Matt Mahady

Minimally invasive myomectomies dropped nearly 20% following the Food and Drug Administration’s warning to avoid power morcellation in the treatment of uterine fibroids, and minimally invasive hysterectomies fell nearly 6%, according to a time-series analysis of a Florida health system.

But the decline in the use of these techniques varied by subspecialty, with ob.gyns. and minimally invasive gynecologic specialists being more likely to shy away from minimally invasive hysterectomy, while reproductive endocrinologists and minimally invasive gynecologists were the subspecialists most likely not to perform minimally invasive myomectomy after the FDA warning, according to the researchers (Obstet Gynecol. 2015;126:1174-80).

On April 17, 2014, the FDA issued a warning against the use of power morcellators in the surgical treatment of uterine leiomyomas because of the risk of iatrogenic dissemination of malignant tissue in the event of an unsuspected sarcoma. In the aftermath of that warning, many hospitals have banned the use of power morcellators for myoma surgery.

Dr. Kenneth I. Barron of Florida Hospital Medical Group, Orlando, and his colleagues performed a time-series, retrospective analysis of 3,573 patients who underwent a hysterectomy or myomectomy between Aug. 1, 2013, and Dec. 31, 2014, to gauge the impact of the warning on gynecologic practice. They compared surgical interventions performed during the 8 months before the FDA announcement with surgical interventions performed during the 8 months after the announcement, quantifying the proportion of minimally invasive vaginal, laparoscopic, or robotic-assisted surgery cases for each study period.

In the pre-FDA warning arm, 1,694 hysterectomies and 102 myomectomies met inclusion criteria; in the post-FDA warning cohort, 1,690 hysterectomies and 87 myomectomies met inclusion criteria. Subjects were drawn from the surgical case logs of the operating room documentation system of the Florida Hospital System, where the use of power morcellation was suspended immediately following the FDA warning. The analysis included six hospitals and 98 surgeons.

During the study period, minimally invasive myomectomies decreased by 19%. The percentage of myomectomies performed with minimally invasive techniques fell from 62.7% before the FDA warning to 43.7% after (P = .009).

Minimally invasive hysterectomies decreased by 5.8%, dropping from 85.7% to 79.9% (P less than .001) following the FDA warning statement. The drop in minimally invasive hysterectomies were due largely to a 60% drop in laparoscopic supracervical hysterectomies, according to the study.

The findings were subspecialty specific. For instance, the researchers observed that there was an 8.7% decrease in minimally invasive hysterectomies when gynecologic oncology cases were excluded from the sample (P less than .001). Ob.gyns. and minimally invasive gynecologic specialists had the greatest decreases in minimally invasive hysterectomies. Significant decreases were not observed with urogynecologists or oncologists.

In terms of minimally invasive myomectomies, there was a drop among reproductive endocrinologists (P = .006) and minimally invasive gynecologic specialists (P = .01), but not among ob.gyns.

“Caution should be taken in interpreting this data to mean there has been an irreversible backslide toward open surgery,” the researchers wrote. “Our results reflect the immediate change in surgical practice after a policy change, and this might be neutralized once newer techniques for removing myomas and myomatous uteri by minimally invasive measures are adopted more broadly.”

Minimally invasive myomectomies dropped nearly 20% following the Food and Drug Administration’s warning to avoid power morcellation in the treatment of uterine fibroids, and minimally invasive hysterectomies fell nearly 6%, according to a time-series analysis of a Florida health system.

But the decline in the use of these techniques varied by subspecialty, with ob.gyns. and minimally invasive gynecologic specialists being more likely to shy away from minimally invasive hysterectomy, while reproductive endocrinologists and minimally invasive gynecologists were the subspecialists most likely not to perform minimally invasive myomectomy after the FDA warning, according to the researchers (Obstet Gynecol. 2015;126:1174-80).

On April 17, 2014, the FDA issued a warning against the use of power morcellators in the surgical treatment of uterine leiomyomas because of the risk of iatrogenic dissemination of malignant tissue in the event of an unsuspected sarcoma. In the aftermath of that warning, many hospitals have banned the use of power morcellators for myoma surgery.

Dr. Kenneth I. Barron of Florida Hospital Medical Group, Orlando, and his colleagues performed a time-series, retrospective analysis of 3,573 patients who underwent a hysterectomy or myomectomy between Aug. 1, 2013, and Dec. 31, 2014, to gauge the impact of the warning on gynecologic practice. They compared surgical interventions performed during the 8 months before the FDA announcement with surgical interventions performed during the 8 months after the announcement, quantifying the proportion of minimally invasive vaginal, laparoscopic, or robotic-assisted surgery cases for each study period.

In the pre-FDA warning arm, 1,694 hysterectomies and 102 myomectomies met inclusion criteria; in the post-FDA warning cohort, 1,690 hysterectomies and 87 myomectomies met inclusion criteria. Subjects were drawn from the surgical case logs of the operating room documentation system of the Florida Hospital System, where the use of power morcellation was suspended immediately following the FDA warning. The analysis included six hospitals and 98 surgeons.

During the study period, minimally invasive myomectomies decreased by 19%. The percentage of myomectomies performed with minimally invasive techniques fell from 62.7% before the FDA warning to 43.7% after (P = .009).

Minimally invasive hysterectomies decreased by 5.8%, dropping from 85.7% to 79.9% (P less than .001) following the FDA warning statement. The drop in minimally invasive hysterectomies were due largely to a 60% drop in laparoscopic supracervical hysterectomies, according to the study.

The findings were subspecialty specific. For instance, the researchers observed that there was an 8.7% decrease in minimally invasive hysterectomies when gynecologic oncology cases were excluded from the sample (P less than .001). Ob.gyns. and minimally invasive gynecologic specialists had the greatest decreases in minimally invasive hysterectomies. Significant decreases were not observed with urogynecologists or oncologists.

