listening” and are picking up any anxiety or panic adults are expressing.
Children are soaking up information about this virus from the Internet, the media, friends, teachers, and elsewhere. Lebowitz suggests asking children what they have already heard, which provides an opportunity to correct rumors and inaccurate information.
“A child might have a very inflated sense of what the actual risk is. For example, they may think that anyone who gets the virus dies,” he said.
Myth busting
Adults should let children know that not everything they hear from friends or on the Internet “is necessarily correct,” he added.
Some children who have experienced serious illness or losses may be particularly vulnerable to experiencing intense reactions to graphic news reports or images of illness or death and may need extra support, said Fassler.
Adults could use the “framework of knowledge” that children already have, said Lebowitz. He noted that all children are aware of sickness.
“They know people get sick, and they themselves have probably been sick, so you can tell them that this is a sickness like a bad flu,” he said.
Children should be encouraged to approach adults they trust, such as their pediatrician, a parent, or a teacher, with their questions, said Lebowitz. “Those are the people who are able to give them the most accurate information.”
Fassler noted that accurate, up-to-date information is available via fact sheets developed by the Centers for Disease Control and Prevention and the World Health Organization.
Although it’s helpful and appropriate to be reassuring, Fassler advises not to make unrealistic promises.
“It’s fine to tell kids that you’ll deal with whatever happens, even if it means altering travel plans or work schedules, but you can’t promise that no one in your state or community will get sick,” he said.
Maintain healthy habits
Physicians and other adults can tell children “in an age-appropriate way” how the virus is transmitted and what the symptoms are, but it’s important to emphasize that most people who are sick don’t have COVID-19, said Lebowitz.
“I would emphasize that the people who are the sickest are the elderly who are already sick, rather than healthy younger people,” he said.
Lebowitz recommends continuing to follow guidelines on staying healthy, including coughing into a sleeve instead of your hand and regular handwashing.
It’s also important at this time for children to maintain healthy habits – getting enough physical activity and sleep, eating well, and being outside – because this regime will go a long way toward reducing anxiety, said Lebowitz. Deep breathing and muscle-relaxing exercises can also help, he said.
Lebowitz also suggests maintaining a supportive attitude and showing “some acceptance and validation of what children are feeling, as well as some confidence that they can cope and tolerate feeling uncomfortable sometimes, that they can handle some anxiety.”
While accepting that the child could be anxious, it’s important not to encourage excessive avoidance or unhealthy coping strategies. Fassler and Lebowitz agree that children who are overly anxious or preoccupied with concerns about the coronavirus should be evaluated by a trained, qualified mental health professional.
Signs that a child may need additional help include ongoing sleep difficulties, intrusive thoughts or worries, obsessive-compulsive behaviors, or reluctance or refusal to go to school, said Fassler.
The good news is that most children are resilient, said Fassler. “They’ll adjust, adapt, and go on with their lives.”
This article first appeared on Medscape.com.
AAD-NPF releases first guidelines for nonbiologic treatments of psoriasis
It’s been 11 years since monotherapy and suggest a framework for a number of off-label treatments.
The guidelines, issued jointly with the National Psoriasis Foundation (NPF), were published in the Journal of the American Academy of Dermatology.
“I think we are way behind,” Alan Menter, MD, chairman of the division of dermatology at Baylor University Medical Center, Dallas, and cochair of the guideline writing committee, said in an interview. “Most other countries update their guidelines every 1 or 2 years; we were 10 years behind.” The guidelines for systemic nonbiologic drugs follow up psoriasis guidelines issued by the AAD and the NPF on pediatric patients issued earlier this year, and on phototherapy, biologic treatments, and management of comorbidities issued last year.
“A lot has happened in the last 10 years,” said cochair Craig Elmets, MD, professor of dermatology at the University of Alabama at Birmingham. “While much of the interest is on biologic agents, nonbiologics are still used quite frequently, and the guidelines for their appropriate use have changed. Use of the guidelines provides people in the health profession with the most up to date evidence-based information so they can give their patients the best care.”
The guidelines acknowledge that the medications it covers are still widely used, either by themselves or in combination with biologic agents; readily available; easy to use; and, in the case of older therapies, relatively cheap.
Methotrexate has been available since the 1970s. Given as an injection or taken orally, the guidelines recommend supplementation with folic acid to counteract methotrexate’s side effects, particularly GI upset. The guidelines note that folic acid is less expensive than folinic acid. Combination therapy with methotrexate and tumor necrosis factor (TNF) inhibitors is more effective than methotrexate monotherapy, with a similar side effect profile, the guidelines state.
Methotrexate is more widely used outside the United States, “but it is a very good, quick fix and it’s much safer in children and young people than it is in people with cardiovascular disease,” Dr. Menter noted. “It’s still the most commonly used drug worldwide because it’s cheap, and you do have to worry about the long-term toxicity which is related the liver issues.”
The guidelines say that subcutaneous administration of methotrexate “may be particularly useful” for patients on higher doses, which when taken orally, are associated with a higher risk of GI effects.
Dr. Menter referred to a 2017 study, which reported 41% of patients treated with subcutaneous methotrexate once a week achieved a Psoriasis Area and Severity Index 75 score of 41% after a year of treatment, compared with 10% of those on placebo (Lancet. 2017 Feb 4;389[10068]:528-37).
The guidelines rate strength of recommendation as class A for methotrexate for moderate to severe psoriasis in adults, recommend supplementation with folic or folinic acid to counteract GI complications and liver problems, and note that adalimumab and infliximab are more effective than methotrexate for cutaneous psoriasis. Class B recommendations for methotrexate and psoriasis include statements that patients should begin with a test dose, especially if they have impaired kidney function; methotrexate is effective for peripheral, but not axial, psoriatic arthritis (PsA); and TNF inhibitors are more effective than methotrexate for PsA.
Approved by the FDA in 2014 for psoriasis, apremilast, which inhibits phosphodiesterase-4, is the newest drug in the recommendations. The guidelines recommend its use for moderate to severe psoriasis in adults, with a class A recommendation. Patients should start on a low dose and then build up to the 30-mg, twice-daily dose over 6 days and should be counseled about the risk of depression before starting treatment. Routine laboratory testing can be considered on an individual basis.
The guidelines also lay out three recommendations (and strength of recommendation) for cyclosporine, a drug that’s been around since the 1990s: for severe, recalcitrant cases (class A); for erythrodermic, general pustular, and palmoplantar psoriasis (class B); and as short-term therapy for psoriasis flare in patients already on another drug (class C).
Acitretin is another longstanding therapy used mostly for palmar-plantar psoriasis, but it can also be used as monotherapy for plaque psoriasis as well as erythrodermic and pustular disease. It can also be used in combination with psoralens with UVA for psoriasis and combined with broadband UVB phototherapy for plaque psoriasis. The acitretin recommendations are class B.
The oral Janus kinase (JAK) inhibitor tofacitinib isn’t specifically approved for psoriasis, but it is approved for RA, PsA, and ulcerative colitis. The drug targets the JAK-STAT signaling pathway that causes inflammation. The guidelines state that tofacitinib can be considered for moderate to severe psoriasis, but lists no strength of recommendation. The recommended dose is either 5 or 10 mg orally twice a day, with a caveat that the higher dose carries a higher risk of adverse events. Patients should be evaluated for getting a zoster vaccine before they begin therapy.
“We thought that, because there was probably a small chance that it might get approved for psoriasis, that we would discuss it briefly,” Dr. Menter said of tofacitinib.
Another off-label use the guidelines address is for fumaric and acid esters, also known as fumarates, which are used to in Europe to treat moderate to severe psoriasis. Dimethyl fumarate is approved for relapsing forms of multiple sclerosis in the United States. The guidelines state that fumarates can be used for psoriasis, but offer no strength of recommendation. Side effects include gastrointestinal disturbance and flushing.
Other treatments that are also addressed in the guidelines include a host of systemic immunosuppressants and antimetabolites: azathioprine, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus, none of which are FDA approved for psoriasis. They’re rarely used for psoriasis, but may have value in selected cases, the guidelines state.
Dr. Menter said that apremilast is the only oral drug in the guidelines, but they are the wave of the future for treating psoriasis. “I think there’s a tremendous potential for new oral drugs – TK2 [thymidine kinase], the JAK inhibitors, and other drugs coming down the pipelines. The majority of patients, if you ask them their preference, would like to take an oral drug rather than an injectable drug. And it would be much easier for dermatologists, they wouldn’t have to train patients on how to do the injections.”
Dr. Menter and Dr. Elmets disclosed financial relationships with numerous pharmaceutical companies. Other authors/work group members also had disclosures related to pharmaceutical manufacturers, and several had no disclosures.
SOURCE: Menter A et al. J Am Acad Dermatol. 2020 Feb 28. doi: 10.1016/j.jaad.2020.02.044.
It’s been 11 years since monotherapy and suggest a framework for a number of off-label treatments.
The guidelines, issued jointly with the National Psoriasis Foundation (NPF), were published in the Journal of the American Academy of Dermatology.
“I think we are way behind,” Alan Menter, MD, chairman of the division of dermatology at Baylor University Medical Center, Dallas, and cochair of the guideline writing committee, said in an interview. “Most other countries update their guidelines every 1 or 2 years; we were 10 years behind.” The guidelines for systemic nonbiologic drugs follow up psoriasis guidelines issued by the AAD and the NPF on pediatric patients issued earlier this year, and on phototherapy, biologic treatments, and management of comorbidities issued last year.
“A lot has happened in the last 10 years,” said cochair Craig Elmets, MD, professor of dermatology at the University of Alabama at Birmingham. “While much of the interest is on biologic agents, nonbiologics are still used quite frequently, and the guidelines for their appropriate use have changed. Use of the guidelines provides people in the health profession with the most up to date evidence-based information so they can give their patients the best care.”
The guidelines acknowledge that the medications it covers are still widely used, either by themselves or in combination with biologic agents; readily available; easy to use; and, in the case of older therapies, relatively cheap.
Methotrexate has been available since the 1970s. Given as an injection or taken orally, the guidelines recommend supplementation with folic acid to counteract methotrexate’s side effects, particularly GI upset. The guidelines note that folic acid is less expensive than folinic acid. Combination therapy with methotrexate and tumor necrosis factor (TNF) inhibitors is more effective than methotrexate monotherapy, with a similar side effect profile, the guidelines state.
Methotrexate is more widely used outside the United States, “but it is a very good, quick fix and it’s much safer in children and young people than it is in people with cardiovascular disease,” Dr. Menter noted. “It’s still the most commonly used drug worldwide because it’s cheap, and you do have to worry about the long-term toxicity which is related the liver issues.”
The guidelines say that subcutaneous administration of methotrexate “may be particularly useful” for patients on higher doses, which when taken orally, are associated with a higher risk of GI effects.
Dr. Menter referred to a 2017 study, which reported 41% of patients treated with subcutaneous methotrexate once a week achieved a Psoriasis Area and Severity Index 75 score of 41% after a year of treatment, compared with 10% of those on placebo (Lancet. 2017 Feb 4;389[10068]:528-37).
The guidelines rate strength of recommendation as class A for methotrexate for moderate to severe psoriasis in adults, recommend supplementation with folic or folinic acid to counteract GI complications and liver problems, and note that adalimumab and infliximab are more effective than methotrexate for cutaneous psoriasis. Class B recommendations for methotrexate and psoriasis include statements that patients should begin with a test dose, especially if they have impaired kidney function; methotrexate is effective for peripheral, but not axial, psoriatic arthritis (PsA); and TNF inhibitors are more effective than methotrexate for PsA.
Approved by the FDA in 2014 for psoriasis, apremilast, which inhibits phosphodiesterase-4, is the newest drug in the recommendations. The guidelines recommend its use for moderate to severe psoriasis in adults, with a class A recommendation. Patients should start on a low dose and then build up to the 30-mg, twice-daily dose over 6 days and should be counseled about the risk of depression before starting treatment. Routine laboratory testing can be considered on an individual basis.
