Computational psychiatry is an emerging field in which artificial intelligence and machine learning are used to find hidden patterns in big data to better understand, predict, and treat mental illness. The field uses various mathematical models to predict the dependent variable y based on the independent variable x. One application of analytics in medicine was the Framingham Heart Study, which used multivariate logistic regression to predict heart disease.¹

Analytics could be used to predict the number of bad outcomes associated with different psychiatric medications over time. To demonstrate this, I examined a select data set of 8 psychiatric medications (aripiprazole, ziprasidone, risperidone, olanzapine, sertraline, trazodone, amitriptyline, and lithium) accounting for 59,827 bad outcomes during a 15-year period as reported by U.S. poison control centers,² and plotted these on the y-axis.

When considering the independent variable to use as a predictor for bad outcomes, I used a composite index derived with the relative lethality (RL) equation, f(x) = 310x /LD50, where x is the daily dose of a medication prescribed for 30 days, and LD50 is the rat oral lethal dose 50.³ I plotted the RL of the 8 medications on the x-axis. Then I attempted to find a mathematical function that would best fit the x and y intersection points (Figure 1). I used the Excel data analysis pack to run a logarithmic regression model (Figure 2).

The model predicts that medications with a lower RL will have fewer serious outcomes, including mortality. The coefficient of determination r² = 0.968, which indicates that 97% of the variation in serious outcomes is attributed to variation in RL, and 3% may be due to other factors, such as the poor quality of U.S. poison control data. This is a very significant correlation, and the causality is self-evident.

Continued to: The distribution of bad outcomes in the model was...

The distribution of bad outcomes in the model was: 1,446 for aripiprazole (RL = 9.76%), 2,387 for ziprasidone (RL = 24.80%), 5,352 for risperidone (RL = 32.63%), 5,798 for olanzapine (RL = 35.03%), 6,120 for sertraline (RL = 46.72%), 10,343 for trazodone (RL = 269.57%), 13,345 for amitriptyline (RL = 387.50%), and 15,036 for lithium (RL = 1,062.86%). The regression equation is: serious outcomes = –5,677.7 + 3,015.7 × ln (RL).

Some doctors may argue that such a data set is too small to make a meaningful model. However, the number of possible ways of ranking the drugs by bad outcomes is 8! = 40,320, so the probability of guessing the right sequence is P = .000024801. To appreciate how small this probability is, imagine trying to find a person of interest in half a football stadium on Superbowl Sunday.

The RL composite index correctly predicted the ranking order of serious outcomes for the 8 medications and may be useful for finding such outcomes in any drug class. For example, with angiotensin-converting enzyme inhibitors (n = 11) the number of possible combinations is 11! = 39,916,800. The probability of guessing the right sequence is like finding a person of interest in Poland. The model predicts the following decreasing sequence: 1) captopril, 2) fosinopril, 3) quinapril, 4) benazepril, 5) enalapril, 6) lisinopril, 7) moexipril, 8) perindopril, 9) cilazapril, 10) ramipril, 11) trandolapril. The predicted number of bad outcomes is highest for captopril, and lowest for trandolapril. The usefulness of the machine learning algorithm becomes immediately apparent.

Data can inform prescribing

Analytics can expose a critical flaw in the academic psychiatry paradigm for prescribing medications. For example, some doctors may regard lithium as the “gold standard” for treating certain mood disorders, but there is evidence that olanzapine is “significantly more effective than lithium in preventing recurrence of manic and mixed episodes.”⁴ Olanzapine is also 30 times safer than lithium based on its RL index, and had 9,238 fewer bad outcomes based on the 15-year data from U.S. poison control centers.² A patient who intends to attempt suicide would easily be able to find the lethal dose of lithium from a “suicide” web site, and would quickly be able to figure out that the monthly amount of lithium his or her psychiatrist prescribed, would exceed the lethal dose.

When academia and reality collide, the use of analytics will have the final word by preventing suicide in the short term and reducing the number of bad outcomes in the long term. The irony of data science is that mathematical models can find optimal solutions to complex problems in a fraction of a second, but it may take years for a paradigm shift.

Computational psychiatry is an emerging field in which artificial intelligence and machine learning are used to find hidden patterns in big data to better understand, predict, and treat mental illness. The field uses various mathematical models to predict the dependent variable y based on the independent variable x. One application of analytics in medicine was the Framingham Heart Study, which used multivariate logistic regression to predict heart disease.¹

Analytics could be used to predict the number of bad outcomes associated with different psychiatric medications over time. To demonstrate this, I examined a select data set of 8 psychiatric medications (aripiprazole, ziprasidone, risperidone, olanzapine, sertraline, trazodone, amitriptyline, and lithium) accounting for 59,827 bad outcomes during a 15-year period as reported by U.S. poison control centers,² and plotted these on the y-axis.

When considering the independent variable to use as a predictor for bad outcomes, I used a composite index derived with the relative lethality (RL) equation, f(x) = 310x /LD50, where x is the daily dose of a medication prescribed for 30 days, and LD50 is the rat oral lethal dose 50.³ I plotted the RL of the 8 medications on the x-axis. Then I attempted to find a mathematical function that would best fit the x and y intersection points (Figure 1). I used the Excel data analysis pack to run a logarithmic regression model (Figure 2).

The model predicts that medications with a lower RL will have fewer serious outcomes, including mortality. The coefficient of determination r² = 0.968, which indicates that 97% of the variation in serious outcomes is attributed to variation in RL, and 3% may be due to other factors, such as the poor quality of U.S. poison control data. This is a very significant correlation, and the causality is self-evident.

Continued to: The distribution of bad outcomes in the model was...

The distribution of bad outcomes in the model was: 1,446 for aripiprazole (RL = 9.76%), 2,387 for ziprasidone (RL = 24.80%), 5,352 for risperidone (RL = 32.63%), 5,798 for olanzapine (RL = 35.03%), 6,120 for sertraline (RL = 46.72%), 10,343 for trazodone (RL = 269.57%), 13,345 for amitriptyline (RL = 387.50%), and 15,036 for lithium (RL = 1,062.86%). The regression equation is: serious outcomes = –5,677.7 + 3,015.7 × ln (RL).

Some doctors may argue that such a data set is too small to make a meaningful model. However, the number of possible ways of ranking the drugs by bad outcomes is 8! = 40,320, so the probability of guessing the right sequence is P = .000024801. To appreciate how small this probability is, imagine trying to find a person of interest in half a football stadium on Superbowl Sunday.

The RL composite index correctly predicted the ranking order of serious outcomes for the 8 medications and may be useful for finding such outcomes in any drug class. For example, with angiotensin-converting enzyme inhibitors (n = 11) the number of possible combinations is 11! = 39,916,800. The probability of guessing the right sequence is like finding a person of interest in Poland. The model predicts the following decreasing sequence: 1) captopril, 2) fosinopril, 3) quinapril, 4) benazepril, 5) enalapril, 6) lisinopril, 7) moexipril, 8) perindopril, 9) cilazapril, 10) ramipril, 11) trandolapril. The predicted number of bad outcomes is highest for captopril, and lowest for trandolapril. The usefulness of the machine learning algorithm becomes immediately apparent.

Data can inform prescribing

Analytics can expose a critical flaw in the academic psychiatry paradigm for prescribing medications. For example, some doctors may regard lithium as the “gold standard” for treating certain mood disorders, but there is evidence that olanzapine is “significantly more effective than lithium in preventing recurrence of manic and mixed episodes.”⁴ Olanzapine is also 30 times safer than lithium based on its RL index, and had 9,238 fewer bad outcomes based on the 15-year data from U.S. poison control centers.² A patient who intends to attempt suicide would easily be able to find the lethal dose of lithium from a “suicide” web site, and would quickly be able to figure out that the monthly amount of lithium his or her psychiatrist prescribed, would exceed the lethal dose.

