LIVERPOOL, ENGLAND – The measurement of acoustic emissions and kinetic instability of the knee could become a promising noninvasive way to detect osteoarthritis (OA), according to a recent study.

Researchers at the University of Oulu (Finland) have developed a prototype device that allows multimodal assessment of the sound and motion of the knee.

“The OA diagnostic chain has many problems, some modalities are very expensive, and some have a low sensitivity as well,” said study investigator Aleksei Tiulpin, MSc, at the World Congress on Osteoarthritis, referring to magnetic resonance imaging, x-ray imaging, and symptomatic assessment, respectively.

Sara Freeman/MDedge News

The participants were asked to perform three exercise tests while wearing the device. First, they had to stand from a sitting position 10 times. Second, they were asked to extend the leg from the knee while sitting down (flexion-extension) 10 times. Third, and finally, they were asked to perform a one leg stand on the right leg twice.

For the acoustic data analysis, data from the standing phase of the sit-to-stand test and the extension phase of the flexion-extension tests were used. Mr. Tuilpin explained that the acoustic signals underwent processing to segment and filter them into candidate locations. The average sound patterns seen in the candidate locations were then analyzed, then a consistency analysis was undertaken. With this approach, inconsistent patterns of knee crepitation could be captured, Mr. Tiulpin explained.

Kinematic signals received from the movement sensors were used to determine the degree of knee instability. Higher signal magnitudes could potentially indicate stability problems, which can be quantified using signal power, Mr. Tiulpin’s slides stated.

A variety of statistical calculations were made to see how well the device might predict OA changes, and a model combining body mass index and age had an area under the curve of 84%, which suggested that it might be possible to improve OA detection with the addition of the device versus BMI and age alone.

“Our results indicated highly promising applications of the method,” Mr. Tiulpin suggested.

These findings are “very interesting,” commented one of the moderators of the session, Erwin van Spil, MD, of University Medical Center Utrecht (The Netherlands) as he opened up the floor to questions.

“I’ve had this question for years … what causes the clicks?” one delegate asked Mr. Tiulpin during discussion. He responded that it could be down to many things, one of which is cartilage components grinding against each other.

Dr. Spil, who was not involved in the study, commented in an interview that using acoustics in the detection of knee OA was still quite a novel concept. “It’s noninvasive, which is quite unique in our general approach, and it might enable an early diagnosis of OA, which is what we are aiming for.”

Although the study did have control subjects, it’s not clear at this point whether very early OA was being assessed, Dr. Spil suggested. “We did not have the opportunity to ask about the OA characteristics. I think they had radiographic OA, but we don’t know the grade and we were not informed about the clinical situation, so we don’t know if anyone had pain, for example.”

Mr. Tiulpin did not have any conflicts of interest to disclose.

SOURCE: Tiulpin A et al. Osteoarthritis Cartilage 2018;26(1):S40–S41.

LIVERPOOL, ENGLAND – The measurement of acoustic emissions and kinetic instability of the knee could become a promising noninvasive way to detect osteoarthritis (OA), according to a recent study.

Researchers at the University of Oulu (Finland) have developed a prototype device that allows multimodal assessment of the sound and motion of the knee.

“The OA diagnostic chain has many problems, some modalities are very expensive, and some have a low sensitivity as well,” said study investigator Aleksei Tiulpin, MSc, at the World Congress on Osteoarthritis, referring to magnetic resonance imaging, x-ray imaging, and symptomatic assessment, respectively.

Sara Freeman/MDedge News

The participants were asked to perform three exercise tests while wearing the device. First, they had to stand from a sitting position 10 times. Second, they were asked to extend the leg from the knee while sitting down (flexion-extension) 10 times. Third, and finally, they were asked to perform a one leg stand on the right leg twice.

For the acoustic data analysis, data from the standing phase of the sit-to-stand test and the extension phase of the flexion-extension tests were used. Mr. Tuilpin explained that the acoustic signals underwent processing to segment and filter them into candidate locations. The average sound patterns seen in the candidate locations were then analyzed, then a consistency analysis was undertaken. With this approach, inconsistent patterns of knee crepitation could be captured, Mr. Tiulpin explained.

Kinematic signals received from the movement sensors were used to determine the degree of knee instability. Higher signal magnitudes could potentially indicate stability problems, which can be quantified using signal power, Mr. Tiulpin’s slides stated.

A variety of statistical calculations were made to see how well the device might predict OA changes, and a model combining body mass index and age had an area under the curve of 84%, which suggested that it might be possible to improve OA detection with the addition of the device versus BMI and age alone.

“Our results indicated highly promising applications of the method,” Mr. Tiulpin suggested.

These findings are “very interesting,” commented one of the moderators of the session, Erwin van Spil, MD, of University Medical Center Utrecht (The Netherlands) as he opened up the floor to questions.

“I’ve had this question for years … what causes the clicks?” one delegate asked Mr. Tiulpin during discussion. He responded that it could be down to many things, one of which is cartilage components grinding against each other.

Dr. Spil, who was not involved in the study, commented in an interview that using acoustics in the detection of knee OA was still quite a novel concept. “It’s noninvasive, which is quite unique in our general approach, and it might enable an early diagnosis of OA, which is what we are aiming for.”

Although the study did have control subjects, it’s not clear at this point whether very early OA was being assessed, Dr. Spil suggested. “We did not have the opportunity to ask about the OA characteristics. I think they had radiographic OA, but we don’t know the grade and we were not informed about the clinical situation, so we don’t know if anyone had pain, for example.”

Mr. Tiulpin did not have any conflicts of interest to disclose.

SOURCE: Tiulpin A et al. Osteoarthritis Cartilage 2018;26(1):S40–S41.

LIVERPOOL, ENGLAND – The measurement of acoustic emissions and kinetic instability of the knee could become a promising noninvasive way to detect osteoarthritis (OA), according to a recent study.

Researchers at the University of Oulu (Finland) have developed a prototype device that allows multimodal assessment of the sound and motion of the knee.

“The OA diagnostic chain has many problems, some modalities are very expensive, and some have a low sensitivity as well,” said study investigator Aleksei Tiulpin, MSc, at the World Congress on Osteoarthritis, referring to magnetic resonance imaging, x-ray imaging, and symptomatic assessment, respectively.

Sara Freeman/MDedge News

The participants were asked to perform three exercise tests while wearing the device. First, they had to stand from a sitting position 10 times. Second, they were asked to extend the leg from the knee while sitting down (flexion-extension) 10 times. Third, and finally, they were asked to perform a one leg stand on the right leg twice.

For the acoustic data analysis, data from the standing phase of the sit-to-stand test and the extension phase of the flexion-extension tests were used. Mr. Tuilpin explained that the acoustic signals underwent processing to segment and filter them into candidate locations. The average sound patterns seen in the candidate locations were then analyzed, then a consistency analysis was undertaken. With this approach, inconsistent patterns of knee crepitation could be captured, Mr. Tiulpin explained.