The guidelines also lay out three recommendations (and strength of recommendation) for cyclosporine, a drug that’s been around since the 1990s: for severe, recalcitrant cases (class A); for erythrodermic, general pustular, and palmoplantar psoriasis (class B); and as short-term therapy for psoriasis flare in patients already on another drug (class C).
Acitretin is another longstanding therapy used mostly for palmar-plantar psoriasis, but it can also be used as monotherapy for plaque psoriasis as well as erythrodermic and pustular disease. It can also be used in combination with psoralens with UVA for psoriasis and combined with broadband UVB phototherapy for plaque psoriasis. The acitretin recommendations are class B.
The oral Janus kinase (JAK) inhibitor tofacitinib isn’t specifically approved for psoriasis, but it is approved for RA, PsA, and ulcerative colitis. The drug targets the JAK-STAT signaling pathway that causes inflammation. The guidelines state that tofacitinib can be considered for moderate to severe psoriasis, but lists no strength of recommendation. The recommended dose is either 5 or 10 mg orally twice a day, with a caveat that the higher dose carries a higher risk of adverse events. Patients should be evaluated for getting a zoster vaccine before they begin therapy.
“We thought that, because there was probably a small chance that it might get approved for psoriasis, that we would discuss it briefly,” Dr. Menter said of tofacitinib.
Another off-label use the guidelines address is for fumaric and acid esters, also known as fumarates, which are used to in Europe to treat moderate to severe psoriasis. Dimethyl fumarate is approved for relapsing forms of multiple sclerosis in the United States. The guidelines state that fumarates can be used for psoriasis, but offer no strength of recommendation. Side effects include gastrointestinal disturbance and flushing.
Other treatments that are also addressed in the guidelines include a host of systemic immunosuppressants and antimetabolites: azathioprine, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus, none of which are FDA approved for psoriasis. They’re rarely used for psoriasis, but may have value in selected cases, the guidelines state.
Dr. Menter said that apremilast is the only oral drug in the guidelines, but they are the wave of the future for treating psoriasis. “I think there’s a tremendous potential for new oral drugs – TK2 [thymidine kinase], the JAK inhibitors, and other drugs coming down the pipelines. The majority of patients, if you ask them their preference, would like to take an oral drug rather than an injectable drug. And it would be much easier for dermatologists, they wouldn’t have to train patients on how to do the injections.”
Dr. Menter and Dr. Elmets disclosed financial relationships with numerous pharmaceutical companies. Other authors/work group members also had disclosures related to pharmaceutical manufacturers, and several had no disclosures.
SOURCE: Menter A et al. J Am Acad Dermatol. 2020 Feb 28. doi: 10.1016/j.jaad.2020.02.044.
It’s been 11 years since monotherapy and suggest a framework for a number of off-label treatments.
The guidelines, issued jointly with the National Psoriasis Foundation (NPF), were published in the Journal of the American Academy of Dermatology.
“I think we are way behind,” Alan Menter, MD, chairman of the division of dermatology at Baylor University Medical Center, Dallas, and cochair of the guideline writing committee, said in an interview. “Most other countries update their guidelines every 1 or 2 years; we were 10 years behind.” The guidelines for systemic nonbiologic drugs follow up psoriasis guidelines issued by the AAD and the NPF on pediatric patients issued earlier this year, and on phototherapy, biologic treatments, and management of comorbidities issued last year.
“A lot has happened in the last 10 years,” said cochair Craig Elmets, MD, professor of dermatology at the University of Alabama at Birmingham. “While much of the interest is on biologic agents, nonbiologics are still used quite frequently, and the guidelines for their appropriate use have changed. Use of the guidelines provides people in the health profession with the most up to date evidence-based information so they can give their patients the best care.”
The guidelines acknowledge that the medications it covers are still widely used, either by themselves or in combination with biologic agents; readily available; easy to use; and, in the case of older therapies, relatively cheap.
Methotrexate has been available since the 1970s. Given as an injection or taken orally, the guidelines recommend supplementation with folic acid to counteract methotrexate’s side effects, particularly GI upset. The guidelines note that folic acid is less expensive than folinic acid. Combination therapy with methotrexate and tumor necrosis factor (TNF) inhibitors is more effective than methotrexate monotherapy, with a similar side effect profile, the guidelines state.
Methotrexate is more widely used outside the United States, “but it is a very good, quick fix and it’s much safer in children and young people than it is in people with cardiovascular disease,” Dr. Menter noted. “It’s still the most commonly used drug worldwide because it’s cheap, and you do have to worry about the long-term toxicity which is related the liver issues.”
The guidelines say that subcutaneous administration of methotrexate “may be particularly useful” for patients on higher doses, which when taken orally, are associated with a higher risk of GI effects.
Dr. Menter referred to a 2017 study, which reported 41% of patients treated with subcutaneous methotrexate once a week achieved a Psoriasis Area and Severity Index 75 score of 41% after a year of treatment, compared with 10% of those on placebo (Lancet. 2017 Feb 4;389[10068]:528-37).
The guidelines rate strength of recommendation as class A for methotrexate for moderate to severe psoriasis in adults, recommend supplementation with folic or folinic acid to counteract GI complications and liver problems, and note that adalimumab and infliximab are more effective than methotrexate for cutaneous psoriasis. Class B recommendations for methotrexate and psoriasis include statements that patients should begin with a test dose, especially if they have impaired kidney function; methotrexate is effective for peripheral, but not axial, psoriatic arthritis (PsA); and TNF inhibitors are more effective than methotrexate for PsA.
Approved by the FDA in 2014 for psoriasis, apremilast, which inhibits phosphodiesterase-4, is the newest drug in the recommendations. The guidelines recommend its use for moderate to severe psoriasis in adults, with a class A recommendation. Patients should start on a low dose and then build up to the 30-mg, twice-daily dose over 6 days and should be counseled about the risk of depression before starting treatment. Routine laboratory testing can be considered on an individual basis.
The guidelines also lay out three recommendations (and strength of recommendation) for cyclosporine, a drug that’s been around since the 1990s: for severe, recalcitrant cases (class A); for erythrodermic, general pustular, and palmoplantar psoriasis (class B); and as short-term therapy for psoriasis flare in patients already on another drug (class C).
Acitretin is another longstanding therapy used mostly for palmar-plantar psoriasis, but it can also be used as monotherapy for plaque psoriasis as well as erythrodermic and pustular disease. It can also be used in combination with psoralens with UVA for psoriasis and combined with broadband UVB phototherapy for plaque psoriasis. The acitretin recommendations are class B.
The oral Janus kinase (JAK) inhibitor tofacitinib isn’t specifically approved for psoriasis, but it is approved for RA, PsA, and ulcerative colitis. The drug targets the JAK-STAT signaling pathway that causes inflammation. The guidelines state that tofacitinib can be considered for moderate to severe psoriasis, but lists no strength of recommendation. The recommended dose is either 5 or 10 mg orally twice a day, with a caveat that the higher dose carries a higher risk of adverse events. Patients should be evaluated for getting a zoster vaccine before they begin therapy.
“We thought that, because there was probably a small chance that it might get approved for psoriasis, that we would discuss it briefly,” Dr. Menter said of tofacitinib.
Another off-label use the guidelines address is for fumaric and acid esters, also known as fumarates, which are used to in Europe to treat moderate to severe psoriasis. Dimethyl fumarate is approved for relapsing forms of multiple sclerosis in the United States. The guidelines state that fumarates can be used for psoriasis, but offer no strength of recommendation. Side effects include gastrointestinal disturbance and flushing.
Other treatments that are also addressed in the guidelines include a host of systemic immunosuppressants and antimetabolites: azathioprine, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus, none of which are FDA approved for psoriasis. They’re rarely used for psoriasis, but may have value in selected cases, the guidelines state.
Dr. Menter said that apremilast is the only oral drug in the guidelines, but they are the wave of the future for treating psoriasis. “I think there’s a tremendous potential for new oral drugs – TK2 [thymidine kinase], the JAK inhibitors, and other drugs coming down the pipelines. The majority of patients, if you ask them their preference, would like to take an oral drug rather than an injectable drug. And it would be much easier for dermatologists, they wouldn’t have to train patients on how to do the injections.”
Dr. Menter and Dr. Elmets disclosed financial relationships with numerous pharmaceutical companies. Other authors/work group members also had disclosures related to pharmaceutical manufacturers, and several had no disclosures.
SOURCE: Menter A et al. J Am Acad Dermatol. 2020 Feb 28. doi: 10.1016/j.jaad.2020.02.044.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
DMT use is common in older patients with MS
WEST PALM BEACH, FLA. –
MS disease activity typically declines with age. At the same time, evidence to support the efficacy of MS drugs in older patients is limited, said Yinan Zhang, MD, a researcher at Icahn School of Medicine at Mount Sinai, New York. Clinical trials have tended to enroll younger patients and to include only patients with active disease, which is not representative of most older patients in the real world, Dr. Zhang said.
“DMTs for MS may be less efficacious in the elderly, especially in the absence of active disease, yet real-world prescribing patterns still show widespread use of DMTs in older patients,” Dr. Zhang and colleagues said. Physicians may be able to use the presence of disease activity to identify older patients who should receive therapy. “Continuing DMTs in elderly patients who have no evidence of disease activity should be questioned rather than accepted,” they said at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.
To investigate whether age affects the efficacy of DMTs in patients with relapsing-remitting MS and how often DMTs are used in different age groups, Dr. Zhang and coinvestigators conducted a meta-analysis of group-level data from clinical trial, analyzed individual-level data from one of the trials, and reviewed survey data from two registries.
The meta-analysis included 26 clinical trials of 13 DMTs with more than 12,400 patients. Participants had an average age of about 37 years. “An age-dependent relationship of DMTs on relapse rate in RRMS [relapsing-remitting MS] cannot be established with currently published aggregate summary data,” the researchers said. “The meta-analysis was limited by the use of group-level data resulting in a narrow range of mean age.”
In an effort to overcome the limitations of group-level data, they analyzed individual-level data from approximately 1,000 patients in the CombiRx trial, which compared interferon beta-1a plus glatiramer acetate versus the agents alone. Thirty-seven of the patients were aged 55 years or older. The results suggest that each “1-year increase in baseline age was associated with a 3.2% reduction in the odds of having a relapse” during the trial, the investigators said. Change in annualized relapse rate was not significantly associated with age group, which may have resulted from “enrollment criteria selecting for patients with active disease, where DMTs are expected to show the greatest efficacy,” the researchers said.
Finally, Dr. Zhang and colleagues reviewed data on DMT use by age group from the North American Research Committee on Multiple Sclerosis (NARCOMS) and the Multiple Sclerosis Surveillance Registry (MSSR) from Veterans Affairs. In a 2018 survey of nearly 7,000 patients in the NARCOMS registry, 39.2% of patients older than 60 years were taking a DMT, including 44.5% of patients aged 61-70, 28.6% of patients aged 71-80, and 11% of patients aged 81 years and older. In comparison, about 62% of patients aged 41-50 years were taking DMT.
A 2019 survey of about 1,700 veterans in the MSSR found that 36.3% of patients older than 60 years were taking a DMT, including 41.1% of patients aged 61-70, 27.2% of patients aged 71-80, and 7.1% of patients aged 81 years and older. Among patients aged 41-50 years, more than 72% were taking a DMT. “The continued use of DMTs in the elderly may be the result of the perceived notion that disease inactivity is due to the effect of DMTs rather than the natural disease course with aging,” they said.
Dr. Zhang had no relevant disclosures. Coauthors disclosed consulting for and grant support from various pharmaceutical companies.
SOURCE: Zhang Y et al. ACTRIMS Forum 2020. Abstract P263.
WEST PALM BEACH, FLA. –
MS disease activity typically declines with age. At the same time, evidence to support the efficacy of MS drugs in older patients is limited, said Yinan Zhang, MD, a researcher at Icahn School of Medicine at Mount Sinai, New York. Clinical trials have tended to enroll younger patients and to include only patients with active disease, which is not representative of most older patients in the real world, Dr. Zhang said.