When academia and reality collide, the use of analytics will have the final word by preventing suicide in the short term and reducing the number of bad outcomes in the long term. The irony of data science is that mathematical models can find optimal solutions to complex problems in a fraction of a second, but it may take years for a paradigm shift.

Computational psychiatry is an emerging field in which artificial intelligence and machine learning are used to find hidden patterns in big data to better understand, predict, and treat mental illness. The field uses various mathematical models to predict the dependent variable y based on the independent variable x. One application of analytics in medicine was the Framingham Heart Study, which used multivariate logistic regression to predict heart disease.¹

Analytics could be used to predict the number of bad outcomes associated with different psychiatric medications over time. To demonstrate this, I examined a select data set of 8 psychiatric medications (aripiprazole, ziprasidone, risperidone, olanzapine, sertraline, trazodone, amitriptyline, and lithium) accounting for 59,827 bad outcomes during a 15-year period as reported by U.S. poison control centers,² and plotted these on the y-axis.

When considering the independent variable to use as a predictor for bad outcomes, I used a composite index derived with the relative lethality (RL) equation, f(x) = 310x /LD50, where x is the daily dose of a medication prescribed for 30 days, and LD50 is the rat oral lethal dose 50.³ I plotted the RL of the 8 medications on the x-axis. Then I attempted to find a mathematical function that would best fit the x and y intersection points (Figure 1). I used the Excel data analysis pack to run a logarithmic regression model (Figure 2).

The model predicts that medications with a lower RL will have fewer serious outcomes, including mortality. The coefficient of determination r² = 0.968, which indicates that 97% of the variation in serious outcomes is attributed to variation in RL, and 3% may be due to other factors, such as the poor quality of U.S. poison control data. This is a very significant correlation, and the causality is self-evident.

Continued to: The distribution of bad outcomes in the model was...

The distribution of bad outcomes in the model was: 1,446 for aripiprazole (RL = 9.76%), 2,387 for ziprasidone (RL = 24.80%), 5,352 for risperidone (RL = 32.63%), 5,798 for olanzapine (RL = 35.03%), 6,120 for sertraline (RL = 46.72%), 10,343 for trazodone (RL = 269.57%), 13,345 for amitriptyline (RL = 387.50%), and 15,036 for lithium (RL = 1,062.86%). The regression equation is: serious outcomes = –5,677.7 + 3,015.7 × ln (RL).

Some doctors may argue that such a data set is too small to make a meaningful model. However, the number of possible ways of ranking the drugs by bad outcomes is 8! = 40,320, so the probability of guessing the right sequence is P = .000024801. To appreciate how small this probability is, imagine trying to find a person of interest in half a football stadium on Superbowl Sunday.

The RL composite index correctly predicted the ranking order of serious outcomes for the 8 medications and may be useful for finding such outcomes in any drug class. For example, with angiotensin-converting enzyme inhibitors (n = 11) the number of possible combinations is 11! = 39,916,800. The probability of guessing the right sequence is like finding a person of interest in Poland. The model predicts the following decreasing sequence: 1) captopril, 2) fosinopril, 3) quinapril, 4) benazepril, 5) enalapril, 6) lisinopril, 7) moexipril, 8) perindopril, 9) cilazapril, 10) ramipril, 11) trandolapril. The predicted number of bad outcomes is highest for captopril, and lowest for trandolapril. The usefulness of the machine learning algorithm becomes immediately apparent.

Data can inform prescribing

Analytics can expose a critical flaw in the academic psychiatry paradigm for prescribing medications. For example, some doctors may regard lithium as the “gold standard” for treating certain mood disorders, but there is evidence that olanzapine is “significantly more effective than lithium in preventing recurrence of manic and mixed episodes.”⁴ Olanzapine is also 30 times safer than lithium based on its RL index, and had 9,238 fewer bad outcomes based on the 15-year data from U.S. poison control centers.² A patient who intends to attempt suicide would easily be able to find the lethal dose of lithium from a “suicide” web site, and would quickly be able to figure out that the monthly amount of lithium his or her psychiatrist prescribed, would exceed the lethal dose.

When academia and reality collide, the use of analytics will have the final word by preventing suicide in the short term and reducing the number of bad outcomes in the long term. The irony of data science is that mathematical models can find optimal solutions to complex problems in a fraction of a second, but it may take years for a paradigm shift.

ABSTRACT

The incidence of acetabular fractures and associated in-hospital complication rates in the United States are poorly defined. Studies evaluating predictors of outcome for isolated acetabular fractures are weakly generalizable due to small sample sizes or the inclusion of all types of pelvic fractures. This study sought to analyze trends in acetabular fractures and associated complications in the US using the largest and most recent national dataset available.

The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with acetabular fractures between 1990 and 2010. A representative cohort of 497,389 patients was identified, and multivariable logistic regression was used to identify independent predictors of mortality, adverse events, requirement of blood transfusion, and operative treatment with open reduction and internal fixation (ORIF).

Between 1990 and 2010, the population-adjusted incidence of acetabular fractures increased from 7.8 to 9.5/100,000 capita (P < .001). Mortality declined from 5.9% to 0.4% (P < .001), paralleling an increase in the proportion of patients treated with ORIF (12.6%-20.4%, P < .001), which was the variable associated with the lowest odds of mortality. Surgical intervention was associated with higher odds of adverse events and a requirement for blood transfusion. The average in-hospital length of stay decreased from 17.0 days to 10.3 days (P < .001).

This study provides the largest and most comprehensive epidemiologic analysis of acetabular fractures in the US. Knowledge of the increasing incidence of acetabular fractures and prognostic factors associated with poor outcomes may improve outcomes.

Continue to: Acetabular fractures are major injuries...

Acetabular fractures are major injuries frequently associated with life-altering sequelae¹ and a significant resulting cost to society.² Acetabular fractures are most often the result of a high-energy trauma^3-5 or fall from a height.^5,6 Functional outcomes and the prevention of post-traumatic arthritis have been shown to depend upon the accuracy of operative reduction.^7-9 However, literature on the epidemiology of acetabular fractures is largely limited to European countries,^1,10 and their incidence in the United States is more poorly defined.¹¹ Published mortality rates in the existing literature vary widely from 2% to 45%,^12-14 and few studies have identified the risk factors associated with in-hospital complications.¹⁵ While age, gender, and high-velocity mechanisms have been linked to increased mortality and complications,^14-16 the evidence for these associations is poorly generalizable due to the inclusion of all pelvic fractures in these studies. Some reports suggest that advances in surgical management have improved survival and functional outcome,^15,17 but these are based upon small cohorts. Knowledge of the incidence and patterns of disease burden are crucial for the allocation of limited healthcare resources.

ABSTRACT

The incidence of acetabular fractures and associated in-hospital complication rates in the United States are poorly defined. Studies evaluating predictors of outcome for isolated acetabular fractures are weakly generalizable due to small sample sizes or the inclusion of all types of pelvic fractures. This study sought to analyze trends in acetabular fractures and associated complications in the US using the largest and most recent national dataset available.

The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with acetabular fractures between 1990 and 2010. A representative cohort of 497,389 patients was identified, and multivariable logistic regression was used to identify independent predictors of mortality, adverse events, requirement of blood transfusion, and operative treatment with open reduction and internal fixation (ORIF).

Between 1990 and 2010, the population-adjusted incidence of acetabular fractures increased from 7.8 to 9.5/100,000 capita (P < .001). Mortality declined from 5.9% to 0.4% (P < .001), paralleling an increase in the proportion of patients treated with ORIF (12.6%-20.4%, P < .001), which was the variable associated with the lowest odds of mortality. Surgical intervention was associated with higher odds of adverse events and a requirement for blood transfusion. The average in-hospital length of stay decreased from 17.0 days to 10.3 days (P < .001).