Kinematic signals received from the movement sensors were used to determine the degree of knee instability. Higher signal magnitudes could potentially indicate stability problems, which can be quantified using signal power, Mr. Tiulpin’s slides stated.

A variety of statistical calculations were made to see how well the device might predict OA changes, and a model combining body mass index and age had an area under the curve of 84%, which suggested that it might be possible to improve OA detection with the addition of the device versus BMI and age alone.

“Our results indicated highly promising applications of the method,” Mr. Tiulpin suggested.

These findings are “very interesting,” commented one of the moderators of the session, Erwin van Spil, MD, of University Medical Center Utrecht (The Netherlands) as he opened up the floor to questions.

“I’ve had this question for years … what causes the clicks?” one delegate asked Mr. Tiulpin during discussion. He responded that it could be down to many things, one of which is cartilage components grinding against each other.

Dr. Spil, who was not involved in the study, commented in an interview that using acoustics in the detection of knee OA was still quite a novel concept. “It’s noninvasive, which is quite unique in our general approach, and it might enable an early diagnosis of OA, which is what we are aiming for.”

Although the study did have control subjects, it’s not clear at this point whether very early OA was being assessed, Dr. Spil suggested. “We did not have the opportunity to ask about the OA characteristics. I think they had radiographic OA, but we don’t know the grade and we were not informed about the clinical situation, so we don’t know if anyone had pain, for example.”

Mr. Tiulpin did not have any conflicts of interest to disclose.

SOURCE: Tiulpin A et al. Osteoarthritis Cartilage 2018;26(1):S40–S41.

First Anti-CGRP Monoclonal Antibody Gains FDA Approval

The FDA approved Aimovig (erenumab-aooe) for the preventive treatment of migraine in adults. Aimovig is the first FDA-approved preventive migraine treatment in a new class of drugs that blocks the activity of calcitonin gene-related peptide (CGRP). The treatment is given by once-monthly self-injections. Aimovig’s effectiveness was evaluated in three placebo-controlled clinical trials. The first included 955 patients with episodic migraine. Over six months, treated patients had, on average, one to two fewer monthly migraine days than controls. The second study included 577 patients with episodic migraine. Over three months, treated patients had, on average, one fewer migraine day per month than controls. The third study evaluated 667 patients with chronic migraine. Over three months, treated patients had, on average, 2.5 fewer monthly migraine days than controls. Aimovig is marketed by Amgen.

FDA Approves Gilenya for Pediatric Use

The FDA has approved Gilenya (fingolimod) for the treatment of children and adolescents between the ages of 10 and 18 with relapsing forms of multiple sclerosis (MS), making it the first disease-modifying therapy indicated for these young patients. The approval extends the age range for the drug, which was previously approved for patients age 18 and older with relapsing MS. Gilenya was granted Breakthrough Therapy status in December 2017 for this pediatric indication. The approval was supported by PARADIGMS, a double-blind, randomized, multicenter phase III safety and efficacy study of Gilenya versus interferon beta-1a. In this study, oral Gilenya reduced the annualized relapse rate by approximately 82% for as long as two years, compared with interferon beta-1a intramuscular injections in adolescents with relapsing MS. Gilenya is marketed by Novartis.

FDA Approves Treatment for CIDP

The FDA has approved Hizentra (immune globulin subcutaneous [human] 20% liquid) as the first subcutaneous immunoglobulin (SCIg) for the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) as maintenance therapy to prevent relapse of neuromuscular disability and impairment. The approval was based on the phase III PATH study, which was the largest controlled clinical study of patients with CIDP to date. The percentage of patients experiencing CIDP relapse or withdrawal for any other reason during SCIg treatment was significantly lower with Hizentra (38.6% on low-dose Hizentra [0.2 g/kg weekly], 32.8% on high-dose Hizentra [0.4 g/kg weekly]) than with placebo (63.2%). Treated patients reported fewer systemic adverse reactions per infusion, compared with IVIg treatment (2.7% vs 9.8%, respectively). Approximately 93% of infusions caused no adverse reactions. Hizentra is marketed by CSL Behring.

DBS Device Approved for Refractory Epilepsy

The FDA granted premarket approval for Medtronic’s deep brain stimulation (DBS) therapy as adjunctive treatment for reducing the frequency of partial-onset seizures in patients age 18 or older who are refractory to three or more antiepileptic drugs. The approval is based on the blinded phase and seven-year follow-up data from the SANTE trial, which included 110 patients. The median total seizure frequency reduction from baseline was 40.4% in implanted patients versus 14.5% for the placebo group at three months and 75% at seven years with ongoing open-label therapy. Twenty subjects (18%) had at least one six-month seizure-free period between implant and year seven, including eight subjects (7%) who were seizure-free for the preceding two years. Seizure severity and quality-of-life scales showed statistically significant improvement from baseline to year seven. No significant cognitive declines or worsening of depression were noted.

FDA Issues Warning About Lamictal

The FDA recently warned that Lamictal (lamotrigine), frequently used for treating seizures and bipolar disorder, can cause a rare but serious immune system reaction called hemophagocytic lymphohistiocytosis (HLH), which can be life-threatening. HLH typically presents as a persistent fever, usually greater than 101° F, and can lead to severe problems with blood cells and vital organs. Health care professionals should be aware that prompt recognition and early treatment are important for improving HLH outcomes and decreasing mortality. Diagnosis is often complicated because early signs and symptoms, such as rash and fever, are not specific. HLH also may be confused with other serious immune-related adverse reactions such as drug reaction with eosinophilia and systemic symptoms (DRESS). The FDA is requiring a change to the drug’s prescribing information and drug labeling.

First Anti-CGRP Monoclonal Antibody Gains FDA Approval

The FDA approved Aimovig (erenumab-aooe) for the preventive treatment of migraine in adults. Aimovig is the first FDA-approved preventive migraine treatment in a new class of drugs that blocks the activity of calcitonin gene-related peptide (CGRP). The treatment is given by once-monthly self-injections. Aimovig’s effectiveness was evaluated in three placebo-controlled clinical trials. The first included 955 patients with episodic migraine. Over six months, treated patients had, on average, one to two fewer monthly migraine days than controls. The second study included 577 patients with episodic migraine. Over three months, treated patients had, on average, one fewer migraine day per month than controls. The third study evaluated 667 patients with chronic migraine. Over three months, treated patients had, on average, 2.5 fewer monthly migraine days than controls. Aimovig is marketed by Amgen.

FDA Approves Gilenya for Pediatric Use

The FDA has approved Gilenya (fingolimod) for the treatment of children and adolescents between the ages of 10 and 18 with relapsing forms of multiple sclerosis (MS), making it the first disease-modifying therapy indicated for these young patients. The approval extends the age range for the drug, which was previously approved for patients age 18 and older with relapsing MS. Gilenya was granted Breakthrough Therapy status in December 2017 for this pediatric indication. The approval was supported by PARADIGMS, a double-blind, randomized, multicenter phase III safety and efficacy study of Gilenya versus interferon beta-1a. In this study, oral Gilenya reduced the annualized relapse rate by approximately 82% for as long as two years, compared with interferon beta-1a intramuscular injections in adolescents with relapsing MS. Gilenya is marketed by Novartis.

