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APA guideline backs naltrexone, acamprosate for alcohol use disorder
Naltrexone or acamprosate should be offered as first-line pharmacologic therapy to patients with moderate to severe alcohol use disorder (AUD) who do not respond to nonpharmacologic therapy alone, according to a practice guideline published by the American Psychiatric Association.
if naltrexone and acamprosate are not effective or well tolerated, the report said.
The APA guideline recommends against the use of antidepressants and benzodiazepines for patients with alcohol use disorder, except for situations where a co-occurring disorder requires treatment. In addition, the guideline recommends against the use of acamprosate in patients with renal impairment, and specifies that naltrexone should not be used by patients with acute hepatitis, hepatic failure, or opioid dependence.
“Naltrexone and acamprosate have the best available evidence as pharmacotherapy for patients with AUD,” wrote Victor I. Reus, MD, and his coauthors in the APA Guideline Writing Group, which formed the guideline using a systematic review of current literature in accordance with Institute of Medicine (now called the National Academy of Medicine) and Agency for Healthcare Research and Quality standards.
Naltrexone, an opioid receptor antagonist, is effective in treating both AUD and opioid use disorder. Studies have shown that it may decrease cravings, and is associated with fewer drinking days and a reduced likelihood of return to drinking, the authors reported. In patients with a history of renal impairment, serum creatinine should be measured, and results should be reviewed before initiating treatment with acamprosate – a synthetic amino acid.
Disulfiram breaks down acetaldehyde, an ethanol byproduct, and should be used only to treat patients with a goal of abstinence. It is not recommended as a first-line therapy because of the side effects of concurrent alcohol use, including tachycardia, flushing, headache, nausea, and vomiting, reported Dr. Reus of the psychiatry department at the University of California, San Francisco, and his coauthors.
“Patients should be fully informed of the physiological consequences of consuming alcohol while taking disulfiram and should agree to taking the medication,” the authors wrote. “They should be instructed to abstain from drinking alcohol for at least 12 hours before taking a dose of the medication and be advised that reactions with alcohol can occur up to 14 days after taking disulfiram.”
Lastly, topiramate and gabapentin may be used in patients for whom naltrexone and acamprosate are ineffective, though topiramate may have side effects of concern to the patient, including cognitive dysfunction and numbness, tingling, paresthesias, dizziness, taste abnormalities, and decreased appetite or weight loss, the report said.
Although the APA guideline acknowledges the importance of psychiatric evaluation and nonpharmacologic treatments such as cognitive-behavioral therapy and 12-step programs, it does not provide recommendations on those treatment options.
Further research on alcohol use disorder should include study of quantitative measures for longitudinal monitoring, co-occurring medical and psychiatric conditions, and the effectiveness of naltrexone versus combination therapy for patients with both AUD and opioid use disorder, the authors said.
“The overall goal of this guideline is to enhance the treatment of AUD for millions of affected individuals, thereby reducing the significant psychosocial and public health consequences of this important psychiatric condition,” the report concluded. An executive summary of the guideline was published in the American Journal of Psychiatry.
The guideline authors disclosed no conflicts of interest with their work on the guideline.
SOURCE: Reus VI et al. Am J Psychiatry. 2018;175:86-90.
Naltrexone or acamprosate should be offered as first-line pharmacologic therapy to patients with moderate to severe alcohol use disorder (AUD) who do not respond to nonpharmacologic therapy alone, according to a practice guideline published by the American Psychiatric Association.
if naltrexone and acamprosate are not effective or well tolerated, the report said.
The APA guideline recommends against the use of antidepressants and benzodiazepines for patients with alcohol use disorder, except for situations where a co-occurring disorder requires treatment. In addition, the guideline recommends against the use of acamprosate in patients with renal impairment, and specifies that naltrexone should not be used by patients with acute hepatitis, hepatic failure, or opioid dependence.