“DMTs for MS may be less efficacious in the elderly, especially in the absence of active disease, yet real-world prescribing patterns still show widespread use of DMTs in older patients,” Dr. Zhang and colleagues said. Physicians may be able to use the presence of disease activity to identify older patients who should receive therapy. “Continuing DMTs in elderly patients who have no evidence of disease activity should be questioned rather than accepted,” they said at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.
To investigate whether age affects the efficacy of DMTs in patients with relapsing-remitting MS and how often DMTs are used in different age groups, Dr. Zhang and coinvestigators conducted a meta-analysis of group-level data from clinical trial, analyzed individual-level data from one of the trials, and reviewed survey data from two registries.
The meta-analysis included 26 clinical trials of 13 DMTs with more than 12,400 patients. Participants had an average age of about 37 years. “An age-dependent relationship of DMTs on relapse rate in RRMS [relapsing-remitting MS] cannot be established with currently published aggregate summary data,” the researchers said. “The meta-analysis was limited by the use of group-level data resulting in a narrow range of mean age.”
In an effort to overcome the limitations of group-level data, they analyzed individual-level data from approximately 1,000 patients in the CombiRx trial, which compared interferon beta-1a plus glatiramer acetate versus the agents alone. Thirty-seven of the patients were aged 55 years or older. The results suggest that each “1-year increase in baseline age was associated with a 3.2% reduction in the odds of having a relapse” during the trial, the investigators said. Change in annualized relapse rate was not significantly associated with age group, which may have resulted from “enrollment criteria selecting for patients with active disease, where DMTs are expected to show the greatest efficacy,” the researchers said.
Finally, Dr. Zhang and colleagues reviewed data on DMT use by age group from the North American Research Committee on Multiple Sclerosis (NARCOMS) and the Multiple Sclerosis Surveillance Registry (MSSR) from Veterans Affairs. In a 2018 survey of nearly 7,000 patients in the NARCOMS registry, 39.2% of patients older than 60 years were taking a DMT, including 44.5% of patients aged 61-70, 28.6% of patients aged 71-80, and 11% of patients aged 81 years and older. In comparison, about 62% of patients aged 41-50 years were taking DMT.
A 2019 survey of about 1,700 veterans in the MSSR found that 36.3% of patients older than 60 years were taking a DMT, including 41.1% of patients aged 61-70, 27.2% of patients aged 71-80, and 7.1% of patients aged 81 years and older. Among patients aged 41-50 years, more than 72% were taking a DMT. “The continued use of DMTs in the elderly may be the result of the perceived notion that disease inactivity is due to the effect of DMTs rather than the natural disease course with aging,” they said.
Dr. Zhang had no relevant disclosures. Coauthors disclosed consulting for and grant support from various pharmaceutical companies.
SOURCE: Zhang Y et al. ACTRIMS Forum 2020. Abstract P263.
WEST PALM BEACH, FLA. –
MS disease activity typically declines with age. At the same time, evidence to support the efficacy of MS drugs in older patients is limited, said Yinan Zhang, MD, a researcher at Icahn School of Medicine at Mount Sinai, New York. Clinical trials have tended to enroll younger patients and to include only patients with active disease, which is not representative of most older patients in the real world, Dr. Zhang said.
“DMTs for MS may be less efficacious in the elderly, especially in the absence of active disease, yet real-world prescribing patterns still show widespread use of DMTs in older patients,” Dr. Zhang and colleagues said. Physicians may be able to use the presence of disease activity to identify older patients who should receive therapy. “Continuing DMTs in elderly patients who have no evidence of disease activity should be questioned rather than accepted,” they said at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.
To investigate whether age affects the efficacy of DMTs in patients with relapsing-remitting MS and how often DMTs are used in different age groups, Dr. Zhang and coinvestigators conducted a meta-analysis of group-level data from clinical trial, analyzed individual-level data from one of the trials, and reviewed survey data from two registries.
The meta-analysis included 26 clinical trials of 13 DMTs with more than 12,400 patients. Participants had an average age of about 37 years. “An age-dependent relationship of DMTs on relapse rate in RRMS [relapsing-remitting MS] cannot be established with currently published aggregate summary data,” the researchers said. “The meta-analysis was limited by the use of group-level data resulting in a narrow range of mean age.”
In an effort to overcome the limitations of group-level data, they analyzed individual-level data from approximately 1,000 patients in the CombiRx trial, which compared interferon beta-1a plus glatiramer acetate versus the agents alone. Thirty-seven of the patients were aged 55 years or older. The results suggest that each “1-year increase in baseline age was associated with a 3.2% reduction in the odds of having a relapse” during the trial, the investigators said. Change in annualized relapse rate was not significantly associated with age group, which may have resulted from “enrollment criteria selecting for patients with active disease, where DMTs are expected to show the greatest efficacy,” the researchers said.
Finally, Dr. Zhang and colleagues reviewed data on DMT use by age group from the North American Research Committee on Multiple Sclerosis (NARCOMS) and the Multiple Sclerosis Surveillance Registry (MSSR) from Veterans Affairs. In a 2018 survey of nearly 7,000 patients in the NARCOMS registry, 39.2% of patients older than 60 years were taking a DMT, including 44.5% of patients aged 61-70, 28.6% of patients aged 71-80, and 11% of patients aged 81 years and older. In comparison, about 62% of patients aged 41-50 years were taking DMT.
A 2019 survey of about 1,700 veterans in the MSSR found that 36.3% of patients older than 60 years were taking a DMT, including 41.1% of patients aged 61-70, 27.2% of patients aged 71-80, and 7.1% of patients aged 81 years and older. Among patients aged 41-50 years, more than 72% were taking a DMT. “The continued use of DMTs in the elderly may be the result of the perceived notion that disease inactivity is due to the effect of DMTs rather than the natural disease course with aging,” they said.
Dr. Zhang had no relevant disclosures. Coauthors disclosed consulting for and grant support from various pharmaceutical companies.
SOURCE: Zhang Y et al. ACTRIMS Forum 2020. Abstract P263.
REPORTING FROM ACTRIMS FORUM 2020
Use of mHealth technology lags in lupus care, research
Most mobile apps are poor in quality, review finds.
and have limited “The use of mobile technologies to support health (mHealth technologies), specifically mHealth applications (apps), has the potential to improve outcomes in SLE by empowering patients through education, symptom tracking, and peer support,” first author Lucas Ogura Dantas, of Tufts Medical Center, Boston, and coauthors wrote in Lupus. “These may be particularly powerful tools in SLE which commonly affects young adults, who are typically avid smartphone users familiar with the use of mobile apps.”
The authors’ review of 19 mHealth apps on Google Play and the Apple App Store (and 1 not on either platform) gave an overall average score of 2.3 out of a possible 5.0 from individual mean scores for engagement, functionality, aesthetics, and information quality on the 23-item Mobile App Rating Scale, each item of which is rated on a 0-5 point scale. Overall, 10 apps offered educational content, 7 offered tools for tracking patient-reported symptoms, 5 offered interactive online communities, 1 offered emojis to share through text messages or email for the purpose of entertainment, and 1 could not be fully evaluated.
The researchers noted that “most apps scored poorly based on design, user interface, functionality, and credibility,” with mean scores of 2.5 for engagement, 2.9 for functionality, 2.2 for aesthetics, and 1.6 for information. “The majority of the apps provided low-quality information from questionable sources (i.e., sources were not cited or their legitimacy was unknown or unverifiable),” they wrote.
The three highest-rated apps – LupusMinder (overall mean score, 3.3), Lupus Corner Health Manager (3.2), and PatientsLikeMe (3.1) – all focused on tracking patient-reported outcomes, but none used validated outcome measures; offered connectivity with wearable devices; or passively collected data such as step count, walking distances, flights climbed, calories expenditure, or sleep monitoring. However, two did have social network components and interactive support groups. Despite these apps’ interactivity and customizability, none offered “features for patients to create and track goals, directly connect with a physician or expert in the field, or synchronize data with electronic health records. None of the apps provided patients with feedback.”
The authors wrote that the Lupus Corner Health Manager was “the only one that addresses the majority of the preferences of SLE patients identified in our literature review. This app provides educational material, a symptom and medication tracker, and a discussion group for communicating with others living with lupus – all key features of mHealth technologies in the management of chronic diseases.”
However, they noted that the “ideal mHealth app for patients with SLE would incorporate evidence-based educational material, customizable symptom and medication trackers, logs for personalized health goals, and connectivity with external hardware devices to enrich data collection. Additional useful features would include gamification components to engage users, the provision of tailored feedback based on collected data, and secure mechanisms of communication and data access between users and health care providers to facilitate treatment planning and coordination of care.”
In the systematic literature review, the researchers identified a total of 21 original research studies “related to the development or use of mHealth technologies targeting people of all ages with an SLE diagnosis,” including 2 randomized trials, 10 observational studies, 4 qualitative studies, 3 review articles, and 2 study protocols for future randomized trials.
These papers most often focused on developing and using mHealth for providing patient information (11 papers), followed by mHealth interventions (5); study protocols (2); and developing mHealth apps, websites, or mHealth interventions (3).
Seven studies implemented mHealth technologies, including two with wearable devices, two with text-messaging interventions, and three that used web-based systems. These had mixed results and small samples sizes ranging from 9 to 41 patients, making their interpretation difficult, the authors wrote. A total of 11 studies examined the development of mHealth technologies, including 7 that recognized “the need for more interactive educational platforms with high-quality information,” 2 that described a need for “novel methods of disease monitoring,” and 2 that revealed “a need for sources of support such as virtual communities.”
“Though our systematic literature review found that patients seek to use mHealth technologies to aid with disease management, we identified few studies exploring mHealth-based interventions to improve health outcomes, with the limited published literature devoted to the use of mHealth platforms to provide educational information,” Mr. Dantas and associates wrote.
The lack of evidence for mHealth technologies in SLE patients “contrast with the robust evidence supporting the effectiveness of mHealth interventions in improving outcomes in several chronic conditions,” such as chronic low back and musculoskeletal pain and blood pressure control, they noted.
The authors reported no potential conflicts of interest. The study authors received funding from the Saõ Paulo Research Foundation, the National Center for Complementary and Integrative Health, and the National Center for Advancing Translational Sciences.
SOURCE: Dantas LO et al. Lupus. 2020;29:144-56.
Most mobile apps are poor in quality, review finds.
Most mobile apps are poor in quality, review finds.
and have limited “The use of mobile technologies to support health (mHealth technologies), specifically mHealth applications (apps), has the potential to improve outcomes in SLE by empowering patients through education, symptom tracking, and peer support,” first author Lucas Ogura Dantas, of Tufts Medical Center, Boston, and coauthors wrote in Lupus. “These may be particularly powerful tools in SLE which commonly affects young adults, who are typically avid smartphone users familiar with the use of mobile apps.”
The authors’ review of 19 mHealth apps on Google Play and the Apple App Store (and 1 not on either platform) gave an overall average score of 2.3 out of a possible 5.0 from individual mean scores for engagement, functionality, aesthetics, and information quality on the 23-item Mobile App Rating Scale, each item of which is rated on a 0-5 point scale. Overall, 10 apps offered educational content, 7 offered tools for tracking patient-reported symptoms, 5 offered interactive online communities, 1 offered emojis to share through text messages or email for the purpose of entertainment, and 1 could not be fully evaluated.
The researchers noted that “most apps scored poorly based on design, user interface, functionality, and credibility,” with mean scores of 2.5 for engagement, 2.9 for functionality, 2.2 for aesthetics, and 1.6 for information. “The majority of the apps provided low-quality information from questionable sources (i.e., sources were not cited or their legitimacy was unknown or unverifiable),” they wrote.
The three highest-rated apps – LupusMinder (overall mean score, 3.3), Lupus Corner Health Manager (3.2), and PatientsLikeMe (3.1) – all focused on tracking patient-reported outcomes, but none used validated outcome measures; offered connectivity with wearable devices; or passively collected data such as step count, walking distances, flights climbed, calories expenditure, or sleep monitoring. However, two did have social network components and interactive support groups. Despite these apps’ interactivity and customizability, none offered “features for patients to create and track goals, directly connect with a physician or expert in the field, or synchronize data with electronic health records. None of the apps provided patients with feedback.”