FDA Approves Treatment for CIDP

The FDA has approved Hizentra (immune globulin subcutaneous [human] 20% liquid) as the first subcutaneous immunoglobulin (SCIg) for the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) as maintenance therapy to prevent relapse of neuromuscular disability and impairment. The approval was based on the phase III PATH study, which was the largest controlled clinical study of patients with CIDP to date. The percentage of patients experiencing CIDP relapse or withdrawal for any other reason during SCIg treatment was significantly lower with Hizentra (38.6% on low-dose Hizentra [0.2 g/kg weekly], 32.8% on high-dose Hizentra [0.4 g/kg weekly]) than with placebo (63.2%). Treated patients reported fewer systemic adverse reactions per infusion, compared with IVIg treatment (2.7% vs 9.8%, respectively). Approximately 93% of infusions caused no adverse reactions. Hizentra is marketed by CSL Behring.

DBS Device Approved for Refractory Epilepsy

The FDA granted premarket approval for Medtronic’s deep brain stimulation (DBS) therapy as adjunctive treatment for reducing the frequency of partial-onset seizures in patients age 18 or older who are refractory to three or more antiepileptic drugs. The approval is based on the blinded phase and seven-year follow-up data from the SANTE trial, which included 110 patients. The median total seizure frequency reduction from baseline was 40.4% in implanted patients versus 14.5% for the placebo group at three months and 75% at seven years with ongoing open-label therapy. Twenty subjects (18%) had at least one six-month seizure-free period between implant and year seven, including eight subjects (7%) who were seizure-free for the preceding two years. Seizure severity and quality-of-life scales showed statistically significant improvement from baseline to year seven. No significant cognitive declines or worsening of depression were noted.

FDA Issues Warning About Lamictal

The FDA recently warned that Lamictal (lamotrigine), frequently used for treating seizures and bipolar disorder, can cause a rare but serious immune system reaction called hemophagocytic lymphohistiocytosis (HLH), which can be life-threatening. HLH typically presents as a persistent fever, usually greater than 101° F, and can lead to severe problems with blood cells and vital organs. Health care professionals should be aware that prompt recognition and early treatment are important for improving HLH outcomes and decreasing mortality. Diagnosis is often complicated because early signs and symptoms, such as rash and fever, are not specific. HLH also may be confused with other serious immune-related adverse reactions such as drug reaction with eosinophilia and systemic symptoms (DRESS). The FDA is requiring a change to the drug’s prescribing information and drug labeling.

First Anti-CGRP Monoclonal Antibody Gains FDA Approval

The FDA approved Aimovig (erenumab-aooe) for the preventive treatment of migraine in adults. Aimovig is the first FDA-approved preventive migraine treatment in a new class of drugs that blocks the activity of calcitonin gene-related peptide (CGRP). The treatment is given by once-monthly self-injections. Aimovig’s effectiveness was evaluated in three placebo-controlled clinical trials. The first included 955 patients with episodic migraine. Over six months, treated patients had, on average, one to two fewer monthly migraine days than controls. The second study included 577 patients with episodic migraine. Over three months, treated patients had, on average, one fewer migraine day per month than controls. The third study evaluated 667 patients with chronic migraine. Over three months, treated patients had, on average, 2.5 fewer monthly migraine days than controls. Aimovig is marketed by Amgen.

FDA Approves Gilenya for Pediatric Use

The FDA has approved Gilenya (fingolimod) for the treatment of children and adolescents between the ages of 10 and 18 with relapsing forms of multiple sclerosis (MS), making it the first disease-modifying therapy indicated for these young patients. The approval extends the age range for the drug, which was previously approved for patients age 18 and older with relapsing MS. Gilenya was granted Breakthrough Therapy status in December 2017 for this pediatric indication. The approval was supported by PARADIGMS, a double-blind, randomized, multicenter phase III safety and efficacy study of Gilenya versus interferon beta-1a. In this study, oral Gilenya reduced the annualized relapse rate by approximately 82% for as long as two years, compared with interferon beta-1a intramuscular injections in adolescents with relapsing MS. Gilenya is marketed by Novartis.

FDA Approves Treatment for CIDP

The FDA has approved Hizentra (immune globulin subcutaneous [human] 20% liquid) as the first subcutaneous immunoglobulin (SCIg) for the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) as maintenance therapy to prevent relapse of neuromuscular disability and impairment. The approval was based on the phase III PATH study, which was the largest controlled clinical study of patients with CIDP to date. The percentage of patients experiencing CIDP relapse or withdrawal for any other reason during SCIg treatment was significantly lower with Hizentra (38.6% on low-dose Hizentra [0.2 g/kg weekly], 32.8% on high-dose Hizentra [0.4 g/kg weekly]) than with placebo (63.2%). Treated patients reported fewer systemic adverse reactions per infusion, compared with IVIg treatment (2.7% vs 9.8%, respectively). Approximately 93% of infusions caused no adverse reactions. Hizentra is marketed by CSL Behring.

DBS Device Approved for Refractory Epilepsy

The FDA granted premarket approval for Medtronic’s deep brain stimulation (DBS) therapy as adjunctive treatment for reducing the frequency of partial-onset seizures in patients age 18 or older who are refractory to three or more antiepileptic drugs. The approval is based on the blinded phase and seven-year follow-up data from the SANTE trial, which included 110 patients. The median total seizure frequency reduction from baseline was 40.4% in implanted patients versus 14.5% for the placebo group at three months and 75% at seven years with ongoing open-label therapy. Twenty subjects (18%) had at least one six-month seizure-free period between implant and year seven, including eight subjects (7%) who were seizure-free for the preceding two years. Seizure severity and quality-of-life scales showed statistically significant improvement from baseline to year seven. No significant cognitive declines or worsening of depression were noted.

FDA Issues Warning About Lamictal

The FDA recently warned that Lamictal (lamotrigine), frequently used for treating seizures and bipolar disorder, can cause a rare but serious immune system reaction called hemophagocytic lymphohistiocytosis (HLH), which can be life-threatening. HLH typically presents as a persistent fever, usually greater than 101° F, and can lead to severe problems with blood cells and vital organs. Health care professionals should be aware that prompt recognition and early treatment are important for improving HLH outcomes and decreasing mortality. Diagnosis is often complicated because early signs and symptoms, such as rash and fever, are not specific. HLH also may be confused with other serious immune-related adverse reactions such as drug reaction with eosinophilia and systemic symptoms (DRESS). The FDA is requiring a change to the drug’s prescribing information and drug labeling.

The 2018 Vascular Annual Meeting is less than a month away. Join colleagues and friends in Boston for this year’s VAM, June 20 to 23. Scientific sessions are June 21-23 and the Exhibit Hall is open June 21 to 22. Click here to register and here to obtain housing (the deadline for housing currently is today, May 22). To get a full schedule and begin creating your own personal agenda, complete with marking sessions as favorites, see the VAM Planner.