In terms of minimally invasive myomectomies, there was a drop among reproductive endocrinologists (P = .006) and minimally invasive gynecologic specialists (P = .01), but not among ob.gyns.

“Caution should be taken in interpreting this data to mean there has been an irreversible backslide toward open surgery,” the researchers wrote. “Our results reflect the immediate change in surgical practice after a policy change, and this might be neutralized once newer techniques for removing myomas and myomatous uteri by minimally invasive measures are adopted more broadly.”

Minimally invasive myomectomies dropped nearly 20% following the Food and Drug Administration’s warning to avoid power morcellation in the treatment of uterine fibroids, and minimally invasive hysterectomies fell nearly 6%, according to a time-series analysis of a Florida health system.

But the decline in the use of these techniques varied by subspecialty, with ob.gyns. and minimally invasive gynecologic specialists being more likely to shy away from minimally invasive hysterectomy, while reproductive endocrinologists and minimally invasive gynecologists were the subspecialists most likely not to perform minimally invasive myomectomy after the FDA warning, according to the researchers (Obstet Gynecol. 2015;126:1174-80).

On April 17, 2014, the FDA issued a warning against the use of power morcellators in the surgical treatment of uterine leiomyomas because of the risk of iatrogenic dissemination of malignant tissue in the event of an unsuspected sarcoma. In the aftermath of that warning, many hospitals have banned the use of power morcellators for myoma surgery.

Dr. Kenneth I. Barron of Florida Hospital Medical Group, Orlando, and his colleagues performed a time-series, retrospective analysis of 3,573 patients who underwent a hysterectomy or myomectomy between Aug. 1, 2013, and Dec. 31, 2014, to gauge the impact of the warning on gynecologic practice. They compared surgical interventions performed during the 8 months before the FDA announcement with surgical interventions performed during the 8 months after the announcement, quantifying the proportion of minimally invasive vaginal, laparoscopic, or robotic-assisted surgery cases for each study period.

In the pre-FDA warning arm, 1,694 hysterectomies and 102 myomectomies met inclusion criteria; in the post-FDA warning cohort, 1,690 hysterectomies and 87 myomectomies met inclusion criteria. Subjects were drawn from the surgical case logs of the operating room documentation system of the Florida Hospital System, where the use of power morcellation was suspended immediately following the FDA warning. The analysis included six hospitals and 98 surgeons.

During the study period, minimally invasive myomectomies decreased by 19%. The percentage of myomectomies performed with minimally invasive techniques fell from 62.7% before the FDA warning to 43.7% after (P = .009).

Minimally invasive hysterectomies decreased by 5.8%, dropping from 85.7% to 79.9% (P less than .001) following the FDA warning statement. The drop in minimally invasive hysterectomies were due largely to a 60% drop in laparoscopic supracervical hysterectomies, according to the study.

The findings were subspecialty specific. For instance, the researchers observed that there was an 8.7% decrease in minimally invasive hysterectomies when gynecologic oncology cases were excluded from the sample (P less than .001). Ob.gyns. and minimally invasive gynecologic specialists had the greatest decreases in minimally invasive hysterectomies. Significant decreases were not observed with urogynecologists or oncologists.

In terms of minimally invasive myomectomies, there was a drop among reproductive endocrinologists (P = .006) and minimally invasive gynecologic specialists (P = .01), but not among ob.gyns.

“Caution should be taken in interpreting this data to mean there has been an irreversible backslide toward open surgery,” the researchers wrote. “Our results reflect the immediate change in surgical practice after a policy change, and this might be neutralized once newer techniques for removing myomas and myomatous uteri by minimally invasive measures are adopted more broadly.”

A dietitian-led lifestyle modification program helped improve obstructive sleep apnea severity and reduce daytime sleepiness over a 12-month period, Dr. Susanna S. S. Ng reported in Chest.

Dr. Ng and colleagues at the Chinese University of Hong Kong evaluated 104 patients aged 30-80 years with moderate to severe obstructive sleep apnea and a body mass index of at least 25 kg/mg². All patients had an apnea-hypopnea index (AHI) of greater than 15. Patients were randomized to receive a dietitian-led lifestyle modification program or usual care for 12 months.

Patients in the lifestyle modification program met with a dietitian weekly for the first 4 months, then monthly for the rest of the year. They were advised to cut calories by 10%-20% and eat more protein and fiber, meet at least once with an exercise instructor, and engage in 30-minute aerobic exercise sessions 2-3 times per week. Diet advice was adjusted over time as patients lost weight. Patients in the control arm received lifestyle advice at baseline and at 6 months into the study.

Patients in the lifestyle modification arm lost an average of 1.8 kg while their AHI scores dropped 17% and BMI dropped 6%. Control patients lost 0.6 kg, their AHI scores increased 0.6%, and their BMI was reduced by 2% (Chest 2015;148[5]:1193-1203).

Changes in AHI correlated with changes in weight. AHI, first measured 4 months after the initial intensive diet counseling session, was maintained at 12-month follow-up assessment, with no rebound even after the intensive phase of the dietary intervention ended at 4 months. Secondary endpoint data also were encouraging. Reduction rates in daytime sleepiness and a modest improvement in mental health were seen in patients in the lifestyle modification group.

“This study has shown that a lifestyle modification program was an effective treatment modality in the majority of patients with moderate to severe OSA,” Dr. Ng and colleagues said, adding that “obesity and OSA are strongly associated. These new data provided strong evidence that weight reduction should be the core element in the treatment of OSA.”

A dietitian-led lifestyle modification program helped improve obstructive sleep apnea severity and reduce daytime sleepiness over a 12-month period, Dr. Susanna S. S. Ng reported in Chest.