The authors wrote that the Lupus Corner Health Manager was “the only one that addresses the majority of the preferences of SLE patients identified in our literature review. This app provides educational material, a symptom and medication tracker, and a discussion group for communicating with others living with lupus – all key features of mHealth technologies in the management of chronic diseases.”
However, they noted that the “ideal mHealth app for patients with SLE would incorporate evidence-based educational material, customizable symptom and medication trackers, logs for personalized health goals, and connectivity with external hardware devices to enrich data collection. Additional useful features would include gamification components to engage users, the provision of tailored feedback based on collected data, and secure mechanisms of communication and data access between users and health care providers to facilitate treatment planning and coordination of care.”
In the systematic literature review, the researchers identified a total of 21 original research studies “related to the development or use of mHealth technologies targeting people of all ages with an SLE diagnosis,” including 2 randomized trials, 10 observational studies, 4 qualitative studies, 3 review articles, and 2 study protocols for future randomized trials.
These papers most often focused on developing and using mHealth for providing patient information (11 papers), followed by mHealth interventions (5); study protocols (2); and developing mHealth apps, websites, or mHealth interventions (3).
Seven studies implemented mHealth technologies, including two with wearable devices, two with text-messaging interventions, and three that used web-based systems. These had mixed results and small samples sizes ranging from 9 to 41 patients, making their interpretation difficult, the authors wrote. A total of 11 studies examined the development of mHealth technologies, including 7 that recognized “the need for more interactive educational platforms with high-quality information,” 2 that described a need for “novel methods of disease monitoring,” and 2 that revealed “a need for sources of support such as virtual communities.”
“Though our systematic literature review found that patients seek to use mHealth technologies to aid with disease management, we identified few studies exploring mHealth-based interventions to improve health outcomes, with the limited published literature devoted to the use of mHealth platforms to provide educational information,” Mr. Dantas and associates wrote.
The lack of evidence for mHealth technologies in SLE patients “contrast with the robust evidence supporting the effectiveness of mHealth interventions in improving outcomes in several chronic conditions,” such as chronic low back and musculoskeletal pain and blood pressure control, they noted.
The authors reported no potential conflicts of interest. The study authors received funding from the Saõ Paulo Research Foundation, the National Center for Complementary and Integrative Health, and the National Center for Advancing Translational Sciences.
SOURCE: Dantas LO et al. Lupus. 2020;29:144-56.
and have limited “The use of mobile technologies to support health (mHealth technologies), specifically mHealth applications (apps), has the potential to improve outcomes in SLE by empowering patients through education, symptom tracking, and peer support,” first author Lucas Ogura Dantas, of Tufts Medical Center, Boston, and coauthors wrote in Lupus. “These may be particularly powerful tools in SLE which commonly affects young adults, who are typically avid smartphone users familiar with the use of mobile apps.”
The authors’ review of 19 mHealth apps on Google Play and the Apple App Store (and 1 not on either platform) gave an overall average score of 2.3 out of a possible 5.0 from individual mean scores for engagement, functionality, aesthetics, and information quality on the 23-item Mobile App Rating Scale, each item of which is rated on a 0-5 point scale. Overall, 10 apps offered educational content, 7 offered tools for tracking patient-reported symptoms, 5 offered interactive online communities, 1 offered emojis to share through text messages or email for the purpose of entertainment, and 1 could not be fully evaluated.
The researchers noted that “most apps scored poorly based on design, user interface, functionality, and credibility,” with mean scores of 2.5 for engagement, 2.9 for functionality, 2.2 for aesthetics, and 1.6 for information. “The majority of the apps provided low-quality information from questionable sources (i.e., sources were not cited or their legitimacy was unknown or unverifiable),” they wrote.
The three highest-rated apps – LupusMinder (overall mean score, 3.3), Lupus Corner Health Manager (3.2), and PatientsLikeMe (3.1) – all focused on tracking patient-reported outcomes, but none used validated outcome measures; offered connectivity with wearable devices; or passively collected data such as step count, walking distances, flights climbed, calories expenditure, or sleep monitoring. However, two did have social network components and interactive support groups. Despite these apps’ interactivity and customizability, none offered “features for patients to create and track goals, directly connect with a physician or expert in the field, or synchronize data with electronic health records. None of the apps provided patients with feedback.”
The authors wrote that the Lupus Corner Health Manager was “the only one that addresses the majority of the preferences of SLE patients identified in our literature review. This app provides educational material, a symptom and medication tracker, and a discussion group for communicating with others living with lupus – all key features of mHealth technologies in the management of chronic diseases.”
However, they noted that the “ideal mHealth app for patients with SLE would incorporate evidence-based educational material, customizable symptom and medication trackers, logs for personalized health goals, and connectivity with external hardware devices to enrich data collection. Additional useful features would include gamification components to engage users, the provision of tailored feedback based on collected data, and secure mechanisms of communication and data access between users and health care providers to facilitate treatment planning and coordination of care.”
In the systematic literature review, the researchers identified a total of 21 original research studies “related to the development or use of mHealth technologies targeting people of all ages with an SLE diagnosis,” including 2 randomized trials, 10 observational studies, 4 qualitative studies, 3 review articles, and 2 study protocols for future randomized trials.
These papers most often focused on developing and using mHealth for providing patient information (11 papers), followed by mHealth interventions (5); study protocols (2); and developing mHealth apps, websites, or mHealth interventions (3).
Seven studies implemented mHealth technologies, including two with wearable devices, two with text-messaging interventions, and three that used web-based systems. These had mixed results and small samples sizes ranging from 9 to 41 patients, making their interpretation difficult, the authors wrote. A total of 11 studies examined the development of mHealth technologies, including 7 that recognized “the need for more interactive educational platforms with high-quality information,” 2 that described a need for “novel methods of disease monitoring,” and 2 that revealed “a need for sources of support such as virtual communities.”
“Though our systematic literature review found that patients seek to use mHealth technologies to aid with disease management, we identified few studies exploring mHealth-based interventions to improve health outcomes, with the limited published literature devoted to the use of mHealth platforms to provide educational information,” Mr. Dantas and associates wrote.
The lack of evidence for mHealth technologies in SLE patients “contrast with the robust evidence supporting the effectiveness of mHealth interventions in improving outcomes in several chronic conditions,” such as chronic low back and musculoskeletal pain and blood pressure control, they noted.
The authors reported no potential conflicts of interest. The study authors received funding from the Saõ Paulo Research Foundation, the National Center for Complementary and Integrative Health, and the National Center for Advancing Translational Sciences.
SOURCE: Dantas LO et al. Lupus. 2020;29:144-56.
FROM LUPUS
HRQOL deteriorates after disease progression in metastatic cancer
, results of an observational study suggest.
The findings highlight the importance of patient-relevant outcomes when evaluating novel therapies for patients with metastatic cancers, according to Norbert Marschner, MD, of Praxis für interdisziplinäre onkologie und hämatologie in Freiburg, Germany, and colleagues. The researchers reported the findings in JAMA Network Open.
They used four nationwide German registries to evaluate the association of disease progression with HRQOL in patients receiving systemic therapy for metastatic colorectal, lung, pancreatic, or breast cancer.
The analysis included 2,314 adults with documented disease progression across 203 institutions in Germany. Data collection occurred during routine follow-up visits at participating centers during 2011-2018.
Various patient-reported outcome questionnaires were used to measure HRQOL and symptom severity among participants. For the present study, the team enrolled patients at the start of any systemic palliative treatment, defined as targeted therapy, chemotherapy, or endocrine therapy.
Mixed-model analyses of more than 8,000 questionnaires showed that the first disease progression was associated with significant deterioration in 37 of 45 HRQOL scales overall, 17 of which were considered clinically meaningful.
With respect to cancer type, significant worsening after the first progression occurred in 12 of 14 colorectal cancer HRQOL scales, 11 of 14 lung cancer scales, 10 of 10 pancreatic cancer scales, and 4 of 7 breast cancer scales.
The deterioration in global HRQOL associated with the first progression was of greatest magnitude in lung cancer (6.7 points; P < .001), followed by pancreatic cancer (5.4 points; P < .001), colorectal cancer (3.5 points; P = .002), and breast cancer (2.4 points; P = .001).
The researchers also found that 38 of 45 HRQOL scales showed a greater degree of worsening after the second disease progression than after the first. They observed significant worsening after the second disease progression in 32 of 45 HRQOL scales, and all 32 were considered clinically meaningful.
The researchers acknowledged that a key limitation of this study was the observational design. As a result, the study did not include specifications related to tumor assessment, such as frequency, timing, or criteria.
“We suggest that progression-related endpoints in metastatic breast, colorectal, lung, or pancreatic cancer should be considered when evaluating the benefit of novel treatments, in addition to survival, morbidity, and HRQOL outcomes,” the researchers concluded.
The registries used in this study are funded by iOMEDICO and industry sponsors. The authors disclosed relationships with iOMEDICO and several pharmaceutical companies.
SOURCE: Marschner N et al. JAMA Netw Open. 2020 Mar 10. doi: 10.1001/jamanetworkopen.2020.0643.
, results of an observational study suggest.
The findings highlight the importance of patient-relevant outcomes when evaluating novel therapies for patients with metastatic cancers, according to Norbert Marschner, MD, of Praxis für interdisziplinäre onkologie und hämatologie in Freiburg, Germany, and colleagues. The researchers reported the findings in JAMA Network Open.
They used four nationwide German registries to evaluate the association of disease progression with HRQOL in patients receiving systemic therapy for metastatic colorectal, lung, pancreatic, or breast cancer.
The analysis included 2,314 adults with documented disease progression across 203 institutions in Germany. Data collection occurred during routine follow-up visits at participating centers during 2011-2018.
Various patient-reported outcome questionnaires were used to measure HRQOL and symptom severity among participants. For the present study, the team enrolled patients at the start of any systemic palliative treatment, defined as targeted therapy, chemotherapy, or endocrine therapy.
Mixed-model analyses of more than 8,000 questionnaires showed that the first disease progression was associated with significant deterioration in 37 of 45 HRQOL scales overall, 17 of which were considered clinically meaningful.
With respect to cancer type, significant worsening after the first progression occurred in 12 of 14 colorectal cancer HRQOL scales, 11 of 14 lung cancer scales, 10 of 10 pancreatic cancer scales, and 4 of 7 breast cancer scales.
The deterioration in global HRQOL associated with the first progression was of greatest magnitude in lung cancer (6.7 points; P < .001), followed by pancreatic cancer (5.4 points; P < .001), colorectal cancer (3.5 points; P = .002), and breast cancer (2.4 points; P = .001).
The researchers also found that 38 of 45 HRQOL scales showed a greater degree of worsening after the second disease progression than after the first. They observed significant worsening after the second disease progression in 32 of 45 HRQOL scales, and all 32 were considered clinically meaningful.
The researchers acknowledged that a key limitation of this study was the observational design. As a result, the study did not include specifications related to tumor assessment, such as frequency, timing, or criteria.
“We suggest that progression-related endpoints in metastatic breast, colorectal, lung, or pancreatic cancer should be considered when evaluating the benefit of novel treatments, in addition to survival, morbidity, and HRQOL outcomes,” the researchers concluded.
The registries used in this study are funded by iOMEDICO and industry sponsors. The authors disclosed relationships with iOMEDICO and several pharmaceutical companies.
SOURCE: Marschner N et al. JAMA Netw Open. 2020 Mar 10. doi: 10.1001/jamanetworkopen.2020.0643.
, results of an observational study suggest.
The findings highlight the importance of patient-relevant outcomes when evaluating novel therapies for patients with metastatic cancers, according to Norbert Marschner, MD, of Praxis für interdisziplinäre onkologie und hämatologie in Freiburg, Germany, and colleagues. The researchers reported the findings in JAMA Network Open.