The 2018 Vascular Annual Meeting is less than a month away. Join colleagues and friends in Boston for this year’s VAM, June 20 to 23. Scientific sessions are June 21-23 and the Exhibit Hall is open June 21 to 22. Click here to register and here to obtain housing (the deadline for housing currently is today, May 22). To get a full schedule and begin creating your own personal agenda, complete with marking sessions as favorites, see the VAM Planner.

The 2018 Vascular Annual Meeting is less than a month away. Join colleagues and friends in Boston for this year’s VAM, June 20 to 23. Scientific sessions are June 21-23 and the Exhibit Hall is open June 21 to 22. Click here to register and here to obtain housing (the deadline for housing currently is today, May 22). To get a full schedule and begin creating your own personal agenda, complete with marking sessions as favorites, see the VAM Planner.

The planned revival of a policy dating to Ronald Reagan’s presidency may finally present a way for President Donald Trump to fulfill his campaign promise to “defund” Planned Parenthood. Or at least to evict it from the federal family planning program, where it provides care to more than 40% of that program’s 4 million patients.

Congress last year failed to wipe out funding for Planned Parenthood, because the bill faced overwhelming Democratic objections and would not have received the 60 votes needed to pass in the Senate.

But the imposition of a slightly retooled version of a regulation, which was upheld by the Supreme Court in 1991 after a 5-year fight, could potentially accomplish what Congress could not.

The rules now under review, according to Trump administration officials, would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.

All those changes would particularly affect Planned Parenthood.

Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion groups, which supported candidate Trump.

“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, said in a statement.

In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.

“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.

Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:

What is Title X?

The federal family planning program, known as “Title Ten,” is named for its section in the federal Public Health Service Act. It became law in 1970, 3 years before the Supreme Court legalized abortion in Roe v Wade.

The original bill was sponsored by then Rep. George H.W. Bush (R-Texas) and signed into law by President Richard Nixon.

The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.

In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.

Title X patients are overwhelmingly young, female, and low-income. An estimated 11% of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.

What is Planned Parenthood’s relationship to Title X and Medicaid?

Planned Parenthood affiliates account for about 13% of total Title X sites but serve an estimated 40% of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.

Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X.

Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding is likely not at risk.

While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.

Texas, Iowa, and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials said.

Why is Planned Parenthood’s involvement with Title X controversial?

Even though Planned Parenthood cannot use federal funding for abortions, anti-abortion groups claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.

Planned Parenthood has also been a longtime public target for anti-abortion forces because it is such a visible provider and vocal proponent of legal abortion services.

In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control. That was followed by efforts to eliminate abortion counseling.

Starting in 2011, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts in an effort to get the organization defunded. Planned Parenthood denies the allegations.

What happened the last time an administration tried to move Planned Parenthood out of Title X?

In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the administration’s new proposal is not yet public, because the details are still under review by the Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.

The original gag rule would have forbidden Title X providers from abortion counseling or referring patients for abortions, required physical separation of Title X and abortion-providing facilities and forbidden recipients from using nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)

Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v Sullivan.

Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel patients on the availability of abortion created another round of legal fights.

Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president tried to revive them until now.

How is the Trump administration’s proposal different from earlier rules?

According to the summary of the new proposal, released May 18, it will require physical separation of family planning and abortion facilities, repeal current counseling requirements, and ban abortion referrals.

One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.

But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.

Kashif Syed, a senior policy analyst for the organization said: “Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule.”

What happens next?

All proposed rules are reviewed by the Office of Management and Budget. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.

Meanwhile, Planned Parenthood officials said they will not know if they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the changes that have been made public so far.
 

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

The planned revival of a policy dating to Ronald Reagan’s presidency may finally present a way for President Donald Trump to fulfill his campaign promise to “defund” Planned Parenthood. Or at least to evict it from the federal family planning program, where it provides care to more than 40% of that program’s 4 million patients.

Congress last year failed to wipe out funding for Planned Parenthood, because the bill faced overwhelming Democratic objections and would not have received the 60 votes needed to pass in the Senate.

But the imposition of a slightly retooled version of a regulation, which was upheld by the Supreme Court in 1991 after a 5-year fight, could potentially accomplish what Congress could not.

The rules now under review, according to Trump administration officials, would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.

All those changes would particularly affect Planned Parenthood.

Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion groups, which supported candidate Trump.

“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, said in a statement.

In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.

“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.

Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:

What is Title X?

The federal family planning program, known as “Title Ten,” is named for its section in the federal Public Health Service Act. It became law in 1970, 3 years before the Supreme Court legalized abortion in Roe v Wade.

The original bill was sponsored by then Rep. George H.W. Bush (R-Texas) and signed into law by President Richard Nixon.

The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.

In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.

Title X patients are overwhelmingly young, female, and low-income. An estimated 11% of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.

What is Planned Parenthood’s relationship to Title X and Medicaid?

Planned Parenthood affiliates account for about 13% of total Title X sites but serve an estimated 40% of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.

Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X.

Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding is likely not at risk.

While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.

Texas, Iowa, and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials said.

Why is Planned Parenthood’s involvement with Title X controversial?

Even though Planned Parenthood cannot use federal funding for abortions, anti-abortion groups claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.

Planned Parenthood has also been a longtime public target for anti-abortion forces because it is such a visible provider and vocal proponent of legal abortion services.

In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control. That was followed by efforts to eliminate abortion counseling.

Starting in 2011, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts in an effort to get the organization defunded. Planned Parenthood denies the allegations.

What happened the last time an administration tried to move Planned Parenthood out of Title X?

In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the administration’s new proposal is not yet public, because the details are still under review by the Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.

The original gag rule would have forbidden Title X providers from abortion counseling or referring patients for abortions, required physical separation of Title X and abortion-providing facilities and forbidden recipients from using nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)

Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v Sullivan.

Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel patients on the availability of abortion created another round of legal fights.

Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president tried to revive them until now.

How is the Trump administration’s proposal different from earlier rules?

According to the summary of the new proposal, released May 18, it will require physical separation of family planning and abortion facilities, repeal current counseling requirements, and ban abortion referrals.

One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.

But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.

Kashif Syed, a senior policy analyst for the organization said: “Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule.”

What happens next?

All proposed rules are reviewed by the Office of Management and Budget. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.

Meanwhile, Planned Parenthood officials said they will not know if they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the changes that have been made public so far.
 

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

The planned revival of a policy dating to Ronald Reagan’s presidency may finally present a way for President Donald Trump to fulfill his campaign promise to “defund” Planned Parenthood. Or at least to evict it from the federal family planning program, where it provides care to more than 40% of that program’s 4 million patients.

Congress last year failed to wipe out funding for Planned Parenthood, because the bill faced overwhelming Democratic objections and would not have received the 60 votes needed to pass in the Senate.

But the imposition of a slightly retooled version of a regulation, which was upheld by the Supreme Court in 1991 after a 5-year fight, could potentially accomplish what Congress could not.