This study provides the largest and most comprehensive epidemiologic analysis of acetabular fractures in the US. Knowledge of the increasing incidence of acetabular fractures and prognostic factors associated with poor outcomes may improve outcomes.

Continue to: Acetabular fractures are major injuries...

Acetabular fractures are major injuries frequently associated with life-altering sequelae¹ and a significant resulting cost to society.² Acetabular fractures are most often the result of a high-energy trauma^3-5 or fall from a height.^5,6 Functional outcomes and the prevention of post-traumatic arthritis have been shown to depend upon the accuracy of operative reduction.^7-9 However, literature on the epidemiology of acetabular fractures is largely limited to European countries,^1,10 and their incidence in the United States is more poorly defined.¹¹ Published mortality rates in the existing literature vary widely from 2% to 45%,^12-14 and few studies have identified the risk factors associated with in-hospital complications.¹⁵ While age, gender, and high-velocity mechanisms have been linked to increased mortality and complications,^14-16 the evidence for these associations is poorly generalizable due to the inclusion of all pelvic fractures in these studies. Some reports suggest that advances in surgical management have improved survival and functional outcome,^15,17 but these are based upon small cohorts. Knowledge of the incidence and patterns of disease burden are crucial for the allocation of limited healthcare resources.

ABSTRACT

The incidence of acetabular fractures and associated in-hospital complication rates in the United States are poorly defined. Studies evaluating predictors of outcome for isolated acetabular fractures are weakly generalizable due to small sample sizes or the inclusion of all types of pelvic fractures. This study sought to analyze trends in acetabular fractures and associated complications in the US using the largest and most recent national dataset available.

The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with acetabular fractures between 1990 and 2010. A representative cohort of 497,389 patients was identified, and multivariable logistic regression was used to identify independent predictors of mortality, adverse events, requirement of blood transfusion, and operative treatment with open reduction and internal fixation (ORIF).

Between 1990 and 2010, the population-adjusted incidence of acetabular fractures increased from 7.8 to 9.5/100,000 capita (P < .001). Mortality declined from 5.9% to 0.4% (P < .001), paralleling an increase in the proportion of patients treated with ORIF (12.6%-20.4%, P < .001), which was the variable associated with the lowest odds of mortality. Surgical intervention was associated with higher odds of adverse events and a requirement for blood transfusion. The average in-hospital length of stay decreased from 17.0 days to 10.3 days (P < .001).

This study provides the largest and most comprehensive epidemiologic analysis of acetabular fractures in the US. Knowledge of the increasing incidence of acetabular fractures and prognostic factors associated with poor outcomes may improve outcomes.

Continue to: Acetabular fractures are major injuries...

Acetabular fractures are major injuries frequently associated with life-altering sequelae¹ and a significant resulting cost to society.² Acetabular fractures are most often the result of a high-energy trauma^3-5 or fall from a height.^5,6 Functional outcomes and the prevention of post-traumatic arthritis have been shown to depend upon the accuracy of operative reduction.^7-9 However, literature on the epidemiology of acetabular fractures is largely limited to European countries,^1,10 and their incidence in the United States is more poorly defined.¹¹ Published mortality rates in the existing literature vary widely from 2% to 45%,^12-14 and few studies have identified the risk factors associated with in-hospital complications.¹⁵ While age, gender, and high-velocity mechanisms have been linked to increased mortality and complications,^14-16 the evidence for these associations is poorly generalizable due to the inclusion of all pelvic fractures in these studies. Some reports suggest that advances in surgical management have improved survival and functional outcome,^15,17 but these are based upon small cohorts. Knowledge of the incidence and patterns of disease burden are crucial for the allocation of limited healthcare resources.

This week, a breakthrough for heart failure patients with mitral regurgitation emerges, prosthesis-patient mismatch raises the risk of death following TAVR, a new study challenges anticoagulation guidelines, and a possible blessing in disguise for rivaroxaban comes from the massive COMPASS trial. Subscribe to Cardiocast wherever you get your podcasts.

Amazon Alexa
Apple Podcasts

This week, a breakthrough for heart failure patients with mitral regurgitation emerges, prosthesis-patient mismatch raises the risk of death following TAVR, a new study challenges anticoagulation guidelines, and a possible blessing in disguise for rivaroxaban comes from the massive COMPASS trial. Subscribe to Cardiocast wherever you get your podcasts.

Amazon Alexa
Apple Podcasts

This week, a breakthrough for heart failure patients with mitral regurgitation emerges, prosthesis-patient mismatch raises the risk of death following TAVR, a new study challenges anticoagulation guidelines, and a possible blessing in disguise for rivaroxaban comes from the massive COMPASS trial. Subscribe to Cardiocast wherever you get your podcasts.

Amazon Alexa
Apple Podcasts

A well-woman visit with an ob.gyn. should include preventive services and counseling, according to an updated committee opinion from the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice.

Alexander Raths/Fotolia.com

“A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks,” according to the opinion, published in Obstetrics & Gynecology. The updated opinion coincides with the release of the new Well-Woman Chart from the Women’s Preventive Services Initiative.

Previous research suggests that many women prefer an ob.gyn. or other women’s health care specialist not only for reproductive health care but also for services such as cervical cancer screening, contraception, and treatment for sexually transmitted infections, the committee members wrote. Although surveys of ob.gyns. show that most provide some level of overall health and primary care, the screening and other clinical preventive services were not consistent.

The committee opinion consequently recommends that the “periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors.” However, the committee acknowledged that the interval for specific services varies among patients, as does the scope of services provided in different settings.

“Taking a comprehensive history (specifically obtaining detailed information on symptoms and past medical and gynecologic history) will inform if certain components of the physical examination, including breast or pelvic examination, are indicated at that visit and will inform shared decision making for these examinations,” committee members wrote. Topics that should be addressed during lifespan include sexual health (which may include contraception, prepregnancy counseling, sexually transmitted infections, and infertility), vulvovaginal symptoms, and bone health.

Not all components of a physical may be required at a well-woman visit, but ob.gyns. can play a key role by encouraging and facilitating healthy behaviors, counseling on preventive health strategies, and engaging women in shared decision-making. Screening for smoking, poor diet, and lack of physical activity are important. Ob.gyns. also can be part of the team-based care for women that may include physician assistants, nurse practitioners, and other medical professionals.

The most notable change from the previous opinion is that it coincides with the Women’s Preventive Services Initiative’s release of a Well-Woman Chart, which is designed to help ob.gyns. navigate the implementation of ACOG’s well-woman guidance, Christopher Zahn, MD, vice president of practice activities for ACOG, said in an interview.

“In tandem, these documents support ob.gyns. and other women’s health care providers’ efforts to make well-woman visits more personalized care that prioritizes shared decision-making over a woman’s lifetime,” he said. The opinion statement also includes the Women’s Preventive Services Initiative as a source of information for recommendations on well-woman care, and includes new guidance on the elements of a physical exam, including the pelvic exam.

“Ob.gyns. care for women over their lifetime, and increasingly this includes a lot of preventive care. The committee opinion details ACOG’s overall approach to well-women care and the role of the ob.gyn. as a provider of preventive services,” said Dr. Zahn. “The accompanying well-woman chart, targeted to providers, summarizes needed preventive services ensuring that time can be spent effectively and productively during each well-woman visit. By centering shared decision making and care tailored to each woman’s health care needs at every life stage, the well-woman visit is a fundamental part of the patient-provider relationship.”

Dr. Zahn noted that ongoing, high-quality research is essential to determine what strategies are most effective for women’s preventive care needs at every life stage. “Further research is also needed to identify screening strategies for women in certain higher risk groups and to reduce disparities in outcomes in certain populations of women. From cancer screening to new contraceptive methods, to managing symptoms of menopause, the more research we have to support our recommendations for these services, the more effectively we can care for women and help to keep them healthy for many, many years,” he emphasized.