“Naltrexone and acamprosate have the best available evidence as pharmacotherapy for patients with AUD,” wrote Victor I. Reus, MD, and his coauthors in the APA Guideline Writing Group, which formed the guideline using a systematic review of current literature in accordance with Institute of Medicine (now called the National Academy of Medicine) and Agency for Healthcare Research and Quality standards.
Naltrexone, an opioid receptor antagonist, is effective in treating both AUD and opioid use disorder. Studies have shown that it may decrease cravings, and is associated with fewer drinking days and a reduced likelihood of return to drinking, the authors reported. In patients with a history of renal impairment, serum creatinine should be measured, and results should be reviewed before initiating treatment with acamprosate – a synthetic amino acid.
Disulfiram breaks down acetaldehyde, an ethanol byproduct, and should be used only to treat patients with a goal of abstinence. It is not recommended as a first-line therapy because of the side effects of concurrent alcohol use, including tachycardia, flushing, headache, nausea, and vomiting, reported Dr. Reus of the psychiatry department at the University of California, San Francisco, and his coauthors.
“Patients should be fully informed of the physiological consequences of consuming alcohol while taking disulfiram and should agree to taking the medication,” the authors wrote. “They should be instructed to abstain from drinking alcohol for at least 12 hours before taking a dose of the medication and be advised that reactions with alcohol can occur up to 14 days after taking disulfiram.”
Lastly, topiramate and gabapentin may be used in patients for whom naltrexone and acamprosate are ineffective, though topiramate may have side effects of concern to the patient, including cognitive dysfunction and numbness, tingling, paresthesias, dizziness, taste abnormalities, and decreased appetite or weight loss, the report said.
Although the APA guideline acknowledges the importance of psychiatric evaluation and nonpharmacologic treatments such as cognitive-behavioral therapy and 12-step programs, it does not provide recommendations on those treatment options.
Further research on alcohol use disorder should include study of quantitative measures for longitudinal monitoring, co-occurring medical and psychiatric conditions, and the effectiveness of naltrexone versus combination therapy for patients with both AUD and opioid use disorder, the authors said.
“The overall goal of this guideline is to enhance the treatment of AUD for millions of affected individuals, thereby reducing the significant psychosocial and public health consequences of this important psychiatric condition,” the report concluded. An executive summary of the guideline was published in the American Journal of Psychiatry.
The guideline authors disclosed no conflicts of interest with their work on the guideline.
SOURCE: Reus VI et al. Am J Psychiatry. 2018;175:86-90.
Naltrexone or acamprosate should be offered as first-line pharmacologic therapy to patients with moderate to severe alcohol use disorder (AUD) who do not respond to nonpharmacologic therapy alone, according to a practice guideline published by the American Psychiatric Association.
if naltrexone and acamprosate are not effective or well tolerated, the report said.
The APA guideline recommends against the use of antidepressants and benzodiazepines for patients with alcohol use disorder, except for situations where a co-occurring disorder requires treatment. In addition, the guideline recommends against the use of acamprosate in patients with renal impairment, and specifies that naltrexone should not be used by patients with acute hepatitis, hepatic failure, or opioid dependence.
“Naltrexone and acamprosate have the best available evidence as pharmacotherapy for patients with AUD,” wrote Victor I. Reus, MD, and his coauthors in the APA Guideline Writing Group, which formed the guideline using a systematic review of current literature in accordance with Institute of Medicine (now called the National Academy of Medicine) and Agency for Healthcare Research and Quality standards.
Naltrexone, an opioid receptor antagonist, is effective in treating both AUD and opioid use disorder. Studies have shown that it may decrease cravings, and is associated with fewer drinking days and a reduced likelihood of return to drinking, the authors reported. In patients with a history of renal impairment, serum creatinine should be measured, and results should be reviewed before initiating treatment with acamprosate – a synthetic amino acid.
Disulfiram breaks down acetaldehyde, an ethanol byproduct, and should be used only to treat patients with a goal of abstinence. It is not recommended as a first-line therapy because of the side effects of concurrent alcohol use, including tachycardia, flushing, headache, nausea, and vomiting, reported Dr. Reus of the psychiatry department at the University of California, San Francisco, and his coauthors.