The rules now under review, according to Trump administration officials, would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.

All those changes would particularly affect Planned Parenthood.

Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion groups, which supported candidate Trump.

“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, said in a statement.

In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.

“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.

Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:

What is Title X?

The federal family planning program, known as “Title Ten,” is named for its section in the federal Public Health Service Act. It became law in 1970, 3 years before the Supreme Court legalized abortion in Roe v Wade.

The original bill was sponsored by then Rep. George H.W. Bush (R-Texas) and signed into law by President Richard Nixon.

The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.

In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.

Title X patients are overwhelmingly young, female, and low-income. An estimated 11% of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.

What is Planned Parenthood’s relationship to Title X and Medicaid?

Planned Parenthood affiliates account for about 13% of total Title X sites but serve an estimated 40% of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.

Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X.

Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding is likely not at risk.

While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.

Texas, Iowa, and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials said.

Why is Planned Parenthood’s involvement with Title X controversial?

Even though Planned Parenthood cannot use federal funding for abortions, anti-abortion groups claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.

Planned Parenthood has also been a longtime public target for anti-abortion forces because it is such a visible provider and vocal proponent of legal abortion services.

In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control. That was followed by efforts to eliminate abortion counseling.

Starting in 2011, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts in an effort to get the organization defunded. Planned Parenthood denies the allegations.

What happened the last time an administration tried to move Planned Parenthood out of Title X?

In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the administration’s new proposal is not yet public, because the details are still under review by the Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.

The original gag rule would have forbidden Title X providers from abortion counseling or referring patients for abortions, required physical separation of Title X and abortion-providing facilities and forbidden recipients from using nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)

Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v Sullivan.

Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel patients on the availability of abortion created another round of legal fights.

Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president tried to revive them until now.

How is the Trump administration’s proposal different from earlier rules?

According to the summary of the new proposal, released May 18, it will require physical separation of family planning and abortion facilities, repeal current counseling requirements, and ban abortion referrals.

One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.

But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.

Kashif Syed, a senior policy analyst for the organization said: “Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule.”

What happens next?

All proposed rules are reviewed by the Office of Management and Budget. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.

Meanwhile, Planned Parenthood officials said they will not know if they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the changes that have been made public so far.
 

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

[email protected]

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

[email protected]

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

[email protected]

NEW YORK – A mental health clinic started for an urban Hispanic community in Connecticut in 1972 continues to generate lessons on how to apply cultural sensitivity to improve care, according to a critical assessment of the program presented at the annual meeting of the American Psychiatric Association.

“Reviews of the literature show that there is a difference when clinicians are culturally responsive and sensitive to the populations they serve,” reported Esperanza Díaz, MD, of the department of psychiatry at Yale University and medical director, Latino Behavioral Health System (LBHS), both in New Haven, Conn.

Ted Bosworth/MDedge News

NEW YORK – A mental health clinic started for an urban Hispanic community in Connecticut in 1972 continues to generate lessons on how to apply cultural sensitivity to improve care, according to a critical assessment of the program presented at the annual meeting of the American Psychiatric Association.

“Reviews of the literature show that there is a difference when clinicians are culturally responsive and sensitive to the populations they serve,” reported Esperanza Díaz, MD, of the department of psychiatry at Yale University and medical director, Latino Behavioral Health System (LBHS), both in New Haven, Conn.

Ted Bosworth/MDedge News

NEW YORK – A mental health clinic started for an urban Hispanic community in Connecticut in 1972 continues to generate lessons on how to apply cultural sensitivity to improve care, according to a critical assessment of the program presented at the annual meeting of the American Psychiatric Association.

“Reviews of the literature show that there is a difference when clinicians are culturally responsive and sensitive to the populations they serve,” reported Esperanza Díaz, MD, of the department of psychiatry at Yale University and medical director, Latino Behavioral Health System (LBHS), both in New Haven, Conn.

Ted Bosworth/MDedge News

A system that automatically evaluates bone scans produces a measure that is prognostic for overall survival (OS) in patients with metastatic prostate cancer, investigators are reporting.

The automated bone scan index (BSI) produced by the artificial intelligence–based system provides prognostic discrimination beyond other established risk markers, investigators reported in JAMA Oncology.

The automated BSI also provides significantly greater discriminative ability compared with the current standard, which is manual assessment by counting metastatic lesion numbers, according to Andrew J. Armstrong, MD, of Duke University, Durham, N.C. and his coauthors.

“Incorporating the aBSI into clinical practice to supplement nuclear medicine reports may permit a more objective analysis of bone scan changes over time and their clinical relevance to patient care,” Dr. Armstrong and colleagues said.

The BSI represents tumor burden as a percentage of total skeletal weight. The system used in this study automates BSI methods by using artificial neural networks to detect metastatic hot spots and classify them as malignant or benign.

The automated system was evaluated in a preplanned secondary analysis of a randomized clinical trial of imiquimod in men with chemotherapy-naive metastatic castration-resistant prostate cancer. Evaluable bone scans were available for 721 out of 1,245 total enrollees from 241 sites in 37 countries.

In the secondary analysis, investigators found that baseline aBSI was significantly associated with OS. Risk of death increased by 20% for every doubling of the aBSI score (hazard ratio, 1.20; 95% confidence interval, 1.14-1.26; P less than .001).

The association remained significant in a multivariable model adjusting for five variables associated with OS: albumin, lactate dehydrogenase, C-reactive protein, serum prostate-specific antigen, and Eastern European geographic region.

In addition, the automated BSI had a better discriminating ability in prognosticating OS as compared to manual lesion counting (C-index of 0.63 and 0.60, respectively; P = .03), investigators said.

Secondary analyses showed the automated BSI was also associated with time to symptomatic progression, prostate cancer specific survival, and time to opiate use for cancer pain.

“These data support the clinical utility of the automated BSI, given its association with clinically relevant outcomes that are critically important in patient care,” wrote Dr. Armstrong and his colleagues.

The study was funded by EXINI Diagnostics AB, a subsidiary of Progenics Pharmaceuticals. The researchers reported disclosures related to EXINI Diagnostics AB and Active Biotech.

SOURCE: Armstrong AJ et al. JAMA Oncol. 2018 May 17. doi: 10.1001/jamaoncol.2018.1093.

A system that automatically evaluates bone scans produces a measure that is prognostic for overall survival (OS) in patients with metastatic prostate cancer, investigators are reporting.

The automated bone scan index (BSI) produced by the artificial intelligence–based system provides prognostic discrimination beyond other established risk markers, investigators reported in JAMA Oncology.

The automated BSI also provides significantly greater discriminative ability compared with the current standard, which is manual assessment by counting metastatic lesion numbers, according to Andrew J. Armstrong, MD, of Duke University, Durham, N.C. and his coauthors.

“Incorporating the aBSI into clinical practice to supplement nuclear medicine reports may permit a more objective analysis of bone scan changes over time and their clinical relevance to patient care,” Dr. Armstrong and colleagues said.