The committee recommended additional resources for ob.gyns. and other health care providers, as well as for patients. The resources are available online at www.acog.org/More-Info/WellWoman.

The new opinion statement, which replaces the previous opinion issued in 2012, was developed by the ACOG Committee on Gynecologic Practice in collaboration with committee member Catherine Witkop, MD, MPH, of the Uniformed Health Sciences University in Bethesda, Md. The committee members had no relevant financial conflicts to disclose.
 

A well-woman visit with an ob.gyn. should include preventive services and counseling, according to an updated committee opinion from the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice.

Alexander Raths/Fotolia.com

“A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks,” according to the opinion, published in Obstetrics & Gynecology. The updated opinion coincides with the release of the new Well-Woman Chart from the Women’s Preventive Services Initiative.

Previous research suggests that many women prefer an ob.gyn. or other women’s health care specialist not only for reproductive health care but also for services such as cervical cancer screening, contraception, and treatment for sexually transmitted infections, the committee members wrote. Although surveys of ob.gyns. show that most provide some level of overall health and primary care, the screening and other clinical preventive services were not consistent.

The committee opinion consequently recommends that the “periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors.” However, the committee acknowledged that the interval for specific services varies among patients, as does the scope of services provided in different settings.

“Taking a comprehensive history (specifically obtaining detailed information on symptoms and past medical and gynecologic history) will inform if certain components of the physical examination, including breast or pelvic examination, are indicated at that visit and will inform shared decision making for these examinations,” committee members wrote. Topics that should be addressed during lifespan include sexual health (which may include contraception, prepregnancy counseling, sexually transmitted infections, and infertility), vulvovaginal symptoms, and bone health.

Not all components of a physical may be required at a well-woman visit, but ob.gyns. can play a key role by encouraging and facilitating healthy behaviors, counseling on preventive health strategies, and engaging women in shared decision-making. Screening for smoking, poor diet, and lack of physical activity are important. Ob.gyns. also can be part of the team-based care for women that may include physician assistants, nurse practitioners, and other medical professionals.

The most notable change from the previous opinion is that it coincides with the Women’s Preventive Services Initiative’s release of a Well-Woman Chart, which is designed to help ob.gyns. navigate the implementation of ACOG’s well-woman guidance, Christopher Zahn, MD, vice president of practice activities for ACOG, said in an interview.

“In tandem, these documents support ob.gyns. and other women’s health care providers’ efforts to make well-woman visits more personalized care that prioritizes shared decision-making over a woman’s lifetime,” he said. The opinion statement also includes the Women’s Preventive Services Initiative as a source of information for recommendations on well-woman care, and includes new guidance on the elements of a physical exam, including the pelvic exam.

“Ob.gyns. care for women over their lifetime, and increasingly this includes a lot of preventive care. The committee opinion details ACOG’s overall approach to well-women care and the role of the ob.gyn. as a provider of preventive services,” said Dr. Zahn. “The accompanying well-woman chart, targeted to providers, summarizes needed preventive services ensuring that time can be spent effectively and productively during each well-woman visit. By centering shared decision making and care tailored to each woman’s health care needs at every life stage, the well-woman visit is a fundamental part of the patient-provider relationship.”

Dr. Zahn noted that ongoing, high-quality research is essential to determine what strategies are most effective for women’s preventive care needs at every life stage. “Further research is also needed to identify screening strategies for women in certain higher risk groups and to reduce disparities in outcomes in certain populations of women. From cancer screening to new contraceptive methods, to managing symptoms of menopause, the more research we have to support our recommendations for these services, the more effectively we can care for women and help to keep them healthy for many, many years,” he emphasized.

The committee recommended additional resources for ob.gyns. and other health care providers, as well as for patients. The resources are available online at www.acog.org/More-Info/WellWoman.

The new opinion statement, which replaces the previous opinion issued in 2012, was developed by the ACOG Committee on Gynecologic Practice in collaboration with committee member Catherine Witkop, MD, MPH, of the Uniformed Health Sciences University in Bethesda, Md. The committee members had no relevant financial conflicts to disclose.
 

A well-woman visit with an ob.gyn. should include preventive services and counseling, according to an updated committee opinion from the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice.

Alexander Raths/Fotolia.com

“A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks,” according to the opinion, published in Obstetrics & Gynecology. The updated opinion coincides with the release of the new Well-Woman Chart from the Women’s Preventive Services Initiative.

Previous research suggests that many women prefer an ob.gyn. or other women’s health care specialist not only for reproductive health care but also for services such as cervical cancer screening, contraception, and treatment for sexually transmitted infections, the committee members wrote. Although surveys of ob.gyns. show that most provide some level of overall health and primary care, the screening and other clinical preventive services were not consistent.

The committee opinion consequently recommends that the “periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors.” However, the committee acknowledged that the interval for specific services varies among patients, as does the scope of services provided in different settings.

“Taking a comprehensive history (specifically obtaining detailed information on symptoms and past medical and gynecologic history) will inform if certain components of the physical examination, including breast or pelvic examination, are indicated at that visit and will inform shared decision making for these examinations,” committee members wrote. Topics that should be addressed during lifespan include sexual health (which may include contraception, prepregnancy counseling, sexually transmitted infections, and infertility), vulvovaginal symptoms, and bone health.

Not all components of a physical may be required at a well-woman visit, but ob.gyns. can play a key role by encouraging and facilitating healthy behaviors, counseling on preventive health strategies, and engaging women in shared decision-making. Screening for smoking, poor diet, and lack of physical activity are important. Ob.gyns. also can be part of the team-based care for women that may include physician assistants, nurse practitioners, and other medical professionals.

The most notable change from the previous opinion is that it coincides with the Women’s Preventive Services Initiative’s release of a Well-Woman Chart, which is designed to help ob.gyns. navigate the implementation of ACOG’s well-woman guidance, Christopher Zahn, MD, vice president of practice activities for ACOG, said in an interview.

“In tandem, these documents support ob.gyns. and other women’s health care providers’ efforts to make well-woman visits more personalized care that prioritizes shared decision-making over a woman’s lifetime,” he said. The opinion statement also includes the Women’s Preventive Services Initiative as a source of information for recommendations on well-woman care, and includes new guidance on the elements of a physical exam, including the pelvic exam.

“Ob.gyns. care for women over their lifetime, and increasingly this includes a lot of preventive care. The committee opinion details ACOG’s overall approach to well-women care and the role of the ob.gyn. as a provider of preventive services,” said Dr. Zahn. “The accompanying well-woman chart, targeted to providers, summarizes needed preventive services ensuring that time can be spent effectively and productively during each well-woman visit. By centering shared decision making and care tailored to each woman’s health care needs at every life stage, the well-woman visit is a fundamental part of the patient-provider relationship.”

Dr. Zahn noted that ongoing, high-quality research is essential to determine what strategies are most effective for women’s preventive care needs at every life stage. “Further research is also needed to identify screening strategies for women in certain higher risk groups and to reduce disparities in outcomes in certain populations of women. From cancer screening to new contraceptive methods, to managing symptoms of menopause, the more research we have to support our recommendations for these services, the more effectively we can care for women and help to keep them healthy for many, many years,” he emphasized.

The committee recommended additional resources for ob.gyns. and other health care providers, as well as for patients. The resources are available online at www.acog.org/More-Info/WellWoman.

The new opinion statement, which replaces the previous opinion issued in 2012, was developed by the ACOG Committee on Gynecologic Practice in collaboration with committee member Catherine Witkop, MD, MPH, of the Uniformed Health Sciences University in Bethesda, Md. The committee members had no relevant financial conflicts to disclose.
 

WASHINGTON – The flu vaccine may not be perfect, but it can reduce the severity of illness and curb the risk of spreading the disease to others, William Schaffner, MD, emphasized at a press conference held by the National Foundation for Infectious Diseases.