Dr. Ng and colleagues at the Chinese University of Hong Kong evaluated 104 patients aged 30-80 years with moderate to severe obstructive sleep apnea and a body mass index of at least 25 kg/mg². All patients had an apnea-hypopnea index (AHI) of greater than 15. Patients were randomized to receive a dietitian-led lifestyle modification program or usual care for 12 months.

Patients in the lifestyle modification program met with a dietitian weekly for the first 4 months, then monthly for the rest of the year. They were advised to cut calories by 10%-20% and eat more protein and fiber, meet at least once with an exercise instructor, and engage in 30-minute aerobic exercise sessions 2-3 times per week. Diet advice was adjusted over time as patients lost weight. Patients in the control arm received lifestyle advice at baseline and at 6 months into the study.

Patients in the lifestyle modification arm lost an average of 1.8 kg while their AHI scores dropped 17% and BMI dropped 6%. Control patients lost 0.6 kg, their AHI scores increased 0.6%, and their BMI was reduced by 2% (Chest 2015;148[5]:1193-1203).

Changes in AHI correlated with changes in weight. AHI, first measured 4 months after the initial intensive diet counseling session, was maintained at 12-month follow-up assessment, with no rebound even after the intensive phase of the dietary intervention ended at 4 months. Secondary endpoint data also were encouraging. Reduction rates in daytime sleepiness and a modest improvement in mental health were seen in patients in the lifestyle modification group.

“This study has shown that a lifestyle modification program was an effective treatment modality in the majority of patients with moderate to severe OSA,” Dr. Ng and colleagues said, adding that “obesity and OSA are strongly associated. These new data provided strong evidence that weight reduction should be the core element in the treatment of OSA.”

A dietitian-led lifestyle modification program helped improve obstructive sleep apnea severity and reduce daytime sleepiness over a 12-month period, Dr. Susanna S. S. Ng reported in Chest.

Dr. Ng and colleagues at the Chinese University of Hong Kong evaluated 104 patients aged 30-80 years with moderate to severe obstructive sleep apnea and a body mass index of at least 25 kg/mg². All patients had an apnea-hypopnea index (AHI) of greater than 15. Patients were randomized to receive a dietitian-led lifestyle modification program or usual care for 12 months.

Patients in the lifestyle modification program met with a dietitian weekly for the first 4 months, then monthly for the rest of the year. They were advised to cut calories by 10%-20% and eat more protein and fiber, meet at least once with an exercise instructor, and engage in 30-minute aerobic exercise sessions 2-3 times per week. Diet advice was adjusted over time as patients lost weight. Patients in the control arm received lifestyle advice at baseline and at 6 months into the study.

Patients in the lifestyle modification arm lost an average of 1.8 kg while their AHI scores dropped 17% and BMI dropped 6%. Control patients lost 0.6 kg, their AHI scores increased 0.6%, and their BMI was reduced by 2% (Chest 2015;148[5]:1193-1203).

Changes in AHI correlated with changes in weight. AHI, first measured 4 months after the initial intensive diet counseling session, was maintained at 12-month follow-up assessment, with no rebound even after the intensive phase of the dietary intervention ended at 4 months. Secondary endpoint data also were encouraging. Reduction rates in daytime sleepiness and a modest improvement in mental health were seen in patients in the lifestyle modification group.

“This study has shown that a lifestyle modification program was an effective treatment modality in the majority of patients with moderate to severe OSA,” Dr. Ng and colleagues said, adding that “obesity and OSA are strongly associated. These new data provided strong evidence that weight reduction should be the core element in the treatment of OSA.”

Stillbirth rates in the United States plateaued between 2006 and 2012 at 6.05 stillbirths per 1,000 deliveries, reported Marian F. MacDorman, Ph.D., of the Maryland Population Research Center, University of Maryland, College Park, and colleagues.

The study was published online Nov. 9 in Obstetrics and Gynecology.

National Center for Health Statistics data (totaling 50,045 stillbirths and 8,268,441 live births) were employed to evaluate rates of fetal death and live birth in the 2006 and 2012 delivery cohorts. Age-specific stillbirth rates were calculated at 20 weeks’ of gestation or greater. Changes in rates of stillbirths and live births along with changes in percentage distribution among cohorts (segmented by gestational period duration) were assessed. Although only minimal changes were evident in the percent distribution of stillbirths by gestational age from 2006 to 2012, the percent distribution of live births by gestational age demonstrated considerable variation: births at 34-36 weeks’ gestation decreased by 12% from 2006 to 2012, by 10% at 37 weeks, and by 16% at 38 weeks. Conversely, births at 39 weeks’ gestation increased by 17% (Obstet Gynecol. 2015;126:1146-50).

As the aforementioned data reflect, there is broad support among clinicians for reducing nonmedically indicated deliveries before 39 weeks’ of gestation, but critics have suggested that longer pregnancies might lead to increased stillbirth incidence. However, “the lack of change in the prospective stillbirth rate from 2006 to 2012 suggests that preventing nonmedically indicated deliveries before 39 weeks’ of gestation did not increase the stillbirth rate at the national level,” Dr. MacDorman and associates said.

The research team characterized the lack of improvement in U.S. stillbirth outcomes from 2006 to 2012 as “disappointing.” To effectively decrease the stillbirth rate in a statistically significant manner, investigators suggested more concentrated research focused on better targeting of women in the early stages of pregnancy who are at the highest risk for stillbirth, to facilitate more careful monitoring and necessary interventions.

Dr. MacDorman and colleagues did not report any conflicts of interest.

Stillbirth rates in the United States plateaued between 2006 and 2012 at 6.05 stillbirths per 1,000 deliveries, reported Marian F. MacDorman, Ph.D., of the Maryland Population Research Center, University of Maryland, College Park, and colleagues.