The BSI represents tumor burden as a percentage of total skeletal weight. The system used in this study automates BSI methods by using artificial neural networks to detect metastatic hot spots and classify them as malignant or benign.

The automated system was evaluated in a preplanned secondary analysis of a randomized clinical trial of imiquimod in men with chemotherapy-naive metastatic castration-resistant prostate cancer. Evaluable bone scans were available for 721 out of 1,245 total enrollees from 241 sites in 37 countries.

In the secondary analysis, investigators found that baseline aBSI was significantly associated with OS. Risk of death increased by 20% for every doubling of the aBSI score (hazard ratio, 1.20; 95% confidence interval, 1.14-1.26; P less than .001).

The association remained significant in a multivariable model adjusting for five variables associated with OS: albumin, lactate dehydrogenase, C-reactive protein, serum prostate-specific antigen, and Eastern European geographic region.

In addition, the automated BSI had a better discriminating ability in prognosticating OS as compared to manual lesion counting (C-index of 0.63 and 0.60, respectively; P = .03), investigators said.

Secondary analyses showed the automated BSI was also associated with time to symptomatic progression, prostate cancer specific survival, and time to opiate use for cancer pain.

“These data support the clinical utility of the automated BSI, given its association with clinically relevant outcomes that are critically important in patient care,” wrote Dr. Armstrong and his colleagues.

The study was funded by EXINI Diagnostics AB, a subsidiary of Progenics Pharmaceuticals. The researchers reported disclosures related to EXINI Diagnostics AB and Active Biotech.

SOURCE: Armstrong AJ et al. JAMA Oncol. 2018 May 17. doi: 10.1001/jamaoncol.2018.1093.

A system that automatically evaluates bone scans produces a measure that is prognostic for overall survival (OS) in patients with metastatic prostate cancer, investigators are reporting.

The automated bone scan index (BSI) produced by the artificial intelligence–based system provides prognostic discrimination beyond other established risk markers, investigators reported in JAMA Oncology.

The automated BSI also provides significantly greater discriminative ability compared with the current standard, which is manual assessment by counting metastatic lesion numbers, according to Andrew J. Armstrong, MD, of Duke University, Durham, N.C. and his coauthors.

“Incorporating the aBSI into clinical practice to supplement nuclear medicine reports may permit a more objective analysis of bone scan changes over time and their clinical relevance to patient care,” Dr. Armstrong and colleagues said.

The BSI represents tumor burden as a percentage of total skeletal weight. The system used in this study automates BSI methods by using artificial neural networks to detect metastatic hot spots and classify them as malignant or benign.

The automated system was evaluated in a preplanned secondary analysis of a randomized clinical trial of imiquimod in men with chemotherapy-naive metastatic castration-resistant prostate cancer. Evaluable bone scans were available for 721 out of 1,245 total enrollees from 241 sites in 37 countries.

In the secondary analysis, investigators found that baseline aBSI was significantly associated with OS. Risk of death increased by 20% for every doubling of the aBSI score (hazard ratio, 1.20; 95% confidence interval, 1.14-1.26; P less than .001).

The association remained significant in a multivariable model adjusting for five variables associated with OS: albumin, lactate dehydrogenase, C-reactive protein, serum prostate-specific antigen, and Eastern European geographic region.

In addition, the automated BSI had a better discriminating ability in prognosticating OS as compared to manual lesion counting (C-index of 0.63 and 0.60, respectively; P = .03), investigators said.

Secondary analyses showed the automated BSI was also associated with time to symptomatic progression, prostate cancer specific survival, and time to opiate use for cancer pain.

“These data support the clinical utility of the automated BSI, given its association with clinically relevant outcomes that are critically important in patient care,” wrote Dr. Armstrong and his colleagues.

The study was funded by EXINI Diagnostics AB, a subsidiary of Progenics Pharmaceuticals. The researchers reported disclosures related to EXINI Diagnostics AB and Active Biotech.

SOURCE: Armstrong AJ et al. JAMA Oncol. 2018 May 17. doi: 10.1001/jamaoncol.2018.1093.

Providing free and open access to its high-quality peer-reviewed articles has always been important to Federal Practitioner, but finding them hasn’t always been easy for our readers and researchers. That has now changed. The full text of all Federal Practitioner peer-reviewed articles, editorials, and columns published after December 2014 are now available through the National Library of Medicine (NLM) PubMed Central (PMC) index (https://www.ncbi.nlm.nih.gov/pmc/).

To be sure, Federal Practitioner has always made it easy for print and digital subscribers to find our articles. Print journal subscriptions have been—and will remain—free to the 35,000 subscribers. Furthermore, anyone can access articles online (http://mdedge.com/fedprac), in the Federal Practitioner app, or in our digital edition (http://www.fedprac-digital.com/).

However, until now access beyond our base of loyal readers has been limited. Inclusion in PMC provides a much broader audience for Federal Practitioner authors, because PMC is an integral part of the NLM MEDLINE/PubMed database of 28 million biomedical citations and abstracts from more than 5,000 journals. All PMC articles appear in PubMed searches. On a typical day, about 2.5 million users in the US access PubMed to perform about 3 million searches and access 9 million page views.¹

Inclusion also means that Federal Practitioner has passed a rigorous scientific and technical review of its content. Being included in PMC is a recognition of the quality of scholarship the journal publishes and a pledge of our continuing commitment to the highest quality of clinical education and research. Young investigators, clinician-educators, midcareer professionals, and others seeking to launch or enhance an academic career may want to consider or reconsider Federal Practitioner as the destination for manuscript submission.

One of the goals of this journal has been to provide a forum for federal health care providers (HCPs) to discuss and share with other federal colleagues. Federal HCPs from the Military Health System (MHS), Veterans Health Administration (VHA), and Indian Health Service (IHS) have addressed questions in Federal Practitioner that might not be explored elsewhere. Yet something important was missing from those conversations—engagement with the larger public health community. PubMed and PMC enable an ongoing conversation among health care researchers and providers. These are the places where researchers go to understand and respond to the questions that shape their research and clinical care. Now, Federal Practitioner authors can contribute more fully in ongoing debates.

As large integrated health care systems, the VHA, MHS, and IHS confront and address key public health care policy issues. Whether it’s the responsible and safe prescribing of opioids, the resource allocation decisions regarding the treatment of hepatitis C, or addressing suicide risk, the experience of federal HCPs must be a part of the public health debate. Moreover, many Federal Practitioner articles focus not just on preliminary research, but on the practical aspects of implementing patient-centered care. All US HCPs may benefit from hearing about federal providers challenges and success in providing patient-centered care.

Making available the complete text of all the articles furthers the Federal Practitioner mission: to educate federal HCPs and provide a forum for sharing health-care related studies, best practices, guidelines, program profiles, and case studies. We are excited to provide even more benefits for publication in Federal Practitioner. This journal welcomes submissions from new authors, well-traveled scholars, and everyone in between. Come on, join the conversation.