They used four nationwide German registries to evaluate the association of disease progression with HRQOL in patients receiving systemic therapy for metastatic colorectal, lung, pancreatic, or breast cancer.
The analysis included 2,314 adults with documented disease progression across 203 institutions in Germany. Data collection occurred during routine follow-up visits at participating centers during 2011-2018.
Various patient-reported outcome questionnaires were used to measure HRQOL and symptom severity among participants. For the present study, the team enrolled patients at the start of any systemic palliative treatment, defined as targeted therapy, chemotherapy, or endocrine therapy.
Mixed-model analyses of more than 8,000 questionnaires showed that the first disease progression was associated with significant deterioration in 37 of 45 HRQOL scales overall, 17 of which were considered clinically meaningful.
With respect to cancer type, significant worsening after the first progression occurred in 12 of 14 colorectal cancer HRQOL scales, 11 of 14 lung cancer scales, 10 of 10 pancreatic cancer scales, and 4 of 7 breast cancer scales.
The deterioration in global HRQOL associated with the first progression was of greatest magnitude in lung cancer (6.7 points; P < .001), followed by pancreatic cancer (5.4 points; P < .001), colorectal cancer (3.5 points; P = .002), and breast cancer (2.4 points; P = .001).
The researchers also found that 38 of 45 HRQOL scales showed a greater degree of worsening after the second disease progression than after the first. They observed significant worsening after the second disease progression in 32 of 45 HRQOL scales, and all 32 were considered clinically meaningful.
The researchers acknowledged that a key limitation of this study was the observational design. As a result, the study did not include specifications related to tumor assessment, such as frequency, timing, or criteria.
“We suggest that progression-related endpoints in metastatic breast, colorectal, lung, or pancreatic cancer should be considered when evaluating the benefit of novel treatments, in addition to survival, morbidity, and HRQOL outcomes,” the researchers concluded.
The registries used in this study are funded by iOMEDICO and industry sponsors. The authors disclosed relationships with iOMEDICO and several pharmaceutical companies.
SOURCE: Marschner N et al. JAMA Netw Open. 2020 Mar 10. doi: 10.1001/jamanetworkopen.2020.0643.
FROM JAMA NETWORK OPEN
NMA haploidentical allo-BMT plus post-transplant cyclophosphamide deemed safe, effective for CLL
for patients with chronic lymphocytic leukemia (CLL), according to a study published in Biology of Blood and Marrow Transplantation.
The number of patients undergoing haploidentical allo-BMT has increased substantially, with the advent of new graft-versus-host disease (GVHD) prophylaxis strategies, such as posttransplantation cyclophosphamide (PTCy), that reduce the risk of GVHD complications; however there have been few studies assessing the results of this treatment regimen, according to the authors.
The study assessed 64 consecutive patients with CLL between Jan. 2005 and Aug. 2018 who underwent haploidentical allo-BMT. The median age was 59 years; 4 patients (6.2%) underwent allo-BMT after first-line treatment; 20 patients (31.2%) underwent allo-BMT after second-line treatment, and 40 patients (62.5%) underwent allo-BMT after three or more lines of treatment for relapsed and/or refractory disease.
All patients received a nonmyeloablative (NMA) conditioning regimen consisting of fludarabine, cyclophosphamide, and 200 cGy total body irradiation. Patients received PTCy (i.v. 50 mg/kg per day) on days +3 and +4, along with additional GVHD prophylaxis with mycophenolate mofetil between days +5 and +35 and tacrolimus or sirolimus between days +5 and +180.
For all 64 patients, the median duration of follow-up was 4.4 years based on the reverse Kaplan-Meier method. The 4-year overall survival (OS) was 52%, and the 4-year progression-free survival (PFS) was 37%. The 56 patients with less than 20% marrow CLL involvement before undergoing allo-BMT had a 4-year OS of 61%, a 4-year PFS of 43%, and a median OS of 4.8 years, according to the authors.
Regression analysis demonstrated that donor age, stem cell source, IGHV mutation status, or grade II-III acute GVHD did not affect risk of progression or survival.
“The majority of our patients had unfavorable risk factors, and collectively our data show that haploidentical allo-BMT with PTCy in CLL with less than 20% marrow involvement is a safe treatment option carrying a low risk of serious GVHD and other toxicities,” the researchers concluded.
The study was supported by National Institutes of Health, National Cancer Institute grants. The authors reported that they had no disclosures.
SOURCE: Suman P et al. Biol Blood Marrow Transplant. 2020 Mar 1;26:502-8. doi: 10.1016/j.bbmt.2019.11.008
for patients with chronic lymphocytic leukemia (CLL), according to a study published in Biology of Blood and Marrow Transplantation.
The number of patients undergoing haploidentical allo-BMT has increased substantially, with the advent of new graft-versus-host disease (GVHD) prophylaxis strategies, such as posttransplantation cyclophosphamide (PTCy), that reduce the risk of GVHD complications; however there have been few studies assessing the results of this treatment regimen, according to the authors.
The study assessed 64 consecutive patients with CLL between Jan. 2005 and Aug. 2018 who underwent haploidentical allo-BMT. The median age was 59 years; 4 patients (6.2%) underwent allo-BMT after first-line treatment; 20 patients (31.2%) underwent allo-BMT after second-line treatment, and 40 patients (62.5%) underwent allo-BMT after three or more lines of treatment for relapsed and/or refractory disease.
All patients received a nonmyeloablative (NMA) conditioning regimen consisting of fludarabine, cyclophosphamide, and 200 cGy total body irradiation. Patients received PTCy (i.v. 50 mg/kg per day) on days +3 and +4, along with additional GVHD prophylaxis with mycophenolate mofetil between days +5 and +35 and tacrolimus or sirolimus between days +5 and +180.
For all 64 patients, the median duration of follow-up was 4.4 years based on the reverse Kaplan-Meier method. The 4-year overall survival (OS) was 52%, and the 4-year progression-free survival (PFS) was 37%. The 56 patients with less than 20% marrow CLL involvement before undergoing allo-BMT had a 4-year OS of 61%, a 4-year PFS of 43%, and a median OS of 4.8 years, according to the authors.
Regression analysis demonstrated that donor age, stem cell source, IGHV mutation status, or grade II-III acute GVHD did not affect risk of progression or survival.
“The majority of our patients had unfavorable risk factors, and collectively our data show that haploidentical allo-BMT with PTCy in CLL with less than 20% marrow involvement is a safe treatment option carrying a low risk of serious GVHD and other toxicities,” the researchers concluded.
The study was supported by National Institutes of Health, National Cancer Institute grants. The authors reported that they had no disclosures.
SOURCE: Suman P et al. Biol Blood Marrow Transplant. 2020 Mar 1;26:502-8. doi: 10.1016/j.bbmt.2019.11.008
for patients with chronic lymphocytic leukemia (CLL), according to a study published in Biology of Blood and Marrow Transplantation.
The number of patients undergoing haploidentical allo-BMT has increased substantially, with the advent of new graft-versus-host disease (GVHD) prophylaxis strategies, such as posttransplantation cyclophosphamide (PTCy), that reduce the risk of GVHD complications; however there have been few studies assessing the results of this treatment regimen, according to the authors.
The study assessed 64 consecutive patients with CLL between Jan. 2005 and Aug. 2018 who underwent haploidentical allo-BMT. The median age was 59 years; 4 patients (6.2%) underwent allo-BMT after first-line treatment; 20 patients (31.2%) underwent allo-BMT after second-line treatment, and 40 patients (62.5%) underwent allo-BMT after three or more lines of treatment for relapsed and/or refractory disease.
All patients received a nonmyeloablative (NMA) conditioning regimen consisting of fludarabine, cyclophosphamide, and 200 cGy total body irradiation. Patients received PTCy (i.v. 50 mg/kg per day) on days +3 and +4, along with additional GVHD prophylaxis with mycophenolate mofetil between days +5 and +35 and tacrolimus or sirolimus between days +5 and +180.
For all 64 patients, the median duration of follow-up was 4.4 years based on the reverse Kaplan-Meier method. The 4-year overall survival (OS) was 52%, and the 4-year progression-free survival (PFS) was 37%. The 56 patients with less than 20% marrow CLL involvement before undergoing allo-BMT had a 4-year OS of 61%, a 4-year PFS of 43%, and a median OS of 4.8 years, according to the authors.
Regression analysis demonstrated that donor age, stem cell source, IGHV mutation status, or grade II-III acute GVHD did not affect risk of progression or survival.
“The majority of our patients had unfavorable risk factors, and collectively our data show that haploidentical allo-BMT with PTCy in CLL with less than 20% marrow involvement is a safe treatment option carrying a low risk of serious GVHD and other toxicities,” the researchers concluded.
The study was supported by National Institutes of Health, National Cancer Institute grants. The authors reported that they had no disclosures.
SOURCE: Suman P et al. Biol Blood Marrow Transplant. 2020 Mar 1;26:502-8. doi: 10.1016/j.bbmt.2019.11.008
FROM BIOLOGY OF BLOOD AND MARROW TRANSPLANTATION
As physicians, accountability is part of our innate identity
Recently, Nicolas Badre, MD, challenged psychiatrists who care for patients involved in the legal system. He encouraged “a resurgence of personal accountability and responsibility.”
Using the chronically disenfranchised patients who are repetitiously shuttled between jails and mental hospitals as examples, he pointed out that we psychiatrists must “step up to the plate” and approach clinical problems with the attitude that “the buck stops with me.” As Dr. Badre pointed out, this is especially true when dealing with large, complex systems in which fragmented care exists without clear leadership. This, in turn, allows for a dissolution of accountability.
Accountability is a natural continuation of our training as physicians. We all remember the transition from medical student to intern, the steep learning curve as well as growth and maturation during this changeover. A dramatic transformation occurs over the course of 1 year, from medical students who tag along learning from patients to interns expected to be on their own for endless hours.
Over the course of those hours, we came to the understanding that people’s lives were in our hands. This causes a shift in our identity. This process continues throughout residency and onward in our careers. At some point, it becomes part of our innate identity as physicians or our professional sense of self – which is hard to describe to nonphysicians.
A profound example of a sense of accountability within the medical profession can be found in “How We Live,” a book by National Book Award winner Sherwin B. Nuland, MD. In the book, the late Dr. Nuland recounted how, as a 49-year-old seasoned surgeon working at Yale University, New Haven, Conn., and casually rounding on patients, he heard a frantic message: “Any general surgeon! Any general surgeon! Go immediately to the operating room – immediately – any general surgeon!”
The case involved a 42-year-old wife and mother who had been rushed to the ED after having been found in the community in a profound state of shock. In the ED, it was suspected that the patient was bleeding heavily from a ruptured tubal pregnancy. She was sped rapidly to the operating room with an undetectable blood pressure and a barely palpable pulse. The on-call ob.gyn. had been summoned from home, and he rushed to the operating room along with his department chairman.
Because the woman had lost much of her blood supply, there was no time for crossmatching. The anesthesiologist had placed large-bore intravenous lines and transfused her with O-negative blood (the universal donor blood type) to try maintain some level of blood pressure. Before she could be even fully anesthetized, the ob.gyn had made an incision in her lower abdomen. The bleeding he encountered was profound.
After a quick evaluation, the ob.gyn. realized that the blood was coming from above, not below, leading to the emergency page that Dr. Nuland heard. Dr. Nuland described bounding up the stairs three at a time. He recalled: “[A] very real apprehension had entered my mind. I might encounter a situation that was beyond me, something that I might make even worse, something that would cause me to regret for the rest of my life that I had answered the page’s insistent call instead of simply turning my back on its urgency and slinking off to my car before anyone noticed I was there.”
However, he could not see himself doing such a thing and he rushed up to the operating room because, “walking away from that kind of cry for help would have violated every precept taught me by my life and my training, and every bit of moral sense I had. … . I bear an obsessive preoccupation with accepting responsibility, amounting really to a compulsively neurotic sense of duty.”
And yet in the next few seconds, as he was running to the operating room, he wondered: “Am I about to botch something up? Will I, in one quick stroke of ineptness and fate, bring my career crashing down around my feet and with it my sense of what I am? Am I on my way to destroy an unknown patient and myself at the same time?”