The study was published online Nov. 9 in Obstetrics and Gynecology.

National Center for Health Statistics data (totaling 50,045 stillbirths and 8,268,441 live births) were employed to evaluate rates of fetal death and live birth in the 2006 and 2012 delivery cohorts. Age-specific stillbirth rates were calculated at 20 weeks’ of gestation or greater. Changes in rates of stillbirths and live births along with changes in percentage distribution among cohorts (segmented by gestational period duration) were assessed. Although only minimal changes were evident in the percent distribution of stillbirths by gestational age from 2006 to 2012, the percent distribution of live births by gestational age demonstrated considerable variation: births at 34-36 weeks’ gestation decreased by 12% from 2006 to 2012, by 10% at 37 weeks, and by 16% at 38 weeks. Conversely, births at 39 weeks’ gestation increased by 17% (Obstet Gynecol. 2015;126:1146-50).

As the aforementioned data reflect, there is broad support among clinicians for reducing nonmedically indicated deliveries before 39 weeks’ of gestation, but critics have suggested that longer pregnancies might lead to increased stillbirth incidence. However, “the lack of change in the prospective stillbirth rate from 2006 to 2012 suggests that preventing nonmedically indicated deliveries before 39 weeks’ of gestation did not increase the stillbirth rate at the national level,” Dr. MacDorman and associates said.

The research team characterized the lack of improvement in U.S. stillbirth outcomes from 2006 to 2012 as “disappointing.” To effectively decrease the stillbirth rate in a statistically significant manner, investigators suggested more concentrated research focused on better targeting of women in the early stages of pregnancy who are at the highest risk for stillbirth, to facilitate more careful monitoring and necessary interventions.

Dr. MacDorman and colleagues did not report any conflicts of interest.

Stillbirth rates in the United States plateaued between 2006 and 2012 at 6.05 stillbirths per 1,000 deliveries, reported Marian F. MacDorman, Ph.D., of the Maryland Population Research Center, University of Maryland, College Park, and colleagues.

The study was published online Nov. 9 in Obstetrics and Gynecology.

National Center for Health Statistics data (totaling 50,045 stillbirths and 8,268,441 live births) were employed to evaluate rates of fetal death and live birth in the 2006 and 2012 delivery cohorts. Age-specific stillbirth rates were calculated at 20 weeks’ of gestation or greater. Changes in rates of stillbirths and live births along with changes in percentage distribution among cohorts (segmented by gestational period duration) were assessed. Although only minimal changes were evident in the percent distribution of stillbirths by gestational age from 2006 to 2012, the percent distribution of live births by gestational age demonstrated considerable variation: births at 34-36 weeks’ gestation decreased by 12% from 2006 to 2012, by 10% at 37 weeks, and by 16% at 38 weeks. Conversely, births at 39 weeks’ gestation increased by 17% (Obstet Gynecol. 2015;126:1146-50).

As the aforementioned data reflect, there is broad support among clinicians for reducing nonmedically indicated deliveries before 39 weeks’ of gestation, but critics have suggested that longer pregnancies might lead to increased stillbirth incidence. However, “the lack of change in the prospective stillbirth rate from 2006 to 2012 suggests that preventing nonmedically indicated deliveries before 39 weeks’ of gestation did not increase the stillbirth rate at the national level,” Dr. MacDorman and associates said.

The research team characterized the lack of improvement in U.S. stillbirth outcomes from 2006 to 2012 as “disappointing.” To effectively decrease the stillbirth rate in a statistically significant manner, investigators suggested more concentrated research focused on better targeting of women in the early stages of pregnancy who are at the highest risk for stillbirth, to facilitate more careful monitoring and necessary interventions.

Dr. MacDorman and colleagues did not report any conflicts of interest.

Enhanced gonorrhea susceptibility to third-generation cephalosporin-class antibiotic agents such as injectable ceftriaxone and oral cefixime may have been temporary, according to a retrospective analysis published in the Nov. 3 issue of JAMA.

The findings of Dr. Robert D. Kirkcaldy at the Centers for Disease Control and Prevention’s Division of STD Prevention and his colleagues suggest that treatment-resistant gonorrhea is a challenge that clinicians will likely continue to confront (JAMA. 2015 Nov 3;314[17]:1869-71).

Centers for Disease Control and Prevention

In 2012, the CDC updated its guidelines to recommend ceftriaxone-based combination therapy as the lone preferred treatment for gonorrhea, a common sexually transmitted disease. Subsequently, an apparent “halting of drift toward resistance” was observed by researchers from 2011 to 2013.

However, the 2014 numbers may indicate that the drift toward resistance has resumed. Utilizing data derived from the CDC’s Gonococcal Isolate Surveillance Project – a program that monitors antimicrobial susceptibility in men with gonorrhea treated at U.S. public clinics – investigators tracked recent gonococcal cephalosporin-susceptibility trends by measuring ceftriaxone and cefixime concentrations in 51,144 urethral isolates of consecutive men presenting with gonorrhea over an 8-year period (2006-2014).

Isolates with ceftriaxone minimum inhibitory concentrations of 0.125 mcg/mL or greater or cefixime minimum inhibitory concentrations of 0.25 mcg/mL or greater were defined as exhibiting reduced susceptibility.

Findings indicated that the percentage of isolates with reduced cefixime susceptibility increased from 0.1% in 2006 to 1.4% in 2011, then decreased to 0.4% in 2013 (P less than .001). In 2014, however, the percentage of isolates doubled to 0.8%.

Those trends were mirrored in the ceftriaxone concentration numbers, which also demonstrated a statistically significant elevation in minimum inhibitory concentrations from 2006 to 2011 (P less than .001), a decline from 2011 to 2013 (P less than .001), followed by a sharp increase from 2013 to 2014 (P = .13).