“Give the vaccine credit for softening the blow,” said Dr. Schaffner, medical director of NFID and a professor at Vanderbilt University in Nashville.

Dr. Schaffner and a panel of experts including U.S. Surgeon General Jerome M. Adams, MD, encouraged the public and the health care community to follow recommendation from the Centers for Disease Control & Prevention that everyone aged 6 months and older receive an influenza vaccine.

Dr. Schaffner shared recent data showing that complications from the flu don’t stop when the acute illness resolves. Acute influenza causes a whole-body inflammatory reaction, and consequently “there is an increased risk of heart attack and stroke during the 2-4 weeks of recovery from acute influenza,” he said. In addition, older adults who experience acute flu and are already frail may never regain their pre-flu level of function, as the flu can start a “domino effect of decline and disability.”

Despite last year’s severe flu season that included 180 deaths in children, vaccination remains the most effective protection against the flu, Dr. Adams said.

This year, between 163 million and 168 million doses of vaccine will be available in the United States. The vaccine is available in a range of settings including doctors’ offices, pharmacies, grocery stores, and workplaces, said Dr. Adams.

Flu vaccine choices this year include a return of the live-attenuated influenza vaccine (LAIV) given via nasal spray, along with the standard influenza vaccine that includes either three influenza viruses (trivalent, with two influenza A and one influenza B) or four influenza viruses (quadrivalent, with two influenza A and two influenza B). Other options are adjuvanted vaccine and high-dose vaccine for adults aged 65 years and older, and a cell-based and recombinant vaccine as alternatives to egg-based vaccines.

Dr. Adams emphasized the importance of healthy people getting vaccinated to protect the community. “All the people who died from the flu caught it from someone else,” he said.

Courtesy NFID

WASHINGTON – The flu vaccine may not be perfect, but it can reduce the severity of illness and curb the risk of spreading the disease to others, William Schaffner, MD, emphasized at a press conference held by the National Foundation for Infectious Diseases.

“Give the vaccine credit for softening the blow,” said Dr. Schaffner, medical director of NFID and a professor at Vanderbilt University in Nashville.

Dr. Schaffner and a panel of experts including U.S. Surgeon General Jerome M. Adams, MD, encouraged the public and the health care community to follow recommendation from the Centers for Disease Control & Prevention that everyone aged 6 months and older receive an influenza vaccine.

Dr. Schaffner shared recent data showing that complications from the flu don’t stop when the acute illness resolves. Acute influenza causes a whole-body inflammatory reaction, and consequently “there is an increased risk of heart attack and stroke during the 2-4 weeks of recovery from acute influenza,” he said. In addition, older adults who experience acute flu and are already frail may never regain their pre-flu level of function, as the flu can start a “domino effect of decline and disability.”

Despite last year’s severe flu season that included 180 deaths in children, vaccination remains the most effective protection against the flu, Dr. Adams said.

This year, between 163 million and 168 million doses of vaccine will be available in the United States. The vaccine is available in a range of settings including doctors’ offices, pharmacies, grocery stores, and workplaces, said Dr. Adams.

Flu vaccine choices this year include a return of the live-attenuated influenza vaccine (LAIV) given via nasal spray, along with the standard influenza vaccine that includes either three influenza viruses (trivalent, with two influenza A and one influenza B) or four influenza viruses (quadrivalent, with two influenza A and two influenza B). Other options are adjuvanted vaccine and high-dose vaccine for adults aged 65 years and older, and a cell-based and recombinant vaccine as alternatives to egg-based vaccines.

Dr. Adams emphasized the importance of healthy people getting vaccinated to protect the community. “All the people who died from the flu caught it from someone else,” he said.

Courtesy NFID

WASHINGTON – The flu vaccine may not be perfect, but it can reduce the severity of illness and curb the risk of spreading the disease to others, William Schaffner, MD, emphasized at a press conference held by the National Foundation for Infectious Diseases.

“Give the vaccine credit for softening the blow,” said Dr. Schaffner, medical director of NFID and a professor at Vanderbilt University in Nashville.

Dr. Schaffner and a panel of experts including U.S. Surgeon General Jerome M. Adams, MD, encouraged the public and the health care community to follow recommendation from the Centers for Disease Control & Prevention that everyone aged 6 months and older receive an influenza vaccine.

Dr. Schaffner shared recent data showing that complications from the flu don’t stop when the acute illness resolves. Acute influenza causes a whole-body inflammatory reaction, and consequently “there is an increased risk of heart attack and stroke during the 2-4 weeks of recovery from acute influenza,” he said. In addition, older adults who experience acute flu and are already frail may never regain their pre-flu level of function, as the flu can start a “domino effect of decline and disability.”

Despite last year’s severe flu season that included 180 deaths in children, vaccination remains the most effective protection against the flu, Dr. Adams said.

This year, between 163 million and 168 million doses of vaccine will be available in the United States. The vaccine is available in a range of settings including doctors’ offices, pharmacies, grocery stores, and workplaces, said Dr. Adams.

Flu vaccine choices this year include a return of the live-attenuated influenza vaccine (LAIV) given via nasal spray, along with the standard influenza vaccine that includes either three influenza viruses (trivalent, with two influenza A and one influenza B) or four influenza viruses (quadrivalent, with two influenza A and two influenza B). Other options are adjuvanted vaccine and high-dose vaccine for adults aged 65 years and older, and a cell-based and recombinant vaccine as alternatives to egg-based vaccines.

Dr. Adams emphasized the importance of healthy people getting vaccinated to protect the community. “All the people who died from the flu caught it from someone else,” he said.

Courtesy NFID

PARIS – Using a point-of-care test for viral pathogens, hospital admissions were avoided in about a third of emergency department patients with suspected respiratory infection when other clinical signs also suggested a low risk of a bacterial pathogen, according to a single-center experience presented at the annual congress of the European Respiratory Society.

Wikimedia Commons

“We found that when patients had point-of-care respiratory viral testing soon after they were admitted to the emergency department, we were able to reduce unnecessary admission and improve bed flow in our center,” reported Kay Roy, MBBS, consultant physician in respiratory medicine, West Hertfordshire (England) Hospital NHS Trust.

In a protocol that was launched at Dr. Kay’s institution in January 2018, the point-of-care viral test was combined with other clinical factors, particularly chest x-rays and elevated C-reactive protein (CRP), to determine whether patients had a viral pathogen and whether they could be discharged without antibiotics.

“Clinical judgment will always be required in individual patient decisions regarding antibiotic avoidance and early discharge,” Dr. Roy maintained. “But the point-of-care viral assay can be integrated into a strategy that permits more informed and rapid decision-making.”

This assertion is supported by the experience using a protocol anchored with the point-of-care viral test over a 4-month period. During this time, 901 patients with respiratory symptoms suspected of having a viral etiology were evaluated with the proprietary point-of-care device called FilmArray (bioMérieux).

From a sample taken with a nasopharyngeal swab, the test can identify a broad array of viruses using polymerase chain reaction technology in less than 45 minutes. However, the ED protocol for considering discharge without antibiotics requires additional evidence that the pathogen is viral, including a normal chest x-ray and a CRP less than 50 mg/L.

Of the 901 patients tested, a substantial proportion of whom had chronic obstructive pulmonary disease (COPD) or asthma, 507 (56%) tested positive for at least one virus, including influenza, rhinoviruses, coronaviruses, and adenovirus. Of these, 239 had normal chest x-rays and CRPs less than 50 mg/L. Because of the severity of symptoms or other clinical considerations, 154 patients were admitted, but 85 (36% of those meeting protocol criteria) were discharged without an antibiotic prescription.

“Antibiotics were continued in 90% of the patients who had an abnormal chest x-ray and abnormal CRP,” Dr. Roy reported. However, an objective strategy that permits clinicians to discharge patients at very low risk of a bacterial infection has many advantages even if it applies to a relatively modest proportion of those tested, according to Dr. Roy.