In Dr. Nuland’s thoughts lie the conundrum of responsibility for physicians. Thankfully for Dr. Nuland, he was able to save the day and diagnose a rare case of rupture of an aneurysm of the splenic artery and keep the patient alive. This dramatic story involved a surgical colleague who had to make split-second decisions while a patient’s life hanged in the balance, but the same principles apply to us as psychiatrists.
I would note that, in the above example of the surgical patient, the “system” for saving the woman’s life was well organized and resourced to allow for a comprehensive and time-limited intervention into a life-threatening situation. There was an operating room staffed by various professionals who all had a defined role. It required the leader, Dr. Nuland, to step in, make the right diagnosis, and then issue commands to the identified professionals who all recognized his leadership and were skilled in carrying out their assigned duties. Dr. Nuland clearly was the leader once he took charge.
An outpatient psychiatrist facing a suicidal patient must deal with a different set of challenges, often involving various complex systems as well as multiple barriers. Clinical barriers include available interdisciplinary resources/personnel to assist not only with the critical encounter, but also with extended evaluation and treatment in a secure, well-resourced environment. Administrative barriers can include justifying the optimal treatment plan to payors. Our lethal patients often require both outpatient and inpatient services with sometimes-conflicting agendas. In a recent article, I pointed out some of the vexing problems that arise when communication and collaboration are poor between inpatient and outpatient psychiatrists. In such complex environments, it is less clear what is involved in the outpatient psychiatrist stepping up to the plate and asserting leadership.
An emotionally wrenching article about an emergency physician, Matthew E. Seaman, MD, who died by suicide, reminds us of the potential for suicide in a complicated patient (in this case, a medical colleague) involving complex systems. Plagued by a review of his care by the medical board (they had forced him to surrender his medical license and allowed the allegations to go public in lieu of further disciplinary proceedings), a subsequent lawsuit and an ultimate attempt by the plaintiff to obtain Dr. Seaman’s personal assets led to his worsening mental health. According to his wife, also a physician, he was getting “more depressed by the insults and assaults on his integrity and professionalism.”
Just before the investigation, he had received a 30-year pin from the American Board of Emergency Medicine for his “dedication to the specialty.” He fell into a deep depression from which he could not recover despite several psychiatric admissions and several medication trials. Along with his depression, he suffered from severe anxiety, a known risk factor for suicide. Dr. Seaman was feeling overwhelmed by the lengthy legal process targeting him as being negligent. He begged his attorney to settle the case, but his insurance carrier would not allow it. According to his wife: “All sense of human worth had been beaten out of him.”
Dr. Seaman had been known as resilient. He could handle complex ED situations, including simultaneously dealing with multiple traumas. He previously had been named in three malpractice lawsuits and had prevailed in each one. But his resilience had greatly diminished, and he became overwhelmed. He previously had, as a physician, been able to step up to the plate of accountability. But now, because of a confluence of depression and anxiety as well as the “insults and assaults on his integrity and professionalism,” he found life to be unbearable with the resulting tragic end.
So how would we as psychiatrists step up to the plate and be accountable when faced with a struggling fellow physician at risk for suicide such as Dr. Seaman?
Be aware of relevant risk factors
In addition to being aware of the usual risk factors for suicide, it would behoove us to also understand how physician suicides differ from suicides among nonphysicians.1 For example, physicians who have died by suicide were far more likely to have experienced job-related problems than nonphysicians, but less likely to have experienced the recent death of a loved one. Also noteworthy is that physicians who end their lives were more often married. In addition, Michael F. Myers, MD, a psychiatrist who has studied physician suicides, noted in the article about Dr. Seaman that struggling physicians are likely to suffer from shame and embarrassment.
Consider shame, burdensomeness, and secrecy
When suicide risk factors are taught to students and professionals, rarely is shame mentioned. Perhaps it is not a common risk factor in the general population, but shame and its cousin, disgrace, are known risk factors that likely apply more to people – such as physicians – who have built a reputation over their careers. One whole chapter is given to disgrace suicides in a book about suicide notes.2 A reputation often is one of the most important factors for professionals, which creates their sense of identity and, by extension, a sense of purpose in life.
When a doctor perceives that his or her reputation is being destroyed, it can produce a profound sense of shame, one of the most powerful of negative emotions.3 Another feature among completed suicides that applies more generally is perceived burdensomeness, according to Thomas E. Joiner Jr., PhD, one of the deep and innovative researchers in the field of suicidology.4 Once a doctor starts feeling that he has been a failure in his professional life and starts ruminating about it, the feelings of failure may generalize to other areas of his life, so that he starts feeling that he is a burden to his spouse. This, then, only increases his shame.
The issue of secrecy also is noteworthy. I was struck reading a book by Dr. Myers on physician suicide by the many spouses and family members who were caught completely unaware of problems when their spouse, a doctor, ended their lives by suicide.5 The doctors hid their problems well, perhaps not wanting to burden their family members. Also, if feelings of shame are an issue, then concealment tends to occur. This concealment of suicidality runs counter to the current narrative among some in the professional community that suicides are preventable (this despite the continuing increase in rates of suicide at the same time that there are increases in mental health services and suicide prevention programs).6
As pointed out in some of the letters quoted in Dr. Myers’s book, those who completed suicide are smart and know how to hide their symptoms well. Although Dr. Seaman’s wife, Linda Seaman, MD, was aware of her husband’s suicidality, when he eventually determined that he was going to end his life, he apparently did not reveal his more serious intention to her. Aside from spouses and family, determined suicide completers often hide their intentions from their clinicians.7
Attempt to obtain collateral information
By being aware of the usual and less-usual risk factors for suicide that our physician colleagues may present with as explained above, we can use strategies for mitigating risk. If secrecy because of shame and embarrassment prevents our physician patient from being fully candid, include the spouse or another significant family member in sessions. While the physician might hide his suicidal intent from both the clinician and spouse, it remains prudent to include the spouse in the treatment plan. Give the spouse a telephone number with which they can contact you if they notice any worrisome change in functioning or behavior. Collateral information often is helpful. (Example: Is the patient not eating, not sleeping, or giving away valued possessions?)
Assess for competency
In Dr. Seaman’s case, it was noted that, with a trial approaching, Dr. Seaman had written in a journal entry that he could not mentally endure a trial. “For me, the stress is overwhelming.” Such a patient, suffering from severe depression, often is unable to properly assist his attorney in his defense. The outpatient psychiatrist can notify the court or one of the attorneys that the competency of the physician patient is questionable (or express a definite opinion of incompetency), and offer the opinion that it would be best to postpone further legal action until the patient is in a more healthy state of mind.
Know when hospitalization is needed
Obviously, the process will go smoother if the admission is voluntary. If the patient physician resists and the psychiatrist believes that the risk for self-harm is too high for the physician patient to remain as an outpatient, try to get a spouse or family member to persuade him to be admitted. An involuntary admission opens up a whole new can of worms and may fracture the therapeutic alliance.
In the end, it might be better to take that risk rather than having a dead patient on your hands. If a hospitalization is necessary, contact the admitting psychiatrist and verbally express your concerns and the reasons why a hospitalization is needed. Ask the inpatient psychiatrist to contact you when a discharge is approaching so that you have an opportunity to ask relevant questions.
For example, during his second psychiatric admission, as the time for discharge was approaching, Dr. Seaman wrote: “I am not well enough for discharge. I am still mentally ill.” Ask the inpatient doctor whether the patient has gotten sufficiently better and he feels confident he can function as an outpatient. If there is a conflicting opinion about the readiness of the patient for discharge, notify the medical director of the service or an administrator about your concerns.
Ask for consultation
At any stage of the process consider getting consultation for a trusted colleague or senior clinician if you are failing to make progress. Sometimes it helps to get the perspective from a fresh pair of eyes or ears.
Get a reality check
Having recounted the inspiring story of Dr. Nuland’s magnificent efforts and joyous success in preserving a life that was on the verge of being lost in the battle against death at the last possible second, I would note the following: Surgeons will tell you that, despite their most heroic efforts and teamwork, there are times when luck runs out and the patient dies on the operating table. Also, small lapses, which all mortals are prone to despite their best efforts at conscientiousness, sometimes can lead to a bad outcome.
Similarly, in psychiatry, no matter how much effort we put into saving a life, sometimes it is all to no avail. Despite all we have learned about suicide and its risk factors, and no matter how much care we take to contain risk, our patients who are determined will find a way of ending their own lives. The vexing problem of suicide seems intractable. A suicide among our patients humbles us, but also hopefully inspires us to keep trying harder to step up to the plate of accountability.
In conclusion, for us physicians, accountability is not a facet, a trait, or even a pursuit, accountability is at the core of who are and how we define ourselves. Accountability is the reason we leap stairs three at time when we are urgently paged. Accountability is the reason malpractice lawsuits cut at the core of our self-image. Accountability allows us to always have hope for a positive outcome, despite overwhelming barriers, and gives our lives a sense of purpose.
For me, in preparing this article, accountability was reviewing and studying physician suicide and then applying best practices in risk assessment after reading the tragic story of Dr. Seaman. I hope I inspire you to do the same in the pursuit of helping our vulnerable patients.
Learning how to care for our complex patients is a never-ending journey.
References
1. Gold KJ. Gen Hosp Psychiatry. 2013 Jan;35(1):45-9.
2. Etkind M. ...Or Not to Be: A Collection of Suicide Notes. New York: Riverhead Books, 1997.
3. Lamia LC. Shame: A concealed, contagious, and dangerous emotion. Psychology Today. 2011 Apr 4.
4. Joiner TE. Why People Die by Suicide. Cambridge: Harvard University Press, 2005.
5. Myers MF. Why Physicians Die by Suicide. 2017.
6. National Institutes of Health. Suicide Prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml.
7. Levy AG et al. JAMA Netw Open. 2019 Aug 14. doi: 10.1001/jamanetworkopen.2019.9277.
Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University, Cleveland, as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.
Recently, Nicolas Badre, MD, challenged psychiatrists who care for patients involved in the legal system. He encouraged “a resurgence of personal accountability and responsibility.”
Using the chronically disenfranchised patients who are repetitiously shuttled between jails and mental hospitals as examples, he pointed out that we psychiatrists must “step up to the plate” and approach clinical problems with the attitude that “the buck stops with me.” As Dr. Badre pointed out, this is especially true when dealing with large, complex systems in which fragmented care exists without clear leadership. This, in turn, allows for a dissolution of accountability.
Accountability is a natural continuation of our training as physicians. We all remember the transition from medical student to intern, the steep learning curve as well as growth and maturation during this changeover. A dramatic transformation occurs over the course of 1 year, from medical students who tag along learning from patients to interns expected to be on their own for endless hours.
Over the course of those hours, we came to the understanding that people’s lives were in our hands. This causes a shift in our identity. This process continues throughout residency and onward in our careers. At some point, it becomes part of our innate identity as physicians or our professional sense of self – which is hard to describe to nonphysicians.
A profound example of a sense of accountability within the medical profession can be found in “How We Live,” a book by National Book Award winner Sherwin B. Nuland, MD. In the book, the late Dr. Nuland recounted how, as a 49-year-old seasoned surgeon working at Yale University, New Haven, Conn., and casually rounding on patients, he heard a frantic message: “Any general surgeon! Any general surgeon! Go immediately to the operating room – immediately – any general surgeon!”
The case involved a 42-year-old wife and mother who had been rushed to the ED after having been found in the community in a profound state of shock. In the ED, it was suspected that the patient was bleeding heavily from a ruptured tubal pregnancy. She was sped rapidly to the operating room with an undetectable blood pressure and a barely palpable pulse. The on-call ob.gyn. had been summoned from home, and he rushed to the operating room along with his department chairman.
Because the woman had lost much of her blood supply, there was no time for crossmatching. The anesthesiologist had placed large-bore intravenous lines and transfused her with O-negative blood (the universal donor blood type) to try maintain some level of blood pressure. Before she could be even fully anesthetized, the ob.gyn had made an incision in her lower abdomen. The bleeding he encountered was profound.