“The 2014 data suggest that improvements in susceptibility may be short lived,” the study authors noted. “The increased prevalence of reduced cefixime susceptibility in 2014 highlights the need to maintain surveillance, search for new therapeutics, and ensure that gonorrhea is treated according to the CDC’s guidelines.”

The CDC funds the Gonococcal Isolate Surveillance Project. Dr. Kirkcaldy reported no conflicts of interest.

Enhanced gonorrhea susceptibility to third-generation cephalosporin-class antibiotic agents such as injectable ceftriaxone and oral cefixime may have been temporary, according to a retrospective analysis published in the Nov. 3 issue of JAMA.

The findings of Dr. Robert D. Kirkcaldy at the Centers for Disease Control and Prevention’s Division of STD Prevention and his colleagues suggest that treatment-resistant gonorrhea is a challenge that clinicians will likely continue to confront (JAMA. 2015 Nov 3;314[17]:1869-71).

Centers for Disease Control and Prevention

In 2012, the CDC updated its guidelines to recommend ceftriaxone-based combination therapy as the lone preferred treatment for gonorrhea, a common sexually transmitted disease. Subsequently, an apparent “halting of drift toward resistance” was observed by researchers from 2011 to 2013.

However, the 2014 numbers may indicate that the drift toward resistance has resumed. Utilizing data derived from the CDC’s Gonococcal Isolate Surveillance Project – a program that monitors antimicrobial susceptibility in men with gonorrhea treated at U.S. public clinics – investigators tracked recent gonococcal cephalosporin-susceptibility trends by measuring ceftriaxone and cefixime concentrations in 51,144 urethral isolates of consecutive men presenting with gonorrhea over an 8-year period (2006-2014).

Isolates with ceftriaxone minimum inhibitory concentrations of 0.125 mcg/mL or greater or cefixime minimum inhibitory concentrations of 0.25 mcg/mL or greater were defined as exhibiting reduced susceptibility.

Findings indicated that the percentage of isolates with reduced cefixime susceptibility increased from 0.1% in 2006 to 1.4% in 2011, then decreased to 0.4% in 2013 (P less than .001). In 2014, however, the percentage of isolates doubled to 0.8%.

Those trends were mirrored in the ceftriaxone concentration numbers, which also demonstrated a statistically significant elevation in minimum inhibitory concentrations from 2006 to 2011 (P less than .001), a decline from 2011 to 2013 (P less than .001), followed by a sharp increase from 2013 to 2014 (P = .13).

“The 2014 data suggest that improvements in susceptibility may be short lived,” the study authors noted. “The increased prevalence of reduced cefixime susceptibility in 2014 highlights the need to maintain surveillance, search for new therapeutics, and ensure that gonorrhea is treated according to the CDC’s guidelines.”

The CDC funds the Gonococcal Isolate Surveillance Project. Dr. Kirkcaldy reported no conflicts of interest.

Enhanced gonorrhea susceptibility to third-generation cephalosporin-class antibiotic agents such as injectable ceftriaxone and oral cefixime may have been temporary, according to a retrospective analysis published in the Nov. 3 issue of JAMA.

The findings of Dr. Robert D. Kirkcaldy at the Centers for Disease Control and Prevention’s Division of STD Prevention and his colleagues suggest that treatment-resistant gonorrhea is a challenge that clinicians will likely continue to confront (JAMA. 2015 Nov 3;314[17]:1869-71).

Centers for Disease Control and Prevention

In 2012, the CDC updated its guidelines to recommend ceftriaxone-based combination therapy as the lone preferred treatment for gonorrhea, a common sexually transmitted disease. Subsequently, an apparent “halting of drift toward resistance” was observed by researchers from 2011 to 2013.

However, the 2014 numbers may indicate that the drift toward resistance has resumed. Utilizing data derived from the CDC’s Gonococcal Isolate Surveillance Project – a program that monitors antimicrobial susceptibility in men with gonorrhea treated at U.S. public clinics – investigators tracked recent gonococcal cephalosporin-susceptibility trends by measuring ceftriaxone and cefixime concentrations in 51,144 urethral isolates of consecutive men presenting with gonorrhea over an 8-year period (2006-2014).

Isolates with ceftriaxone minimum inhibitory concentrations of 0.125 mcg/mL or greater or cefixime minimum inhibitory concentrations of 0.25 mcg/mL or greater were defined as exhibiting reduced susceptibility.

Findings indicated that the percentage of isolates with reduced cefixime susceptibility increased from 0.1% in 2006 to 1.4% in 2011, then decreased to 0.4% in 2013 (P less than .001). In 2014, however, the percentage of isolates doubled to 0.8%.

Those trends were mirrored in the ceftriaxone concentration numbers, which also demonstrated a statistically significant elevation in minimum inhibitory concentrations from 2006 to 2011 (P less than .001), a decline from 2011 to 2013 (P less than .001), followed by a sharp increase from 2013 to 2014 (P = .13).

“The 2014 data suggest that improvements in susceptibility may be short lived,” the study authors noted. “The increased prevalence of reduced cefixime susceptibility in 2014 highlights the need to maintain surveillance, search for new therapeutics, and ensure that gonorrhea is treated according to the CDC’s guidelines.”

The CDC funds the Gonococcal Isolate Surveillance Project. Dr. Kirkcaldy reported no conflicts of interest.

Danish researchers reported a slightly heightened vulnerability to child-onset epilepsy in infants who contract pertussis, which strikes an estimated 16 million children globally on an annual basis, in a study published in the Nov. 3 issue of JAMA.