“Each respiratory admission can cost around [2,000 pounds] at our center,” reported Dr. Kay, referring to a figure equivalent to more than $2,600. In addition, she said that avoiding hospitalization frees up hospital beds and facilitates improved antimicrobial stewardship, which is vital to stem resistance.

Avoiding antibiotic use in patients with viral respiratory infections also is relevant to improved antibiotic stewardship in the community. For this reason, a randomized trial with a similar protocol involving the point-of-care viral test is planned in the outpatient setting. According to Dr. Roy, this will involve a community hub to which patients can be referred for testing and clinical evaluation.

“We hope that the quality of care can be improved with the point-of-care test for respiratory viruses as well as helping to reduce antibiotic resistance,” Dr. Roy said.

This approach is promising, according to Tobias Welte, MD, of the department of respiratory medicine at Hannover (Germany) Medical School, but he cautioned that it is not a standard approach.

“The protocol described by Dr. Roy will have to be compared to guidelines and recommended best clinical practice to confirm its usefulness,” he said, while conceding that any strategy that reduces unnecessary hospitalizations deserves further evaluation.

PARIS – Using a point-of-care test for viral pathogens, hospital admissions were avoided in about a third of emergency department patients with suspected respiratory infection when other clinical signs also suggested a low risk of a bacterial pathogen, according to a single-center experience presented at the annual congress of the European Respiratory Society.

Wikimedia Commons

“We found that when patients had point-of-care respiratory viral testing soon after they were admitted to the emergency department, we were able to reduce unnecessary admission and improve bed flow in our center,” reported Kay Roy, MBBS, consultant physician in respiratory medicine, West Hertfordshire (England) Hospital NHS Trust.

In a protocol that was launched at Dr. Kay’s institution in January 2018, the point-of-care viral test was combined with other clinical factors, particularly chest x-rays and elevated C-reactive protein (CRP), to determine whether patients had a viral pathogen and whether they could be discharged without antibiotics.

“Clinical judgment will always be required in individual patient decisions regarding antibiotic avoidance and early discharge,” Dr. Roy maintained. “But the point-of-care viral assay can be integrated into a strategy that permits more informed and rapid decision-making.”

This assertion is supported by the experience using a protocol anchored with the point-of-care viral test over a 4-month period. During this time, 901 patients with respiratory symptoms suspected of having a viral etiology were evaluated with the proprietary point-of-care device called FilmArray (bioMérieux).

From a sample taken with a nasopharyngeal swab, the test can identify a broad array of viruses using polymerase chain reaction technology in less than 45 minutes. However, the ED protocol for considering discharge without antibiotics requires additional evidence that the pathogen is viral, including a normal chest x-ray and a CRP less than 50 mg/L.

Of the 901 patients tested, a substantial proportion of whom had chronic obstructive pulmonary disease (COPD) or asthma, 507 (56%) tested positive for at least one virus, including influenza, rhinoviruses, coronaviruses, and adenovirus. Of these, 239 had normal chest x-rays and CRPs less than 50 mg/L. Because of the severity of symptoms or other clinical considerations, 154 patients were admitted, but 85 (36% of those meeting protocol criteria) were discharged without an antibiotic prescription.

“Antibiotics were continued in 90% of the patients who had an abnormal chest x-ray and abnormal CRP,” Dr. Roy reported. However, an objective strategy that permits clinicians to discharge patients at very low risk of a bacterial infection has many advantages even if it applies to a relatively modest proportion of those tested, according to Dr. Roy.

“Each respiratory admission can cost around [2,000 pounds] at our center,” reported Dr. Kay, referring to a figure equivalent to more than $2,600. In addition, she said that avoiding hospitalization frees up hospital beds and facilitates improved antimicrobial stewardship, which is vital to stem resistance.

Avoiding antibiotic use in patients with viral respiratory infections also is relevant to improved antibiotic stewardship in the community. For this reason, a randomized trial with a similar protocol involving the point-of-care viral test is planned in the outpatient setting. According to Dr. Roy, this will involve a community hub to which patients can be referred for testing and clinical evaluation.

“We hope that the quality of care can be improved with the point-of-care test for respiratory viruses as well as helping to reduce antibiotic resistance,” Dr. Roy said.

This approach is promising, according to Tobias Welte, MD, of the department of respiratory medicine at Hannover (Germany) Medical School, but he cautioned that it is not a standard approach.

“The protocol described by Dr. Roy will have to be compared to guidelines and recommended best clinical practice to confirm its usefulness,” he said, while conceding that any strategy that reduces unnecessary hospitalizations deserves further evaluation.

PARIS – Using a point-of-care test for viral pathogens, hospital admissions were avoided in about a third of emergency department patients with suspected respiratory infection when other clinical signs also suggested a low risk of a bacterial pathogen, according to a single-center experience presented at the annual congress of the European Respiratory Society.

Wikimedia Commons

“We found that when patients had point-of-care respiratory viral testing soon after they were admitted to the emergency department, we were able to reduce unnecessary admission and improve bed flow in our center,” reported Kay Roy, MBBS, consultant physician in respiratory medicine, West Hertfordshire (England) Hospital NHS Trust.

In a protocol that was launched at Dr. Kay’s institution in January 2018, the point-of-care viral test was combined with other clinical factors, particularly chest x-rays and elevated C-reactive protein (CRP), to determine whether patients had a viral pathogen and whether they could be discharged without antibiotics.

“Clinical judgment will always be required in individual patient decisions regarding antibiotic avoidance and early discharge,” Dr. Roy maintained. “But the point-of-care viral assay can be integrated into a strategy that permits more informed and rapid decision-making.”

This assertion is supported by the experience using a protocol anchored with the point-of-care viral test over a 4-month period. During this time, 901 patients with respiratory symptoms suspected of having a viral etiology were evaluated with the proprietary point-of-care device called FilmArray (bioMérieux).

From a sample taken with a nasopharyngeal swab, the test can identify a broad array of viruses using polymerase chain reaction technology in less than 45 minutes. However, the ED protocol for considering discharge without antibiotics requires additional evidence that the pathogen is viral, including a normal chest x-ray and a CRP less than 50 mg/L.

Of the 901 patients tested, a substantial proportion of whom had chronic obstructive pulmonary disease (COPD) or asthma, 507 (56%) tested positive for at least one virus, including influenza, rhinoviruses, coronaviruses, and adenovirus. Of these, 239 had normal chest x-rays and CRPs less than 50 mg/L. Because of the severity of symptoms or other clinical considerations, 154 patients were admitted, but 85 (36% of those meeting protocol criteria) were discharged without an antibiotic prescription.

“Antibiotics were continued in 90% of the patients who had an abnormal chest x-ray and abnormal CRP,” Dr. Roy reported. However, an objective strategy that permits clinicians to discharge patients at very low risk of a bacterial infection has many advantages even if it applies to a relatively modest proportion of those tested, according to Dr. Roy.

“Each respiratory admission can cost around [2,000 pounds] at our center,” reported Dr. Kay, referring to a figure equivalent to more than $2,600. In addition, she said that avoiding hospitalization frees up hospital beds and facilitates improved antimicrobial stewardship, which is vital to stem resistance.

Avoiding antibiotic use in patients with viral respiratory infections also is relevant to improved antibiotic stewardship in the community. For this reason, a randomized trial with a similar protocol involving the point-of-care viral test is planned in the outpatient setting. According to Dr. Roy, this will involve a community hub to which patients can be referred for testing and clinical evaluation.

“We hope that the quality of care can be improved with the point-of-care test for respiratory viruses as well as helping to reduce antibiotic resistance,” Dr. Roy said.

This approach is promising, according to Tobias Welte, MD, of the department of respiratory medicine at Hannover (Germany) Medical School, but he cautioned that it is not a standard approach.