“Patients should be fully informed of the physiological consequences of consuming alcohol while taking disulfiram and should agree to taking the medication,” the authors wrote. “They should be instructed to abstain from drinking alcohol for at least 12 hours before taking a dose of the medication and be advised that reactions with alcohol can occur up to 14 days after taking disulfiram.”
Lastly, topiramate and gabapentin may be used in patients for whom naltrexone and acamprosate are ineffective, though topiramate may have side effects of concern to the patient, including cognitive dysfunction and numbness, tingling, paresthesias, dizziness, taste abnormalities, and decreased appetite or weight loss, the report said.
Although the APA guideline acknowledges the importance of psychiatric evaluation and nonpharmacologic treatments such as cognitive-behavioral therapy and 12-step programs, it does not provide recommendations on those treatment options.
Further research on alcohol use disorder should include study of quantitative measures for longitudinal monitoring, co-occurring medical and psychiatric conditions, and the effectiveness of naltrexone versus combination therapy for patients with both AUD and opioid use disorder, the authors said.
“The overall goal of this guideline is to enhance the treatment of AUD for millions of affected individuals, thereby reducing the significant psychosocial and public health consequences of this important psychiatric condition,” the report concluded. An executive summary of the guideline was published in the American Journal of Psychiatry.
The guideline authors disclosed no conflicts of interest with their work on the guideline.
SOURCE: Reus VI et al. Am J Psychiatry. 2018;175:86-90.
FROM THE AMERICAN JOURNAL OF PSYCHIATRY
Mutations on LRRK2 gene modify risks for both Crohn’s and Parkinson’s
Crohn’s and Parkinson’s diseases seem to share a common genetic risk pathway, mediated by mutations in a gene that modify disease risk in both directions.
A multidisciplinary collaboration of researchers have discovered that the Crohn’s risk variant N2081D in the leucine-rich repeat kinase 2 (LRRK2) gene lies close to variant G2019S, the major genetic risk factor for both sporadic and familial Parkinson’s. However, protective mutations also occur in the LRRK2 gene, and Ken Y. Hui, MD, of Yale University, New Haven, Conn., and his associates identified two that, when combined, significantly decrease the risk of Crohn’s.
The team first discovered the association in an exome sequencing study of 50 Crohn’s patients of Ashkenazi Jewish descent. This identified more than 4,000 potentially high-yield mutations, which they then examined in a pure Ashkenazi cohort of 1,477 Crohn’s patients and 2,614 healthy controls.
In this phase, the researchers found that N2081D in LRRK2 was associated with a 73% increased odds of Crohn’s. The LRRK2 N551K variant was associated with protection against Crohn’s, reducing odds for the disease by 35% (odds ratio, 0.65), as was R1398H, which conferred a 29% reduction in the likelihood of developing the disease (OR, 0.71). It has been known that these two mutations can combine to provide a protective genetic signature, and the team investigated this compound interaction as well.
After repeated analyses in large, unique case-control cohorts and tissue samples, they determined that the N2081D allele increased the odds of Crohn’s by 70% in the Ashkenazi subjects and by 60% in non-Ashkenazi subjects. The allele was associated with a 10% increased likelihood of Parkinson’s among the Ashkenazi cohort and a 30% increased likelihood among the non-Ashkenazi cohort.
The researchers also examined the two protective alleles, N551K and R1398H, in these further analyses. In the Ashkenazi cohort, N551K decreased the likelihood of Crohn’s by 33%, and it decreased the likelihood of Parkinson’s by 23% in non-Ashkenazi subjects (OR, 0.67 and 0.77, respectively).
In the Ashkenazi cohort, R1398H reduced the odds of Crohn’s by 29% and the odds of Parkinson’s by 16% (OR, 0.71 and 0.84, respectively). In the non-Ashkenazi cohort, the risk reduction was not significant.