Dr. Morten Olsen of the department of clinical epidemiology, Aarhus (Denmark) University Hospital, and his colleagues collected data from population-based medical registries encompassing every hospital and citizen in Denmark (roughly 5.6 million people) to catalogue all patients presenting with pertussis born between 1978 and 2011. Subjects were tracked for a maximum of 15 years, beginning with their respective initial pertussis diagnosis dates, up until their first-time epilepsy diagnosis, emigration, death, or Dec. 31, 2011 (whichever occurred first). To establish a control cohort, the national Danish Civil Registration System database was mined to identify and select 10 age- and sex-matched individuals from the general population for each patient with pertussis (JAMA. 2015 Nov 3;314[17]:1844-9).

©Jacopo Werther/Wikimedia Commons/ Creative Commons Attribution 2.0

Of the 4,700 identified pertussis patients (53% of whom were younger than 6 months of age when initially diagnosed with pertussis), 90 (2%) subsequently developed epilepsy (incidence rate, 1.56/1,000 person-years; 95% confidence interval, 1.55-1.57), compared with 511 (0.1%) in the 47,000-subject comparison arm (incidence rate, 0.88/1,000 person-years; 95% CI, 0.88-0.88). Pertussis patients were found to have a cumulative epilepsy incidence rate of 1.7% (95% CI, 1.4%-2.1%) at age 10 years; cumulative epilepsy incidence at age 10 years was 0.9% (95% CI, 0.8%-1%) in the control population. Moreover, epilepsy risk was demonstrated to be dependent on age of pertussis onset; a pertussis diagnosis was not associated with increased epilepsy risk in patients over the age of 3 years (hazard ratio, 1; 95% CI, 0.5-1.8).

According to study investigators, one explanation for the role that pertussis could potentially play in the pathophysiology of epilepsy may center on the occurrence of hypoxic brain damage resulting from severe pertussis-related coughing, “perhaps via increased intrathoracic and intra-abdominal pressure and central nervous system hemorrhages.”

The study was funded by the Program for Clinical Research Infrastructure established by the Lundbeck Foundation and the Novo Nordisk Foundation. The department of clinical epidemiology, Aarhus (Denmark) University Hospital, receives funding for other studies from companies in the form of research grants.

Danish researchers reported a slightly heightened vulnerability to child-onset epilepsy in infants who contract pertussis, which strikes an estimated 16 million children globally on an annual basis, in a study published in the Nov. 3 issue of JAMA.

Dr. Morten Olsen of the department of clinical epidemiology, Aarhus (Denmark) University Hospital, and his colleagues collected data from population-based medical registries encompassing every hospital and citizen in Denmark (roughly 5.6 million people) to catalogue all patients presenting with pertussis born between 1978 and 2011. Subjects were tracked for a maximum of 15 years, beginning with their respective initial pertussis diagnosis dates, up until their first-time epilepsy diagnosis, emigration, death, or Dec. 31, 2011 (whichever occurred first). To establish a control cohort, the national Danish Civil Registration System database was mined to identify and select 10 age- and sex-matched individuals from the general population for each patient with pertussis (JAMA. 2015 Nov 3;314[17]:1844-9).

©Jacopo Werther/Wikimedia Commons/ Creative Commons Attribution 2.0

Of the 4,700 identified pertussis patients (53% of whom were younger than 6 months of age when initially diagnosed with pertussis), 90 (2%) subsequently developed epilepsy (incidence rate, 1.56/1,000 person-years; 95% confidence interval, 1.55-1.57), compared with 511 (0.1%) in the 47,000-subject comparison arm (incidence rate, 0.88/1,000 person-years; 95% CI, 0.88-0.88). Pertussis patients were found to have a cumulative epilepsy incidence rate of 1.7% (95% CI, 1.4%-2.1%) at age 10 years; cumulative epilepsy incidence at age 10 years was 0.9% (95% CI, 0.8%-1%) in the control population. Moreover, epilepsy risk was demonstrated to be dependent on age of pertussis onset; a pertussis diagnosis was not associated with increased epilepsy risk in patients over the age of 3 years (hazard ratio, 1; 95% CI, 0.5-1.8).

According to study investigators, one explanation for the role that pertussis could potentially play in the pathophysiology of epilepsy may center on the occurrence of hypoxic brain damage resulting from severe pertussis-related coughing, “perhaps via increased intrathoracic and intra-abdominal pressure and central nervous system hemorrhages.”

The study was funded by the Program for Clinical Research Infrastructure established by the Lundbeck Foundation and the Novo Nordisk Foundation. The department of clinical epidemiology, Aarhus (Denmark) University Hospital, receives funding for other studies from companies in the form of research grants.

Danish researchers reported a slightly heightened vulnerability to child-onset epilepsy in infants who contract pertussis, which strikes an estimated 16 million children globally on an annual basis, in a study published in the Nov. 3 issue of JAMA.

Dr. Morten Olsen of the department of clinical epidemiology, Aarhus (Denmark) University Hospital, and his colleagues collected data from population-based medical registries encompassing every hospital and citizen in Denmark (roughly 5.6 million people) to catalogue all patients presenting with pertussis born between 1978 and 2011. Subjects were tracked for a maximum of 15 years, beginning with their respective initial pertussis diagnosis dates, up until their first-time epilepsy diagnosis, emigration, death, or Dec. 31, 2011 (whichever occurred first). To establish a control cohort, the national Danish Civil Registration System database was mined to identify and select 10 age- and sex-matched individuals from the general population for each patient with pertussis (JAMA. 2015 Nov 3;314[17]:1844-9).