Providing free and open access to its high-quality peer-reviewed articles has always been important to Federal Practitioner, but finding them hasn’t always been easy for our readers and researchers. That has now changed. The full text of all Federal Practitioner peer-reviewed articles, editorials, and columns published after December 2014 are now available through the National Library of Medicine (NLM) PubMed Central (PMC) index (https://www.ncbi.nlm.nih.gov/pmc/).

To be sure, Federal Practitioner has always made it easy for print and digital subscribers to find our articles. Print journal subscriptions have been—and will remain—free to the 35,000 subscribers. Furthermore, anyone can access articles online (http://mdedge.com/fedprac), in the Federal Practitioner app, or in our digital edition (http://www.fedprac-digital.com/).

However, until now access beyond our base of loyal readers has been limited. Inclusion in PMC provides a much broader audience for Federal Practitioner authors, because PMC is an integral part of the NLM MEDLINE/PubMed database of 28 million biomedical citations and abstracts from more than 5,000 journals. All PMC articles appear in PubMed searches. On a typical day, about 2.5 million users in the US access PubMed to perform about 3 million searches and access 9 million page views.¹

Inclusion also means that Federal Practitioner has passed a rigorous scientific and technical review of its content. Being included in PMC is a recognition of the quality of scholarship the journal publishes and a pledge of our continuing commitment to the highest quality of clinical education and research. Young investigators, clinician-educators, midcareer professionals, and others seeking to launch or enhance an academic career may want to consider or reconsider Federal Practitioner as the destination for manuscript submission.

One of the goals of this journal has been to provide a forum for federal health care providers (HCPs) to discuss and share with other federal colleagues. Federal HCPs from the Military Health System (MHS), Veterans Health Administration (VHA), and Indian Health Service (IHS) have addressed questions in Federal Practitioner that might not be explored elsewhere. Yet something important was missing from those conversations—engagement with the larger public health community. PubMed and PMC enable an ongoing conversation among health care researchers and providers. These are the places where researchers go to understand and respond to the questions that shape their research and clinical care. Now, Federal Practitioner authors can contribute more fully in ongoing debates.

As large integrated health care systems, the VHA, MHS, and IHS confront and address key public health care policy issues. Whether it’s the responsible and safe prescribing of opioids, the resource allocation decisions regarding the treatment of hepatitis C, or addressing suicide risk, the experience of federal HCPs must be a part of the public health debate. Moreover, many Federal Practitioner articles focus not just on preliminary research, but on the practical aspects of implementing patient-centered care. All US HCPs may benefit from hearing about federal providers challenges and success in providing patient-centered care.

Making available the complete text of all the articles furthers the Federal Practitioner mission: to educate federal HCPs and provide a forum for sharing health-care related studies, best practices, guidelines, program profiles, and case studies. We are excited to provide even more benefits for publication in Federal Practitioner. This journal welcomes submissions from new authors, well-traveled scholars, and everyone in between. Come on, join the conversation.

Providing free and open access to its high-quality peer-reviewed articles has always been important to Federal Practitioner, but finding them hasn’t always been easy for our readers and researchers. That has now changed. The full text of all Federal Practitioner peer-reviewed articles, editorials, and columns published after December 2014 are now available through the National Library of Medicine (NLM) PubMed Central (PMC) index (https://www.ncbi.nlm.nih.gov/pmc/).

To be sure, Federal Practitioner has always made it easy for print and digital subscribers to find our articles. Print journal subscriptions have been—and will remain—free to the 35,000 subscribers. Furthermore, anyone can access articles online (http://mdedge.com/fedprac), in the Federal Practitioner app, or in our digital edition (http://www.fedprac-digital.com/).

However, until now access beyond our base of loyal readers has been limited. Inclusion in PMC provides a much broader audience for Federal Practitioner authors, because PMC is an integral part of the NLM MEDLINE/PubMed database of 28 million biomedical citations and abstracts from more than 5,000 journals. All PMC articles appear in PubMed searches. On a typical day, about 2.5 million users in the US access PubMed to perform about 3 million searches and access 9 million page views.¹

Inclusion also means that Federal Practitioner has passed a rigorous scientific and technical review of its content. Being included in PMC is a recognition of the quality of scholarship the journal publishes and a pledge of our continuing commitment to the highest quality of clinical education and research. Young investigators, clinician-educators, midcareer professionals, and others seeking to launch or enhance an academic career may want to consider or reconsider Federal Practitioner as the destination for manuscript submission.

One of the goals of this journal has been to provide a forum for federal health care providers (HCPs) to discuss and share with other federal colleagues. Federal HCPs from the Military Health System (MHS), Veterans Health Administration (VHA), and Indian Health Service (IHS) have addressed questions in Federal Practitioner that might not be explored elsewhere. Yet something important was missing from those conversations—engagement with the larger public health community. PubMed and PMC enable an ongoing conversation among health care researchers and providers. These are the places where researchers go to understand and respond to the questions that shape their research and clinical care. Now, Federal Practitioner authors can contribute more fully in ongoing debates.

As large integrated health care systems, the VHA, MHS, and IHS confront and address key public health care policy issues. Whether it’s the responsible and safe prescribing of opioids, the resource allocation decisions regarding the treatment of hepatitis C, or addressing suicide risk, the experience of federal HCPs must be a part of the public health debate. Moreover, many Federal Practitioner articles focus not just on preliminary research, but on the practical aspects of implementing patient-centered care. All US HCPs may benefit from hearing about federal providers challenges and success in providing patient-centered care.

Making available the complete text of all the articles furthers the Federal Practitioner mission: to educate federal HCPs and provide a forum for sharing health-care related studies, best practices, guidelines, program profiles, and case studies. We are excited to provide even more benefits for publication in Federal Practitioner. This journal welcomes submissions from new authors, well-traveled scholars, and everyone in between. Come on, join the conversation.

When interpreting tacrolimus levels, it is important to monitor changes in red blood cells (RBC). A patient who had hepatitis C virus (HCV) genotype 3A lesson reinforced that lesson for clinicians in the dialysis unit at Fraser Health in Abbotsford, Canada who authored a recent case report. Ribavirin-induced anemia reduced the level of tacrolimus in the patien, the authors reported.

The patient, a 37-year-old man, developed renal failure and received a kidney transplant, which subsequently failed (due to complications likely related to HCV). He had been started on tacrolimus while waiting to go back on the transplant list. Eight years later, the patient restarted hemodialysis (HD), with a regimen of sofosbuvir and ribavirin (SOF/RBV). His whole-blood tacrolimus level was 6.6 ng/mL (target 4–6); his hemoglobin (Hb) level was 10.3 g/dL. Two months later, the patient left for a 1-month vacation. When he returned, his Hb was “dramatically low,” at 3.7 g/dL.