Finally, they examined the effect of the mutations on macrophages isolated from four Crohn’s patients who carried the N2081D allele, as well as five patients with the two protective mutations N551K and R1398H and four patients with no mutation. When the macrophages were put in nutrient starvation, those from the N2081D carriers exhibited impaired resting acetylation of alpha-tubulin and poor response to cellular stress. Decreased alpha-tubulin acetylation is associated with poor protein transport through the cytoskeleton. “In contrast, the highest basal acetylation of alpha-tubulin was detected in macrophages of noncarriers and carriers of the protective N551K + R1398H mutations,” the investigators wrote.
“Our study strongly implicates the contribution of LRRK2 in Crohn’s disease risk,” they concluded. “The LRRK2 N2081D risk allele and the N551K/R1398H protective alleles, as well as numerous other variants within the LRRK2 locus, revealed shared genetic effects between Crohn’s and Parkinson’s risk, providing a potential biological basis for clinical co-occurrence. Our findings suggest that LRRK2 may be a useful target for developing drugs to treat Crohn’s disease.”
The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
SOURCE: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
Crohn’s and Parkinson’s diseases seem to share a common genetic risk pathway, mediated by mutations in a gene that modify disease risk in both directions.
A multidisciplinary collaboration of researchers have discovered that the Crohn’s risk variant N2081D in the leucine-rich repeat kinase 2 (LRRK2) gene lies close to variant G2019S, the major genetic risk factor for both sporadic and familial Parkinson’s. However, protective mutations also occur in the LRRK2 gene, and Ken Y. Hui, MD, of Yale University, New Haven, Conn., and his associates identified two that, when combined, significantly decrease the risk of Crohn’s.
The team first discovered the association in an exome sequencing study of 50 Crohn’s patients of Ashkenazi Jewish descent. This identified more than 4,000 potentially high-yield mutations, which they then examined in a pure Ashkenazi cohort of 1,477 Crohn’s patients and 2,614 healthy controls.
In this phase, the researchers found that N2081D in LRRK2 was associated with a 73% increased odds of Crohn’s. The LRRK2 N551K variant was associated with protection against Crohn’s, reducing odds for the disease by 35% (odds ratio, 0.65), as was R1398H, which conferred a 29% reduction in the likelihood of developing the disease (OR, 0.71). It has been known that these two mutations can combine to provide a protective genetic signature, and the team investigated this compound interaction as well.
After repeated analyses in large, unique case-control cohorts and tissue samples, they determined that the N2081D allele increased the odds of Crohn’s by 70% in the Ashkenazi subjects and by 60% in non-Ashkenazi subjects. The allele was associated with a 10% increased likelihood of Parkinson’s among the Ashkenazi cohort and a 30% increased likelihood among the non-Ashkenazi cohort.
The researchers also examined the two protective alleles, N551K and R1398H, in these further analyses. In the Ashkenazi cohort, N551K decreased the likelihood of Crohn’s by 33%, and it decreased the likelihood of Parkinson’s by 23% in non-Ashkenazi subjects (OR, 0.67 and 0.77, respectively).
In the Ashkenazi cohort, R1398H reduced the odds of Crohn’s by 29% and the odds of Parkinson’s by 16% (OR, 0.71 and 0.84, respectively). In the non-Ashkenazi cohort, the risk reduction was not significant.
Finally, they examined the effect of the mutations on macrophages isolated from four Crohn’s patients who carried the N2081D allele, as well as five patients with the two protective mutations N551K and R1398H and four patients with no mutation. When the macrophages were put in nutrient starvation, those from the N2081D carriers exhibited impaired resting acetylation of alpha-tubulin and poor response to cellular stress. Decreased alpha-tubulin acetylation is associated with poor protein transport through the cytoskeleton. “In contrast, the highest basal acetylation of alpha-tubulin was detected in macrophages of noncarriers and carriers of the protective N551K + R1398H mutations,” the investigators wrote.