After a quick evaluation, the ob.gyn. realized that the blood was coming from above, not below, leading to the emergency page that Dr. Nuland heard. Dr. Nuland described bounding up the stairs three at a time. He recalled: “[A] very real apprehension had entered my mind. I might encounter a situation that was beyond me, something that I might make even worse, something that would cause me to regret for the rest of my life that I had answered the page’s insistent call instead of simply turning my back on its urgency and slinking off to my car before anyone noticed I was there.”
However, he could not see himself doing such a thing and he rushed up to the operating room because, “walking away from that kind of cry for help would have violated every precept taught me by my life and my training, and every bit of moral sense I had. … . I bear an obsessive preoccupation with accepting responsibility, amounting really to a compulsively neurotic sense of duty.”
And yet in the next few seconds, as he was running to the operating room, he wondered: “Am I about to botch something up? Will I, in one quick stroke of ineptness and fate, bring my career crashing down around my feet and with it my sense of what I am? Am I on my way to destroy an unknown patient and myself at the same time?”
In Dr. Nuland’s thoughts lie the conundrum of responsibility for physicians. Thankfully for Dr. Nuland, he was able to save the day and diagnose a rare case of rupture of an aneurysm of the splenic artery and keep the patient alive. This dramatic story involved a surgical colleague who had to make split-second decisions while a patient’s life hanged in the balance, but the same principles apply to us as psychiatrists.
I would note that, in the above example of the surgical patient, the “system” for saving the woman’s life was well organized and resourced to allow for a comprehensive and time-limited intervention into a life-threatening situation. There was an operating room staffed by various professionals who all had a defined role. It required the leader, Dr. Nuland, to step in, make the right diagnosis, and then issue commands to the identified professionals who all recognized his leadership and were skilled in carrying out their assigned duties. Dr. Nuland clearly was the leader once he took charge.
An outpatient psychiatrist facing a suicidal patient must deal with a different set of challenges, often involving various complex systems as well as multiple barriers. Clinical barriers include available interdisciplinary resources/personnel to assist not only with the critical encounter, but also with extended evaluation and treatment in a secure, well-resourced environment. Administrative barriers can include justifying the optimal treatment plan to payors. Our lethal patients often require both outpatient and inpatient services with sometimes-conflicting agendas. In a recent article, I pointed out some of the vexing problems that arise when communication and collaboration are poor between inpatient and outpatient psychiatrists. In such complex environments, it is less clear what is involved in the outpatient psychiatrist stepping up to the plate and asserting leadership.
An emotionally wrenching article about an emergency physician, Matthew E. Seaman, MD, who died by suicide, reminds us of the potential for suicide in a complicated patient (in this case, a medical colleague) involving complex systems. Plagued by a review of his care by the medical board (they had forced him to surrender his medical license and allowed the allegations to go public in lieu of further disciplinary proceedings), a subsequent lawsuit and an ultimate attempt by the plaintiff to obtain Dr. Seaman’s personal assets led to his worsening mental health. According to his wife, also a physician, he was getting “more depressed by the insults and assaults on his integrity and professionalism.”
Just before the investigation, he had received a 30-year pin from the American Board of Emergency Medicine for his “dedication to the specialty.” He fell into a deep depression from which he could not recover despite several psychiatric admissions and several medication trials. Along with his depression, he suffered from severe anxiety, a known risk factor for suicide. Dr. Seaman was feeling overwhelmed by the lengthy legal process targeting him as being negligent. He begged his attorney to settle the case, but his insurance carrier would not allow it. According to his wife: “All sense of human worth had been beaten out of him.”
Dr. Seaman had been known as resilient. He could handle complex ED situations, including simultaneously dealing with multiple traumas. He previously had been named in three malpractice lawsuits and had prevailed in each one. But his resilience had greatly diminished, and he became overwhelmed. He previously had, as a physician, been able to step up to the plate of accountability. But now, because of a confluence of depression and anxiety as well as the “insults and assaults on his integrity and professionalism,” he found life to be unbearable with the resulting tragic end.
So how would we as psychiatrists step up to the plate and be accountable when faced with a struggling fellow physician at risk for suicide such as Dr. Seaman?
Be aware of relevant risk factors
In addition to being aware of the usual risk factors for suicide, it would behoove us to also understand how physician suicides differ from suicides among nonphysicians.1 For example, physicians who have died by suicide were far more likely to have experienced job-related problems than nonphysicians, but less likely to have experienced the recent death of a loved one. Also noteworthy is that physicians who end their lives were more often married. In addition, Michael F. Myers, MD, a psychiatrist who has studied physician suicides, noted in the article about Dr. Seaman that struggling physicians are likely to suffer from shame and embarrassment.
Consider shame, burdensomeness, and secrecy
When suicide risk factors are taught to students and professionals, rarely is shame mentioned. Perhaps it is not a common risk factor in the general population, but shame and its cousin, disgrace, are known risk factors that likely apply more to people – such as physicians – who have built a reputation over their careers. One whole chapter is given to disgrace suicides in a book about suicide notes.2 A reputation often is one of the most important factors for professionals, which creates their sense of identity and, by extension, a sense of purpose in life.
When a doctor perceives that his or her reputation is being destroyed, it can produce a profound sense of shame, one of the most powerful of negative emotions.3 Another feature among completed suicides that applies more generally is perceived burdensomeness, according to Thomas E. Joiner Jr., PhD, one of the deep and innovative researchers in the field of suicidology.4 Once a doctor starts feeling that he has been a failure in his professional life and starts ruminating about it, the feelings of failure may generalize to other areas of his life, so that he starts feeling that he is a burden to his spouse. This, then, only increases his shame.
The issue of secrecy also is noteworthy. I was struck reading a book by Dr. Myers on physician suicide by the many spouses and family members who were caught completely unaware of problems when their spouse, a doctor, ended their lives by suicide.5 The doctors hid their problems well, perhaps not wanting to burden their family members. Also, if feelings of shame are an issue, then concealment tends to occur. This concealment of suicidality runs counter to the current narrative among some in the professional community that suicides are preventable (this despite the continuing increase in rates of suicide at the same time that there are increases in mental health services and suicide prevention programs).6
As pointed out in some of the letters quoted in Dr. Myers’s book, those who completed suicide are smart and know how to hide their symptoms well. Although Dr. Seaman’s wife, Linda Seaman, MD, was aware of her husband’s suicidality, when he eventually determined that he was going to end his life, he apparently did not reveal his more serious intention to her. Aside from spouses and family, determined suicide completers often hide their intentions from their clinicians.7
Attempt to obtain collateral information
By being aware of the usual and less-usual risk factors for suicide that our physician colleagues may present with as explained above, we can use strategies for mitigating risk. If secrecy because of shame and embarrassment prevents our physician patient from being fully candid, include the spouse or another significant family member in sessions. While the physician might hide his suicidal intent from both the clinician and spouse, it remains prudent to include the spouse in the treatment plan. Give the spouse a telephone number with which they can contact you if they notice any worrisome change in functioning or behavior. Collateral information often is helpful. (Example: Is the patient not eating, not sleeping, or giving away valued possessions?)
Assess for competency
In Dr. Seaman’s case, it was noted that, with a trial approaching, Dr. Seaman had written in a journal entry that he could not mentally endure a trial. “For me, the stress is overwhelming.” Such a patient, suffering from severe depression, often is unable to properly assist his attorney in his defense. The outpatient psychiatrist can notify the court or one of the attorneys that the competency of the physician patient is questionable (or express a definite opinion of incompetency), and offer the opinion that it would be best to postpone further legal action until the patient is in a more healthy state of mind.
Know when hospitalization is needed
Obviously, the process will go smoother if the admission is voluntary. If the patient physician resists and the psychiatrist believes that the risk for self-harm is too high for the physician patient to remain as an outpatient, try to get a spouse or family member to persuade him to be admitted. An involuntary admission opens up a whole new can of worms and may fracture the therapeutic alliance.
In the end, it might be better to take that risk rather than having a dead patient on your hands. If a hospitalization is necessary, contact the admitting psychiatrist and verbally express your concerns and the reasons why a hospitalization is needed. Ask the inpatient psychiatrist to contact you when a discharge is approaching so that you have an opportunity to ask relevant questions.
For example, during his second psychiatric admission, as the time for discharge was approaching, Dr. Seaman wrote: “I am not well enough for discharge. I am still mentally ill.” Ask the inpatient doctor whether the patient has gotten sufficiently better and he feels confident he can function as an outpatient. If there is a conflicting opinion about the readiness of the patient for discharge, notify the medical director of the service or an administrator about your concerns.
Ask for consultation
At any stage of the process consider getting consultation for a trusted colleague or senior clinician if you are failing to make progress. Sometimes it helps to get the perspective from a fresh pair of eyes or ears.
Get a reality check
Having recounted the inspiring story of Dr. Nuland’s magnificent efforts and joyous success in preserving a life that was on the verge of being lost in the battle against death at the last possible second, I would note the following: Surgeons will tell you that, despite their most heroic efforts and teamwork, there are times when luck runs out and the patient dies on the operating table. Also, small lapses, which all mortals are prone to despite their best efforts at conscientiousness, sometimes can lead to a bad outcome.
Similarly, in psychiatry, no matter how much effort we put into saving a life, sometimes it is all to no avail. Despite all we have learned about suicide and its risk factors, and no matter how much care we take to contain risk, our patients who are determined will find a way of ending their own lives. The vexing problem of suicide seems intractable. A suicide among our patients humbles us, but also hopefully inspires us to keep trying harder to step up to the plate of accountability.
In conclusion, for us physicians, accountability is not a facet, a trait, or even a pursuit, accountability is at the core of who are and how we define ourselves. Accountability is the reason we leap stairs three at time when we are urgently paged. Accountability is the reason malpractice lawsuits cut at the core of our self-image. Accountability allows us to always have hope for a positive outcome, despite overwhelming barriers, and gives our lives a sense of purpose.
For me, in preparing this article, accountability was reviewing and studying physician suicide and then applying best practices in risk assessment after reading the tragic story of Dr. Seaman. I hope I inspire you to do the same in the pursuit of helping our vulnerable patients.
Learning how to care for our complex patients is a never-ending journey.
References
1. Gold KJ. Gen Hosp Psychiatry. 2013 Jan;35(1):45-9.
2. Etkind M. ...Or Not to Be: A Collection of Suicide Notes. New York: Riverhead Books, 1997.
3. Lamia LC. Shame: A concealed, contagious, and dangerous emotion. Psychology Today. 2011 Apr 4.
4. Joiner TE. Why People Die by Suicide. Cambridge: Harvard University Press, 2005.
5. Myers MF. Why Physicians Die by Suicide. 2017.
6. National Institutes of Health. Suicide Prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml.
7. Levy AG et al. JAMA Netw Open. 2019 Aug 14. doi: 10.1001/jamanetworkopen.2019.9277.
Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University, Cleveland, as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.
Recently, Nicolas Badre, MD, challenged psychiatrists who care for patients involved in the legal system. He encouraged “a resurgence of personal accountability and responsibility.”
Using the chronically disenfranchised patients who are repetitiously shuttled between jails and mental hospitals as examples, he pointed out that we psychiatrists must “step up to the plate” and approach clinical problems with the attitude that “the buck stops with me.” As Dr. Badre pointed out, this is especially true when dealing with large, complex systems in which fragmented care exists without clear leadership. This, in turn, allows for a dissolution of accountability.
Accountability is a natural continuation of our training as physicians. We all remember the transition from medical student to intern, the steep learning curve as well as growth and maturation during this changeover. A dramatic transformation occurs over the course of 1 year, from medical students who tag along learning from patients to interns expected to be on their own for endless hours.
Over the course of those hours, we came to the understanding that people’s lives were in our hands. This causes a shift in our identity. This process continues throughout residency and onward in our careers. At some point, it becomes part of our innate identity as physicians or our professional sense of self – which is hard to describe to nonphysicians.