“The protocol described by Dr. Roy will have to be compared to guidelines and recommended best clinical practice to confirm its usefulness,” he said, while conceding that any strategy that reduces unnecessary hospitalizations deserves further evaluation.

CHICAGO – Home BP monitoring has proved its worth, and it’s now time to integrate it into health care and get insurers to pay for it, according to Hayden Bosworth, PhD, a population health sciences professor and health services researcher at Duke University, Durham, N.C.

The devices are on the shelves of pharmacies and discount stores nationwide, sometimes for less than $50, but what to do with them in the clinic hasn’t been worked out. It’s likely patients are soon going to want help interpreting the results, if they aren’t already, but a leap in technology has left clinicians and payors scratching their heads.

There’s more than enough evidence of benefit. Dr. Bosworth has been involved with several trials of home BP monitoring with good results. He was one of the many authors on a recent meta-analysis that found when patients check their BP at home, it can lead to a “clinically significant” reduction “which persists for at least 12 months” (PLoS Med. 2017 Sep 19;14[9]:e1002389).

“Are we talking about efficacy or proof of concept? I think we are beyond that. Now we have to think about how we put it into the system, how do we integrate it, what’s the best way of delivery. I think that’s where the future is,” he said in an interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

Home monitoring came up far more often at this year’s joint sessions than in 2017, which might indicate growing interest, but reimbursement remains a challenge. American Medical Association staff said at this year’s meeting that they are working with the Centers for Medicare & Medicaid Services for coverage of the devices and their use. It seemed likely to them.

In the meantime, Dr. Bosworth had some useful advice for those who are thinking about incorporating home BP monitoring into their practices.

He shared his tips on how to pick out a device – there’s actually a journal called Blood Pressure Monitoring that can help – as well as his thoughts on how often people should monitor themselves and what to do with the numbers.

He envisions a future when patients routinely check their BP at home; it’s even possible they could adjust their medications based on the results, much like diabetes patients track their blood glucose and adjust their insulin. It’s been shown to work in Britain (JAMA. 2014 Aug 27;312[8]:799-808).

Dr. Bosworth reported no relevant disclosures.

[email protected]

CHICAGO – Home BP monitoring has proved its worth, and it’s now time to integrate it into health care and get insurers to pay for it, according to Hayden Bosworth, PhD, a population health sciences professor and health services researcher at Duke University, Durham, N.C.

The devices are on the shelves of pharmacies and discount stores nationwide, sometimes for less than $50, but what to do with them in the clinic hasn’t been worked out. It’s likely patients are soon going to want help interpreting the results, if they aren’t already, but a leap in technology has left clinicians and payors scratching their heads.

There’s more than enough evidence of benefit. Dr. Bosworth has been involved with several trials of home BP monitoring with good results. He was one of the many authors on a recent meta-analysis that found when patients check their BP at home, it can lead to a “clinically significant” reduction “which persists for at least 12 months” (PLoS Med. 2017 Sep 19;14[9]:e1002389).

“Are we talking about efficacy or proof of concept? I think we are beyond that. Now we have to think about how we put it into the system, how do we integrate it, what’s the best way of delivery. I think that’s where the future is,” he said in an interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

Home monitoring came up far more often at this year’s joint sessions than in 2017, which might indicate growing interest, but reimbursement remains a challenge. American Medical Association staff said at this year’s meeting that they are working with the Centers for Medicare & Medicaid Services for coverage of the devices and their use. It seemed likely to them.

In the meantime, Dr. Bosworth had some useful advice for those who are thinking about incorporating home BP monitoring into their practices.

He shared his tips on how to pick out a device – there’s actually a journal called Blood Pressure Monitoring that can help – as well as his thoughts on how often people should monitor themselves and what to do with the numbers.

He envisions a future when patients routinely check their BP at home; it’s even possible they could adjust their medications based on the results, much like diabetes patients track their blood glucose and adjust their insulin. It’s been shown to work in Britain (JAMA. 2014 Aug 27;312[8]:799-808).

Dr. Bosworth reported no relevant disclosures.

[email protected]

CHICAGO – Home BP monitoring has proved its worth, and it’s now time to integrate it into health care and get insurers to pay for it, according to Hayden Bosworth, PhD, a population health sciences professor and health services researcher at Duke University, Durham, N.C.

The devices are on the shelves of pharmacies and discount stores nationwide, sometimes for less than $50, but what to do with them in the clinic hasn’t been worked out. It’s likely patients are soon going to want help interpreting the results, if they aren’t already, but a leap in technology has left clinicians and payors scratching their heads.

There’s more than enough evidence of benefit. Dr. Bosworth has been involved with several trials of home BP monitoring with good results. He was one of the many authors on a recent meta-analysis that found when patients check their BP at home, it can lead to a “clinically significant” reduction “which persists for at least 12 months” (PLoS Med. 2017 Sep 19;14[9]:e1002389).

“Are we talking about efficacy or proof of concept? I think we are beyond that. Now we have to think about how we put it into the system, how do we integrate it, what’s the best way of delivery. I think that’s where the future is,” he said in an interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

Home monitoring came up far more often at this year’s joint sessions than in 2017, which might indicate growing interest, but reimbursement remains a challenge. American Medical Association staff said at this year’s meeting that they are working with the Centers for Medicare & Medicaid Services for coverage of the devices and their use. It seemed likely to them.

In the meantime, Dr. Bosworth had some useful advice for those who are thinking about incorporating home BP monitoring into their practices.

He shared his tips on how to pick out a device – there’s actually a journal called Blood Pressure Monitoring that can help – as well as his thoughts on how often people should monitor themselves and what to do with the numbers.

He envisions a future when patients routinely check their BP at home; it’s even possible they could adjust their medications based on the results, much like diabetes patients track their blood glucose and adjust their insulin. It’s been shown to work in Britain (JAMA. 2014 Aug 27;312[8]:799-808).

Dr. Bosworth reported no relevant disclosures.

[email protected]

An intensive and multifaceted online diabetes prevention program is as effective as face-to-face programs and has the potential to expand reach to those at risk of developing diabetes, researchers report.

Writing in background information to their paper, Tannaz Moin, MD, an endocrinologist at the VA Greater Los Angeles Healthcare System and the Veterans Affairs’ Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, and her associates, said intensive lifestyle interventions such as diabetes prevention programs (DPP) could lower the risk of incident diabetes by 58%, but a lack of reach significantly attenuated their population impact in real-world settings.

“Building evidence for online DPP is important because of its potential for increasing reach because most U.S. adults (87%) use the Internet,” they wrote in their paper, published in the American Journal of Preventive Medicine.

They therefore set out to compare weight loss results from 114 veterans taking part in the Veterans Administration’s face-to-face standard-of-care weight management program MOVE! with an online program involving 268 obese or overweight veterans with prediabetes and 273 people taking part in an in-person program.

MOVE! included 8-12 face-to-face healthy-lifestyle sessions and monthly maintenance sessions but with no specified goals. The online program involved virtual groups of participants: live e-coaches who monitored group interactions and provided the participants with feedback via phone and private online messages; weekly educational modules on healthy eating and exercise; and wireless scales to record participant weights.

The in-person program consisted of 8-22 group-based face-to-face sessions focused on 7% weight loss and at least 150 minutes per session of moderate physical activity.

Weight loss, considered by the authors to be a significant predictor of diabetes risk reduction, was recorded at 6 months and then again at 12 months in all three interventions.

An analysis of 242 participants enrolled in the intensive, multifaceted online DPP intervention (26 were excluded because they did not have more than two available weights) revealed a significant weight change of –4.7 kg at 6 months and –4 kg at 12 months’ follow-up.  On average, these participants lost 3.7% of their baseline weight at 12 months.

At both times weight change (kg and percentage) was not significantly different between the online intervention and those taking part in the in-person DPP (–4.8 and –4.1 kg for online vs –4 kg and –3.9 kg in-person for those completing more than one module/session). Both groups also had higher weight loss (percentage and kg) at 6 and 12 months compared with MOVE! participants (–1.1kg and 0.10 kg).