“Our study strongly implicates the contribution of LRRK2 in Crohn’s disease risk,” they concluded. “The LRRK2 N2081D risk allele and the N551K/R1398H protective alleles, as well as numerous other variants within the LRRK2 locus, revealed shared genetic effects between Crohn’s and Parkinson’s risk, providing a potential biological basis for clinical co-occurrence. Our findings suggest that LRRK2 may be a useful target for developing drugs to treat Crohn’s disease.”
The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
SOURCE: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
Crohn’s and Parkinson’s diseases seem to share a common genetic risk pathway, mediated by mutations in a gene that modify disease risk in both directions.
A multidisciplinary collaboration of researchers have discovered that the Crohn’s risk variant N2081D in the leucine-rich repeat kinase 2 (LRRK2) gene lies close to variant G2019S, the major genetic risk factor for both sporadic and familial Parkinson’s. However, protective mutations also occur in the LRRK2 gene, and Ken Y. Hui, MD, of Yale University, New Haven, Conn., and his associates identified two that, when combined, significantly decrease the risk of Crohn’s.
The team first discovered the association in an exome sequencing study of 50 Crohn’s patients of Ashkenazi Jewish descent. This identified more than 4,000 potentially high-yield mutations, which they then examined in a pure Ashkenazi cohort of 1,477 Crohn’s patients and 2,614 healthy controls.
In this phase, the researchers found that N2081D in LRRK2 was associated with a 73% increased odds of Crohn’s. The LRRK2 N551K variant was associated with protection against Crohn’s, reducing odds for the disease by 35% (odds ratio, 0.65), as was R1398H, which conferred a 29% reduction in the likelihood of developing the disease (OR, 0.71). It has been known that these two mutations can combine to provide a protective genetic signature, and the team investigated this compound interaction as well.
After repeated analyses in large, unique case-control cohorts and tissue samples, they determined that the N2081D allele increased the odds of Crohn’s by 70% in the Ashkenazi subjects and by 60% in non-Ashkenazi subjects. The allele was associated with a 10% increased likelihood of Parkinson’s among the Ashkenazi cohort and a 30% increased likelihood among the non-Ashkenazi cohort.
The researchers also examined the two protective alleles, N551K and R1398H, in these further analyses. In the Ashkenazi cohort, N551K decreased the likelihood of Crohn’s by 33%, and it decreased the likelihood of Parkinson’s by 23% in non-Ashkenazi subjects (OR, 0.67 and 0.77, respectively).
In the Ashkenazi cohort, R1398H reduced the odds of Crohn’s by 29% and the odds of Parkinson’s by 16% (OR, 0.71 and 0.84, respectively). In the non-Ashkenazi cohort, the risk reduction was not significant.
Finally, they examined the effect of the mutations on macrophages isolated from four Crohn’s patients who carried the N2081D allele, as well as five patients with the two protective mutations N551K and R1398H and four patients with no mutation. When the macrophages were put in nutrient starvation, those from the N2081D carriers exhibited impaired resting acetylation of alpha-tubulin and poor response to cellular stress. Decreased alpha-tubulin acetylation is associated with poor protein transport through the cytoskeleton. “In contrast, the highest basal acetylation of alpha-tubulin was detected in macrophages of noncarriers and carriers of the protective N551K + R1398H mutations,” the investigators wrote.
“Our study strongly implicates the contribution of LRRK2 in Crohn’s disease risk,” they concluded. “The LRRK2 N2081D risk allele and the N551K/R1398H protective alleles, as well as numerous other variants within the LRRK2 locus, revealed shared genetic effects between Crohn’s and Parkinson’s risk, providing a potential biological basis for clinical co-occurrence. Our findings suggest that LRRK2 may be a useful target for developing drugs to treat Crohn’s disease.”
The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
SOURCE: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
FROM SCIENCE TRANSLATIONAL MEDICINE
Key clinical point:
Major finding: Variant N2081D in LRRK2 was associated with a 73% increased risk of Crohn’s.
Study details: The study comprised data from 30,269 patients and controls.