©Jacopo Werther/Wikimedia Commons/ Creative Commons Attribution 2.0

Of the 4,700 identified pertussis patients (53% of whom were younger than 6 months of age when initially diagnosed with pertussis), 90 (2%) subsequently developed epilepsy (incidence rate, 1.56/1,000 person-years; 95% confidence interval, 1.55-1.57), compared with 511 (0.1%) in the 47,000-subject comparison arm (incidence rate, 0.88/1,000 person-years; 95% CI, 0.88-0.88). Pertussis patients were found to have a cumulative epilepsy incidence rate of 1.7% (95% CI, 1.4%-2.1%) at age 10 years; cumulative epilepsy incidence at age 10 years was 0.9% (95% CI, 0.8%-1%) in the control population. Moreover, epilepsy risk was demonstrated to be dependent on age of pertussis onset; a pertussis diagnosis was not associated with increased epilepsy risk in patients over the age of 3 years (hazard ratio, 1; 95% CI, 0.5-1.8).

According to study investigators, one explanation for the role that pertussis could potentially play in the pathophysiology of epilepsy may center on the occurrence of hypoxic brain damage resulting from severe pertussis-related coughing, “perhaps via increased intrathoracic and intra-abdominal pressure and central nervous system hemorrhages.”

The study was funded by the Program for Clinical Research Infrastructure established by the Lundbeck Foundation and the Novo Nordisk Foundation. The department of clinical epidemiology, Aarhus (Denmark) University Hospital, receives funding for other studies from companies in the form of research grants.

According to a pair of studies published online Oct. 29 in the Journal of Infectious Diseases, statins – a class of drugs widely utilized by older adults to reduce cholesterol – may have the unintended consequence of reducing immunotherapeutic response to and effectiveness of influenza vaccination.

In a post-hoc analysis (J Infect Dis. 2015 Oct 29. doi: 10.1093/infdis/jiv456), Dr. Steven Black of Cincinnati Children’s Hospital Medical Center and colleagues derived data from an international, multisite, randomized, controlled, influenza vaccine clinical trial population of 6,961 subjects over the age of 65. At 3 weeks post vaccination, the researchers measured the level of antibodies to flu vaccine strains in the blood of both statin and non–statin taking participants. The investigators discovered that hemagglutination-inhibiting geometric mean titers to influenza A (H1NI), A (H3N2), and B strains were 38% (95% confidence interval, 27%-50%), 67% (95% CI, 54%-80%) and 38% (95% CI, 28%-29%) lower, respectively, in the statin therapy arm as compared with the non–statin therapy cohort. The effect was most dramatic in patients on synthetic (as opposed to natural, fermentation-derived) statin treatment regimens.

©Wavebreakmedia/thinkstockphotos.com

“Apparently, statins interfere with the response to influenza vaccine and lower the immune response, and this would seem to also result in a lower effectiveness of influenza vaccines,” Dr. Black and his colleagues wrote. Potential mitigation strategies for statin-induced immunosuppression suggested by the research team include preferential use of high-dose or adjuvanted vaccines.

In addition, a separate retrospective investigation (J Infect Dis. 2015 Oct 29. doi: 10.1093/infdis/jiv457.) tracking 137,488 patients from a Georgia managed care organization database over nine flu seasons (from 2002 to 2011) also generated data implying a connection between statin use and compromised influenza vaccine efficacy and immune response. Dr. Saad Omer of the Emory Vaccine Center at Emory University in Atlanta and his colleagues analyzed the impact of statins on influenza vaccine efficacy against medically attended acute respiratory illness (MAARI). MAARI incidence is routinely employed as an influenza impact marker, although not all MAARI incidence is influenza related.

The Emory University research team found that influenza vaccine effectiveness against MAARI was decreased in statin users, compared with nonusers during periods of local (14.1% vs. 22.9%; mean difference, 11.4%; 95% CI, −1.7%-26.1%) and widespread (12.6% vs. 26.2%; mean difference, 18.4%; 95% CI, 2.9%-36.2%) influenza circulation. “Even after adjustment for several covariates … the observed reduction in influenza vaccine effectiveness among statin users remained statistically significant for periods of widespread influenza circulation with a nonsignificant trend toward reduced vaccine effectiveness during periods of local circulation, as well,” noted Dr. Omer and his coauthors. Said results, wrote the researchers, “have potential implications for clinical guidelines regarding statin use around the time of routine vaccinations.”

Dr. Black is a consultant for Novartis Vaccines, GSK, Takeda Vaccines, Protein Sciences, and the World Health Organization. His coauthors – Dr. Uwe Nicolay, Dr. Giuseppe Del Giudice, and Dr. Rino Rappuoli – are employees of Novartis Vaccines.

Novartis Vaccines funded the post-hoc analysis conducted by Dr. Black and his colleagues, as well as the original clinical trial that developed the data utilized for the analysis. Dr. Omer and his colleagues were funded by Emory University and the National Institute of Allergy and Infectious Diseases and reported no relevant disclosures.

According to a pair of studies published online Oct. 29 in the Journal of Infectious Diseases, statins – a class of drugs widely utilized by older adults to reduce cholesterol – may have the unintended consequence of reducing immunotherapeutic response to and effectiveness of influenza vaccination.

In a post-hoc analysis (J Infect Dis. 2015 Oct 29. doi: 10.1093/infdis/jiv456), Dr. Steven Black of Cincinnati Children’s Hospital Medical Center and colleagues derived data from an international, multisite, randomized, controlled, influenza vaccine clinical trial population of 6,961 subjects over the age of 65. At 3 weeks post vaccination, the researchers measured the level of antibodies to flu vaccine strains in the blood of both statin and non–statin taking participants. The investigators discovered that hemagglutination-inhibiting geometric mean titers to influenza A (H1NI), A (H3N2), and B strains were 38% (95% confidence interval, 27%-50%), 67% (95% CI, 54%-80%) and 38% (95% CI, 28%-29%) lower, respectively, in the statin therapy arm as compared with the non–statin therapy cohort. The effect was most dramatic in patients on synthetic (as opposed to natural, fermentation-derived) statin treatment regimens.