A profound example of a sense of accountability within the medical profession can be found in “How We Live,” a book by National Book Award winner Sherwin B. Nuland, MD. In the book, the late Dr. Nuland recounted how, as a 49-year-old seasoned surgeon working at Yale University, New Haven, Conn., and casually rounding on patients, he heard a frantic message: “Any general surgeon! Any general surgeon! Go immediately to the operating room – immediately – any general surgeon!”
The case involved a 42-year-old wife and mother who had been rushed to the ED after having been found in the community in a profound state of shock. In the ED, it was suspected that the patient was bleeding heavily from a ruptured tubal pregnancy. She was sped rapidly to the operating room with an undetectable blood pressure and a barely palpable pulse. The on-call ob.gyn. had been summoned from home, and he rushed to the operating room along with his department chairman.
Because the woman had lost much of her blood supply, there was no time for crossmatching. The anesthesiologist had placed large-bore intravenous lines and transfused her with O-negative blood (the universal donor blood type) to try maintain some level of blood pressure. Before she could be even fully anesthetized, the ob.gyn had made an incision in her lower abdomen. The bleeding he encountered was profound.
After a quick evaluation, the ob.gyn. realized that the blood was coming from above, not below, leading to the emergency page that Dr. Nuland heard. Dr. Nuland described bounding up the stairs three at a time. He recalled: “[A] very real apprehension had entered my mind. I might encounter a situation that was beyond me, something that I might make even worse, something that would cause me to regret for the rest of my life that I had answered the page’s insistent call instead of simply turning my back on its urgency and slinking off to my car before anyone noticed I was there.”
However, he could not see himself doing such a thing and he rushed up to the operating room because, “walking away from that kind of cry for help would have violated every precept taught me by my life and my training, and every bit of moral sense I had. … . I bear an obsessive preoccupation with accepting responsibility, amounting really to a compulsively neurotic sense of duty.”
And yet in the next few seconds, as he was running to the operating room, he wondered: “Am I about to botch something up? Will I, in one quick stroke of ineptness and fate, bring my career crashing down around my feet and with it my sense of what I am? Am I on my way to destroy an unknown patient and myself at the same time?”
In Dr. Nuland’s thoughts lie the conundrum of responsibility for physicians. Thankfully for Dr. Nuland, he was able to save the day and diagnose a rare case of rupture of an aneurysm of the splenic artery and keep the patient alive. This dramatic story involved a surgical colleague who had to make split-second decisions while a patient’s life hanged in the balance, but the same principles apply to us as psychiatrists.
I would note that, in the above example of the surgical patient, the “system” for saving the woman’s life was well organized and resourced to allow for a comprehensive and time-limited intervention into a life-threatening situation. There was an operating room staffed by various professionals who all had a defined role. It required the leader, Dr. Nuland, to step in, make the right diagnosis, and then issue commands to the identified professionals who all recognized his leadership and were skilled in carrying out their assigned duties. Dr. Nuland clearly was the leader once he took charge.
An outpatient psychiatrist facing a suicidal patient must deal with a different set of challenges, often involving various complex systems as well as multiple barriers. Clinical barriers include available interdisciplinary resources/personnel to assist not only with the critical encounter, but also with extended evaluation and treatment in a secure, well-resourced environment. Administrative barriers can include justifying the optimal treatment plan to payors. Our lethal patients often require both outpatient and inpatient services with sometimes-conflicting agendas. In a recent article, I pointed out some of the vexing problems that arise when communication and collaboration are poor between inpatient and outpatient psychiatrists. In such complex environments, it is less clear what is involved in the outpatient psychiatrist stepping up to the plate and asserting leadership.
An emotionally wrenching article about an emergency physician, Matthew E. Seaman, MD, who died by suicide, reminds us of the potential for suicide in a complicated patient (in this case, a medical colleague) involving complex systems. Plagued by a review of his care by the medical board (they had forced him to surrender his medical license and allowed the allegations to go public in lieu of further disciplinary proceedings), a subsequent lawsuit and an ultimate attempt by the plaintiff to obtain Dr. Seaman’s personal assets led to his worsening mental health. According to his wife, also a physician, he was getting “more depressed by the insults and assaults on his integrity and professionalism.”
Just before the investigation, he had received a 30-year pin from the American Board of Emergency Medicine for his “dedication to the specialty.” He fell into a deep depression from which he could not recover despite several psychiatric admissions and several medication trials. Along with his depression, he suffered from severe anxiety, a known risk factor for suicide. Dr. Seaman was feeling overwhelmed by the lengthy legal process targeting him as being negligent. He begged his attorney to settle the case, but his insurance carrier would not allow it. According to his wife: “All sense of human worth had been beaten out of him.”
Dr. Seaman had been known as resilient. He could handle complex ED situations, including simultaneously dealing with multiple traumas. He previously had been named in three malpractice lawsuits and had prevailed in each one. But his resilience had greatly diminished, and he became overwhelmed. He previously had, as a physician, been able to step up to the plate of accountability. But now, because of a confluence of depression and anxiety as well as the “insults and assaults on his integrity and professionalism,” he found life to be unbearable with the resulting tragic end.
So how would we as psychiatrists step up to the plate and be accountable when faced with a struggling fellow physician at risk for suicide such as Dr. Seaman?
Be aware of relevant risk factors
In addition to being aware of the usual risk factors for suicide, it would behoove us to also understand how physician suicides differ from suicides among nonphysicians.1 For example, physicians who have died by suicide were far more likely to have experienced job-related problems than nonphysicians, but less likely to have experienced the recent death of a loved one. Also noteworthy is that physicians who end their lives were more often married. In addition, Michael F. Myers, MD, a psychiatrist who has studied physician suicides, noted in the article about Dr. Seaman that struggling physicians are likely to suffer from shame and embarrassment.
Consider shame, burdensomeness, and secrecy
When suicide risk factors are taught to students and professionals, rarely is shame mentioned. Perhaps it is not a common risk factor in the general population, but shame and its cousin, disgrace, are known risk factors that likely apply more to people – such as physicians – who have built a reputation over their careers. One whole chapter is given to disgrace suicides in a book about suicide notes.2 A reputation often is one of the most important factors for professionals, which creates their sense of identity and, by extension, a sense of purpose in life.
When a doctor perceives that his or her reputation is being destroyed, it can produce a profound sense of shame, one of the most powerful of negative emotions.3 Another feature among completed suicides that applies more generally is perceived burdensomeness, according to Thomas E. Joiner Jr., PhD, one of the deep and innovative researchers in the field of suicidology.4 Once a doctor starts feeling that he has been a failure in his professional life and starts ruminating about it, the feelings of failure may generalize to other areas of his life, so that he starts feeling that he is a burden to his spouse. This, then, only increases his shame.
The issue of secrecy also is noteworthy. I was struck reading a book by Dr. Myers on physician suicide by the many spouses and family members who were caught completely unaware of problems when their spouse, a doctor, ended their lives by suicide.5 The doctors hid their problems well, perhaps not wanting to burden their family members. Also, if feelings of shame are an issue, then concealment tends to occur. This concealment of suicidality runs counter to the current narrative among some in the professional community that suicides are preventable (this despite the continuing increase in rates of suicide at the same time that there are increases in mental health services and suicide prevention programs).6
As pointed out in some of the letters quoted in Dr. Myers’s book, those who completed suicide are smart and know how to hide their symptoms well. Although Dr. Seaman’s wife, Linda Seaman, MD, was aware of her husband’s suicidality, when he eventually determined that he was going to end his life, he apparently did not reveal his more serious intention to her. Aside from spouses and family, determined suicide completers often hide their intentions from their clinicians.7
Attempt to obtain collateral information
By being aware of the usual and less-usual risk factors for suicide that our physician colleagues may present with as explained above, we can use strategies for mitigating risk. If secrecy because of shame and embarrassment prevents our physician patient from being fully candid, include the spouse or another significant family member in sessions. While the physician might hide his suicidal intent from both the clinician and spouse, it remains prudent to include the spouse in the treatment plan. Give the spouse a telephone number with which they can contact you if they notice any worrisome change in functioning or behavior. Collateral information often is helpful. (Example: Is the patient not eating, not sleeping, or giving away valued possessions?)
Assess for competency
In Dr. Seaman’s case, it was noted that, with a trial approaching, Dr. Seaman had written in a journal entry that he could not mentally endure a trial. “For me, the stress is overwhelming.” Such a patient, suffering from severe depression, often is unable to properly assist his attorney in his defense. The outpatient psychiatrist can notify the court or one of the attorneys that the competency of the physician patient is questionable (or express a definite opinion of incompetency), and offer the opinion that it would be best to postpone further legal action until the patient is in a more healthy state of mind.
Know when hospitalization is needed
Obviously, the process will go smoother if the admission is voluntary. If the patient physician resists and the psychiatrist believes that the risk for self-harm is too high for the physician patient to remain as an outpatient, try to get a spouse or family member to persuade him to be admitted. An involuntary admission opens up a whole new can of worms and may fracture the therapeutic alliance.
In the end, it might be better to take that risk rather than having a dead patient on your hands. If a hospitalization is necessary, contact the admitting psychiatrist and verbally express your concerns and the reasons why a hospitalization is needed. Ask the inpatient psychiatrist to contact you when a discharge is approaching so that you have an opportunity to ask relevant questions.
For example, during his second psychiatric admission, as the time for discharge was approaching, Dr. Seaman wrote: “I am not well enough for discharge. I am still mentally ill.” Ask the inpatient doctor whether the patient has gotten sufficiently better and he feels confident he can function as an outpatient. If there is a conflicting opinion about the readiness of the patient for discharge, notify the medical director of the service or an administrator about your concerns.
Ask for consultation
At any stage of the process consider getting consultation for a trusted colleague or senior clinician if you are failing to make progress. Sometimes it helps to get the perspective from a fresh pair of eyes or ears.
Get a reality check
Having recounted the inspiring story of Dr. Nuland’s magnificent efforts and joyous success in preserving a life that was on the verge of being lost in the battle against death at the last possible second, I would note the following: Surgeons will tell you that, despite their most heroic efforts and teamwork, there are times when luck runs out and the patient dies on the operating table. Also, small lapses, which all mortals are prone to despite their best efforts at conscientiousness, sometimes can lead to a bad outcome.
Similarly, in psychiatry, no matter how much effort we put into saving a life, sometimes it is all to no avail. Despite all we have learned about suicide and its risk factors, and no matter how much care we take to contain risk, our patients who are determined will find a way of ending their own lives. The vexing problem of suicide seems intractable. A suicide among our patients humbles us, but also hopefully inspires us to keep trying harder to step up to the plate of accountability.
In conclusion, for us physicians, accountability is not a facet, a trait, or even a pursuit, accountability is at the core of who are and how we define ourselves. Accountability is the reason we leap stairs three at time when we are urgently paged. Accountability is the reason malpractice lawsuits cut at the core of our self-image. Accountability allows us to always have hope for a positive outcome, despite overwhelming barriers, and gives our lives a sense of purpose.
For me, in preparing this article, accountability was reviewing and studying physician suicide and then applying best practices in risk assessment after reading the tragic story of Dr. Seaman. I hope I inspire you to do the same in the pursuit of helping our vulnerable patients.
Learning how to care for our complex patients is a never-ending journey.
References
1. Gold KJ. Gen Hosp Psychiatry. 2013 Jan;35(1):45-9.
2. Etkind M. ...Or Not to Be: A Collection of Suicide Notes. New York: Riverhead Books, 1997.
3. Lamia LC. Shame: A concealed, contagious, and dangerous emotion. Psychology Today. 2011 Apr 4.
4. Joiner TE. Why People Die by Suicide. Cambridge: Harvard University Press, 2005.
5. Myers MF. Why Physicians Die by Suicide. 2017.
6. National Institutes of Health. Suicide Prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml.
7. Levy AG et al. JAMA Netw Open. 2019 Aug 14. doi: 10.1001/jamanetworkopen.2019.9277.
Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University, Cleveland, as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.