Disclosures: The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
Source: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
Debunking Acne Myths: Do Patients Need to Worry About Acne After Adolescence?
Myth: Acne only occurs in teenagers
Acne typically is associated with teenagers and puberty, and many adult patients may not be aware that acne can persist beyond adolescence or even develop for the first time in adulthood. As the prevalence of adults with acne increases, it is important to educate this population about factors associated with postadolescent acne development and let them know that effective treatments are available.
There are 2 types of adult acne: persistent acne, which refers to adolescent acne that continues beyond 25 years of age, and late-onset acne, which develops for the first time after 25 years of age. Adult acne generally is mild to moderate in severity and may be refractory to treatment. Unlike adolescent acne, which is more prominent in adolescent boys and manifests as the more severe forms of the disease, adult acne primarily affects women and is more inflammatory in nature, making these patients more susceptible to scarring. In one study, acne prevalence among 1055 adult participants (age range, 20–60 years) was estimated at 61.5%; however, only 36.8% were aware of their condition and only 25% sought treatment. The most commonly affected area was the malar region, which differs from acne seen in teenagers. In addition to the cheeks, adult acne generally is more prominent on the lower chin, jawline, and neck, and lesions more commonly present as closed comedones.
Fluctuating hormone levels are a common cause of adult acne, particularly in women during menses or pregnancy, menopause, or perimenopause; women also may experience breakouts after starting or discontinuing birth control pills. Acne flare-ups in adults also have been linked to chronic stress, family history, hair and skin care products, medication side effects, undiagnosed medical conditions, steroid use, increased calorie intake, whole and fat-reduced milk consumption, and tobacco smoking. Adult acne also has been found to be associated with other dermatologic conditions including hirsutism, alopecia, and seborrhea.
Early diagnosis and treatment of adult acne is crucial to ensure good cosmetic outcomes and minimize disease burden. When treating adult acne, particularly in women, dermatologists should consider a variety of factors that set this condition apart from adolescent acne, including the predisposition of older skin to irritation, possible slow response to treatment, a high likelihood of good adherence to treatment, and the psychosocial impact of acne in the adult population. In adult women, it also is important to consider whether patients are of childbearing age when selecting a treatment. Patients also should be encouraged to read the labels on their personal care products to ensure they are noncomedogenic and will not clog pores.
Adult acne. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/adult-acne. Accessed January 9, 2018.
Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm [published online January 10, 2013]. J Eur Acad Dermatol Venereol. 2013;27:1063-1070.
Khunger N, Kumar C. A clinic-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78:335-341.
Semedo D, Ladeiro F, Ruivo M, et al. Adult acne: prevalence and portrayal in primary healthcare patients, in the Great Porto Area, Portugal [published online September 30, 2016]. Acta Med Port. 2016;29:507-513.
Myth: Acne only occurs in teenagers
Acne typically is associated with teenagers and puberty, and many adult patients may not be aware that acne can persist beyond adolescence or even develop for the first time in adulthood. As the prevalence of adults with acne increases, it is important to educate this population about factors associated with postadolescent acne development and let them know that effective treatments are available.
There are 2 types of adult acne: persistent acne, which refers to adolescent acne that continues beyond 25 years of age, and late-onset acne, which develops for the first time after 25 years of age. Adult acne generally is mild to moderate in severity and may be refractory to treatment. Unlike adolescent acne, which is more prominent in adolescent boys and manifests as the more severe forms of the disease, adult acne primarily affects women and is more inflammatory in nature, making these patients more susceptible to scarring. In one study, acne prevalence among 1055 adult participants (age range, 20–60 years) was estimated at 61.5%; however, only 36.8% were aware of their condition and only 25% sought treatment. The most commonly affected area was the malar region, which differs from acne seen in teenagers. In addition to the cheeks, adult acne generally is more prominent on the lower chin, jawline, and neck, and lesions more commonly present as closed comedones.