©Wavebreakmedia/thinkstockphotos.com

“Apparently, statins interfere with the response to influenza vaccine and lower the immune response, and this would seem to also result in a lower effectiveness of influenza vaccines,” Dr. Black and his colleagues wrote. Potential mitigation strategies for statin-induced immunosuppression suggested by the research team include preferential use of high-dose or adjuvanted vaccines.

In addition, a separate retrospective investigation (J Infect Dis. 2015 Oct 29. doi: 10.1093/infdis/jiv457.) tracking 137,488 patients from a Georgia managed care organization database over nine flu seasons (from 2002 to 2011) also generated data implying a connection between statin use and compromised influenza vaccine efficacy and immune response. Dr. Saad Omer of the Emory Vaccine Center at Emory University in Atlanta and his colleagues analyzed the impact of statins on influenza vaccine efficacy against medically attended acute respiratory illness (MAARI). MAARI incidence is routinely employed as an influenza impact marker, although not all MAARI incidence is influenza related.

The Emory University research team found that influenza vaccine effectiveness against MAARI was decreased in statin users, compared with nonusers during periods of local (14.1% vs. 22.9%; mean difference, 11.4%; 95% CI, −1.7%-26.1%) and widespread (12.6% vs. 26.2%; mean difference, 18.4%; 95% CI, 2.9%-36.2%) influenza circulation. “Even after adjustment for several covariates … the observed reduction in influenza vaccine effectiveness among statin users remained statistically significant for periods of widespread influenza circulation with a nonsignificant trend toward reduced vaccine effectiveness during periods of local circulation, as well,” noted Dr. Omer and his coauthors. Said results, wrote the researchers, “have potential implications for clinical guidelines regarding statin use around the time of routine vaccinations.”

Dr. Black is a consultant for Novartis Vaccines, GSK, Takeda Vaccines, Protein Sciences, and the World Health Organization. His coauthors – Dr. Uwe Nicolay, Dr. Giuseppe Del Giudice, and Dr. Rino Rappuoli – are employees of Novartis Vaccines.

Novartis Vaccines funded the post-hoc analysis conducted by Dr. Black and his colleagues, as well as the original clinical trial that developed the data utilized for the analysis. Dr. Omer and his colleagues were funded by Emory University and the National Institute of Allergy and Infectious Diseases and reported no relevant disclosures.

According to a pair of studies published online Oct. 29 in the Journal of Infectious Diseases, statins – a class of drugs widely utilized by older adults to reduce cholesterol – may have the unintended consequence of reducing immunotherapeutic response to and effectiveness of influenza vaccination.

In a post-hoc analysis (J Infect Dis. 2015 Oct 29. doi: 10.1093/infdis/jiv456), Dr. Steven Black of Cincinnati Children’s Hospital Medical Center and colleagues derived data from an international, multisite, randomized, controlled, influenza vaccine clinical trial population of 6,961 subjects over the age of 65. At 3 weeks post vaccination, the researchers measured the level of antibodies to flu vaccine strains in the blood of both statin and non–statin taking participants. The investigators discovered that hemagglutination-inhibiting geometric mean titers to influenza A (H1NI), A (H3N2), and B strains were 38% (95% confidence interval, 27%-50%), 67% (95% CI, 54%-80%) and 38% (95% CI, 28%-29%) lower, respectively, in the statin therapy arm as compared with the non–statin therapy cohort. The effect was most dramatic in patients on synthetic (as opposed to natural, fermentation-derived) statin treatment regimens.

©Wavebreakmedia/thinkstockphotos.com

“Apparently, statins interfere with the response to influenza vaccine and lower the immune response, and this would seem to also result in a lower effectiveness of influenza vaccines,” Dr. Black and his colleagues wrote. Potential mitigation strategies for statin-induced immunosuppression suggested by the research team include preferential use of high-dose or adjuvanted vaccines.

In addition, a separate retrospective investigation (J Infect Dis. 2015 Oct 29. doi: 10.1093/infdis/jiv457.) tracking 137,488 patients from a Georgia managed care organization database over nine flu seasons (from 2002 to 2011) also generated data implying a connection between statin use and compromised influenza vaccine efficacy and immune response. Dr. Saad Omer of the Emory Vaccine Center at Emory University in Atlanta and his colleagues analyzed the impact of statins on influenza vaccine efficacy against medically attended acute respiratory illness (MAARI). MAARI incidence is routinely employed as an influenza impact marker, although not all MAARI incidence is influenza related.

The Emory University research team found that influenza vaccine effectiveness against MAARI was decreased in statin users, compared with nonusers during periods of local (14.1% vs. 22.9%; mean difference, 11.4%; 95% CI, −1.7%-26.1%) and widespread (12.6% vs. 26.2%; mean difference, 18.4%; 95% CI, 2.9%-36.2%) influenza circulation. “Even after adjustment for several covariates … the observed reduction in influenza vaccine effectiveness among statin users remained statistically significant for periods of widespread influenza circulation with a nonsignificant trend toward reduced vaccine effectiveness during periods of local circulation, as well,” noted Dr. Omer and his coauthors. Said results, wrote the researchers, “have potential implications for clinical guidelines regarding statin use around the time of routine vaccinations.”

Dr. Black is a consultant for Novartis Vaccines, GSK, Takeda Vaccines, Protein Sciences, and the World Health Organization. His coauthors – Dr. Uwe Nicolay, Dr. Giuseppe Del Giudice, and Dr. Rino Rappuoli – are employees of Novartis Vaccines.

Novartis Vaccines funded the post-hoc analysis conducted by Dr. Black and his colleagues, as well as the original clinical trial that developed the data utilized for the analysis. Dr. Omer and his colleagues were funded by Emory University and the National Institute of Allergy and Infectious Diseases and reported no relevant disclosures.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.