The clinicians put the ribavirin on hold and increased darbepoetin. The patient was given packed RBCs; a bone marrow biopsy ruled out myeloproliferative disorder. Two weeks later, the tacrolimus level was 1.0 mg/mL and then dropped to an undetectable level 5 days later. The clinicians increased the dose. During the next month, the patient’s Hb “gradually bounced back,” to > 10 g/dL, whereupon the clinicians restarted RBV. When the tacrolimus level reached 7.2 ng/mL, the dosages were gradually cut back.  Sofosbuvir and RBV were stopped a couple of months later. The patient’s HCV RNA level was undetectable 12 weeks after therapy finished.

Practitioners are always facing the dilemma of risk (anemia) vs benefit (efficacy) in deciding whether and how much RBV should be reduced in renal impairment, the case report authors say. They note that the guidelines for treatment-naïve genotype 3 patients have changed. The recommendation for SOF/RBV has been replaced by one for glecaprevir/pibrentasvir or SOF/velpatasvir.

With the availability of newer direct antivirals, they add, the case again supports the abandoning of RBV-containing regimens. In the “very unlikely instance” that RBV is warranted in a patient on HD, the clinicians advise careful monitoring of Hb, especially 1 month after RBV therapy has started. Consider increasing the dosage of erythropoietin-stimulating agents if the patient’s Hb is at the lower end of the target range.

The decision to increase tacrolimus dosage based on a lower tacrolimus whole-blood concentration induced by anemia is “debatable,” the clinicians say. Nevertheless, this case reminds practitioners to take account of changes in RBC counts when interpreting tacrolimus levels—especially when a drastic change is not expected.

Source:

Liu HY, Cheung CYS, Cooper SE. BMJ Case Rep. 2018;2018. pii: bcr-2017-222477.
doi: 10.1136/bcr-2017-222477.

When interpreting tacrolimus levels, it is important to monitor changes in red blood cells (RBC). A patient who had hepatitis C virus (HCV) genotype 3A lesson reinforced that lesson for clinicians in the dialysis unit at Fraser Health in Abbotsford, Canada who authored a recent case report. Ribavirin-induced anemia reduced the level of tacrolimus in the patien, the authors reported.

The patient, a 37-year-old man, developed renal failure and received a kidney transplant, which subsequently failed (due to complications likely related to HCV). He had been started on tacrolimus while waiting to go back on the transplant list. Eight years later, the patient restarted hemodialysis (HD), with a regimen of sofosbuvir and ribavirin (SOF/RBV). His whole-blood tacrolimus level was 6.6 ng/mL (target 4–6); his hemoglobin (Hb) level was 10.3 g/dL. Two months later, the patient left for a 1-month vacation. When he returned, his Hb was “dramatically low,” at 3.7 g/dL.

The clinicians put the ribavirin on hold and increased darbepoetin. The patient was given packed RBCs; a bone marrow biopsy ruled out myeloproliferative disorder. Two weeks later, the tacrolimus level was 1.0 mg/mL and then dropped to an undetectable level 5 days later. The clinicians increased the dose. During the next month, the patient’s Hb “gradually bounced back,” to > 10 g/dL, whereupon the clinicians restarted RBV. When the tacrolimus level reached 7.2 ng/mL, the dosages were gradually cut back.  Sofosbuvir and RBV were stopped a couple of months later. The patient’s HCV RNA level was undetectable 12 weeks after therapy finished.

Practitioners are always facing the dilemma of risk (anemia) vs benefit (efficacy) in deciding whether and how much RBV should be reduced in renal impairment, the case report authors say. They note that the guidelines for treatment-naïve genotype 3 patients have changed. The recommendation for SOF/RBV has been replaced by one for glecaprevir/pibrentasvir or SOF/velpatasvir.

With the availability of newer direct antivirals, they add, the case again supports the abandoning of RBV-containing regimens. In the “very unlikely instance” that RBV is warranted in a patient on HD, the clinicians advise careful monitoring of Hb, especially 1 month after RBV therapy has started. Consider increasing the dosage of erythropoietin-stimulating agents if the patient’s Hb is at the lower end of the target range.

The decision to increase tacrolimus dosage based on a lower tacrolimus whole-blood concentration induced by anemia is “debatable,” the clinicians say. Nevertheless, this case reminds practitioners to take account of changes in RBC counts when interpreting tacrolimus levels—especially when a drastic change is not expected.

Source:

Liu HY, Cheung CYS, Cooper SE. BMJ Case Rep. 2018;2018. pii: bcr-2017-222477.
doi: 10.1136/bcr-2017-222477.

When interpreting tacrolimus levels, it is important to monitor changes in red blood cells (RBC). A patient who had hepatitis C virus (HCV) genotype 3A lesson reinforced that lesson for clinicians in the dialysis unit at Fraser Health in Abbotsford, Canada who authored a recent case report. Ribavirin-induced anemia reduced the level of tacrolimus in the patien, the authors reported.

The patient, a 37-year-old man, developed renal failure and received a kidney transplant, which subsequently failed (due to complications likely related to HCV). He had been started on tacrolimus while waiting to go back on the transplant list. Eight years later, the patient restarted hemodialysis (HD), with a regimen of sofosbuvir and ribavirin (SOF/RBV). His whole-blood tacrolimus level was 6.6 ng/mL (target 4–6); his hemoglobin (Hb) level was 10.3 g/dL. Two months later, the patient left for a 1-month vacation. When he returned, his Hb was “dramatically low,” at 3.7 g/dL.

The clinicians put the ribavirin on hold and increased darbepoetin. The patient was given packed RBCs; a bone marrow biopsy ruled out myeloproliferative disorder. Two weeks later, the tacrolimus level was 1.0 mg/mL and then dropped to an undetectable level 5 days later. The clinicians increased the dose. During the next month, the patient’s Hb “gradually bounced back,” to > 10 g/dL, whereupon the clinicians restarted RBV. When the tacrolimus level reached 7.2 ng/mL, the dosages were gradually cut back.  Sofosbuvir and RBV were stopped a couple of months later. The patient’s HCV RNA level was undetectable 12 weeks after therapy finished.

Practitioners are always facing the dilemma of risk (anemia) vs benefit (efficacy) in deciding whether and how much RBV should be reduced in renal impairment, the case report authors say. They note that the guidelines for treatment-naïve genotype 3 patients have changed. The recommendation for SOF/RBV has been replaced by one for glecaprevir/pibrentasvir or SOF/velpatasvir.

With the availability of newer direct antivirals, they add, the case again supports the abandoning of RBV-containing regimens. In the “very unlikely instance” that RBV is warranted in a patient on HD, the clinicians advise careful monitoring of Hb, especially 1 month after RBV therapy has started. Consider increasing the dosage of erythropoietin-stimulating agents if the patient’s Hb is at the lower end of the target range.

The decision to increase tacrolimus dosage based on a lower tacrolimus whole-blood concentration induced by anemia is “debatable,” the clinicians say. Nevertheless, this case reminds practitioners to take account of changes in RBC counts when interpreting tacrolimus levels—especially when a drastic change is not expected.

Source:

Liu HY, Cheung CYS, Cooper SE. BMJ Case Rep. 2018;2018. pii: bcr-2017-222477.
doi: 10.1136/bcr-2017-222477.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.