The research team noted that the online program had better participation than did the in-person program, with 87% of online participants completing eight or more sessions, compared with 59% for the in-person program and 55% for MOVE!

They suggested this was because the online program had several user-friendly features that increased the frequency of potential “touches” participants received over time.

“Future studies examining how inline DPP intervention components can work together to impact participation and engagement are key,” they said.

“This is one of the first studies to report weight outcomes irrespective of the level of engagement with an online DPP intervention and to examine outcomes compared with in person DPP. Overall, these findings may have important implications for national efforts to disseminate DPP,” they concluded.

The authors conceded that the generalizability of their study was limited as it included veterans receiving care in the VHA. 
 

SOURCE: Am J Prev Med. 2018 Sep 24. doi: 10.1016/j.amepre.2018.06.028

An intensive and multifaceted online diabetes prevention program is as effective as face-to-face programs and has the potential to expand reach to those at risk of developing diabetes, researchers report.

Writing in background information to their paper, Tannaz Moin, MD, an endocrinologist at the VA Greater Los Angeles Healthcare System and the Veterans Affairs’ Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, and her associates, said intensive lifestyle interventions such as diabetes prevention programs (DPP) could lower the risk of incident diabetes by 58%, but a lack of reach significantly attenuated their population impact in real-world settings.

“Building evidence for online DPP is important because of its potential for increasing reach because most U.S. adults (87%) use the Internet,” they wrote in their paper, published in the American Journal of Preventive Medicine.

They therefore set out to compare weight loss results from 114 veterans taking part in the Veterans Administration’s face-to-face standard-of-care weight management program MOVE! with an online program involving 268 obese or overweight veterans with prediabetes and 273 people taking part in an in-person program.

MOVE! included 8-12 face-to-face healthy-lifestyle sessions and monthly maintenance sessions but with no specified goals. The online program involved virtual groups of participants: live e-coaches who monitored group interactions and provided the participants with feedback via phone and private online messages; weekly educational modules on healthy eating and exercise; and wireless scales to record participant weights.

The in-person program consisted of 8-22 group-based face-to-face sessions focused on 7% weight loss and at least 150 minutes per session of moderate physical activity.

Weight loss, considered by the authors to be a significant predictor of diabetes risk reduction, was recorded at 6 months and then again at 12 months in all three interventions.

An analysis of 242 participants enrolled in the intensive, multifaceted online DPP intervention (26 were excluded because they did not have more than two available weights) revealed a significant weight change of –4.7 kg at 6 months and –4 kg at 12 months’ follow-up.  On average, these participants lost 3.7% of their baseline weight at 12 months.

At both times weight change (kg and percentage) was not significantly different between the online intervention and those taking part in the in-person DPP (–4.8 and –4.1 kg for online vs –4 kg and –3.9 kg in-person for those completing more than one module/session). Both groups also had higher weight loss (percentage and kg) at 6 and 12 months compared with MOVE! participants (–1.1kg and 0.10 kg).

The research team noted that the online program had better participation than did the in-person program, with 87% of online participants completing eight or more sessions, compared with 59% for the in-person program and 55% for MOVE!

They suggested this was because the online program had several user-friendly features that increased the frequency of potential “touches” participants received over time.

“Future studies examining how inline DPP intervention components can work together to impact participation and engagement are key,” they said.

“This is one of the first studies to report weight outcomes irrespective of the level of engagement with an online DPP intervention and to examine outcomes compared with in person DPP. Overall, these findings may have important implications for national efforts to disseminate DPP,” they concluded.

The authors conceded that the generalizability of their study was limited as it included veterans receiving care in the VHA. 
 

SOURCE: Am J Prev Med. 2018 Sep 24. doi: 10.1016/j.amepre.2018.06.028

An intensive and multifaceted online diabetes prevention program is as effective as face-to-face programs and has the potential to expand reach to those at risk of developing diabetes, researchers report.

Writing in background information to their paper, Tannaz Moin, MD, an endocrinologist at the VA Greater Los Angeles Healthcare System and the Veterans Affairs’ Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, and her associates, said intensive lifestyle interventions such as diabetes prevention programs (DPP) could lower the risk of incident diabetes by 58%, but a lack of reach significantly attenuated their population impact in real-world settings.

“Building evidence for online DPP is important because of its potential for increasing reach because most U.S. adults (87%) use the Internet,” they wrote in their paper, published in the American Journal of Preventive Medicine.

They therefore set out to compare weight loss results from 114 veterans taking part in the Veterans Administration’s face-to-face standard-of-care weight management program MOVE! with an online program involving 268 obese or overweight veterans with prediabetes and 273 people taking part in an in-person program.

MOVE! included 8-12 face-to-face healthy-lifestyle sessions and monthly maintenance sessions but with no specified goals. The online program involved virtual groups of participants: live e-coaches who monitored group interactions and provided the participants with feedback via phone and private online messages; weekly educational modules on healthy eating and exercise; and wireless scales to record participant weights.

The in-person program consisted of 8-22 group-based face-to-face sessions focused on 7% weight loss and at least 150 minutes per session of moderate physical activity.

Weight loss, considered by the authors to be a significant predictor of diabetes risk reduction, was recorded at 6 months and then again at 12 months in all three interventions.

An analysis of 242 participants enrolled in the intensive, multifaceted online DPP intervention (26 were excluded because they did not have more than two available weights) revealed a significant weight change of –4.7 kg at 6 months and –4 kg at 12 months’ follow-up.  On average, these participants lost 3.7% of their baseline weight at 12 months.

At both times weight change (kg and percentage) was not significantly different between the online intervention and those taking part in the in-person DPP (–4.8 and –4.1 kg for online vs –4 kg and –3.9 kg in-person for those completing more than one module/session). Both groups also had higher weight loss (percentage and kg) at 6 and 12 months compared with MOVE! participants (–1.1kg and 0.10 kg).

The research team noted that the online program had better participation than did the in-person program, with 87% of online participants completing eight or more sessions, compared with 59% for the in-person program and 55% for MOVE!

They suggested this was because the online program had several user-friendly features that increased the frequency of potential “touches” participants received over time.

“Future studies examining how inline DPP intervention components can work together to impact participation and engagement are key,” they said.

“This is one of the first studies to report weight outcomes irrespective of the level of engagement with an online DPP intervention and to examine outcomes compared with in person DPP. Overall, these findings may have important implications for national efforts to disseminate DPP,” they concluded.

The authors conceded that the generalizability of their study was limited as it included veterans receiving care in the VHA. 
 

SOURCE: Am J Prev Med. 2018 Sep 24. doi: 10.1016/j.amepre.2018.06.028

Subcutaneous apomorphine infusion significantly reduces off time in patients with Parkinson’s disease and inadequately controlled motor fluctuations, according to data published in the September issue of Lancet Neurology. The data result from the first randomized controlled trial of apomorphine in this population.

In 1988, an open-label study indicated that apomorphine had antiparkinsonian efficacy equivalent to that of levodopa. Several uncontrolled studies have indicated that it effectively reduces off time, improves dyskinesias, and allows doses of oral levodopa to be decreased.

A Multicenter European Study

Regina Katzenschlager, MD, a neurologist at Danube Hospital in Vienna, and colleagues investigated the safety and efficacy of apomorphine infusion in a randomized, placebo-controlled, double-blind trial. They enrolled patients at 23 European hospitals who had received a diagnosis of Parkinson’s disease more than three years previously and had motor fluctuations that were inadequately controlled. Patients were randomized in equal groups to 3–8-mg/h infusions of apomorphine or saline for approximately 16 h/day. The treatment period lasted for 12 weeks. During the first four weeks, investigators adjusted the dose according to efficacy and tolerability, and the remaining eight weeks were a maintenance period.