Fluctuating hormone levels are a common cause of adult acne, particularly in women during menses or pregnancy, menopause, or perimenopause; women also may experience breakouts after starting or discontinuing birth control pills. Acne flare-ups in adults also have been linked to chronic stress, family history, hair and skin care products, medication side effects, undiagnosed medical conditions, steroid use, increased calorie intake, whole and fat-reduced milk consumption, and tobacco smoking. Adult acne also has been found to be associated with other dermatologic conditions including hirsutism, alopecia, and seborrhea.
Early diagnosis and treatment of adult acne is crucial to ensure good cosmetic outcomes and minimize disease burden. When treating adult acne, particularly in women, dermatologists should consider a variety of factors that set this condition apart from adolescent acne, including the predisposition of older skin to irritation, possible slow response to treatment, a high likelihood of good adherence to treatment, and the psychosocial impact of acne in the adult population. In adult women, it also is important to consider whether patients are of childbearing age when selecting a treatment. Patients also should be encouraged to read the labels on their personal care products to ensure they are noncomedogenic and will not clog pores.
Myth: Acne only occurs in teenagers
Acne typically is associated with teenagers and puberty, and many adult patients may not be aware that acne can persist beyond adolescence or even develop for the first time in adulthood. As the prevalence of adults with acne increases, it is important to educate this population about factors associated with postadolescent acne development and let them know that effective treatments are available.
There are 2 types of adult acne: persistent acne, which refers to adolescent acne that continues beyond 25 years of age, and late-onset acne, which develops for the first time after 25 years of age. Adult acne generally is mild to moderate in severity and may be refractory to treatment. Unlike adolescent acne, which is more prominent in adolescent boys and manifests as the more severe forms of the disease, adult acne primarily affects women and is more inflammatory in nature, making these patients more susceptible to scarring. In one study, acne prevalence among 1055 adult participants (age range, 20–60 years) was estimated at 61.5%; however, only 36.8% were aware of their condition and only 25% sought treatment. The most commonly affected area was the malar region, which differs from acne seen in teenagers. In addition to the cheeks, adult acne generally is more prominent on the lower chin, jawline, and neck, and lesions more commonly present as closed comedones.
Fluctuating hormone levels are a common cause of adult acne, particularly in women during menses or pregnancy, menopause, or perimenopause; women also may experience breakouts after starting or discontinuing birth control pills. Acne flare-ups in adults also have been linked to chronic stress, family history, hair and skin care products, medication side effects, undiagnosed medical conditions, steroid use, increased calorie intake, whole and fat-reduced milk consumption, and tobacco smoking. Adult acne also has been found to be associated with other dermatologic conditions including hirsutism, alopecia, and seborrhea.
Early diagnosis and treatment of adult acne is crucial to ensure good cosmetic outcomes and minimize disease burden. When treating adult acne, particularly in women, dermatologists should consider a variety of factors that set this condition apart from adolescent acne, including the predisposition of older skin to irritation, possible slow response to treatment, a high likelihood of good adherence to treatment, and the psychosocial impact of acne in the adult population. In adult women, it also is important to consider whether patients are of childbearing age when selecting a treatment. Patients also should be encouraged to read the labels on their personal care products to ensure they are noncomedogenic and will not clog pores.
Adult acne. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/adult-acne. Accessed January 9, 2018.
Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm [published online January 10, 2013]. J Eur Acad Dermatol Venereol. 2013;27:1063-1070.
Khunger N, Kumar C. A clinic-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78:335-341.
Semedo D, Ladeiro F, Ruivo M, et al. Adult acne: prevalence and portrayal in primary healthcare patients, in the Great Porto Area, Portugal [published online September 30, 2016]. Acta Med Port. 2016;29:507-513.
Adult acne. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/adult-acne. Accessed January 9, 2018.
Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm [published online January 10, 2013]. J Eur Acad Dermatol Venereol. 2013;27:1063-1070.
Khunger N, Kumar C. A clinic-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78:335-341.
Semedo D, Ladeiro F, Ruivo M, et al. Adult acne: prevalence and portrayal in primary healthcare patients, in the Great Porto Area, Portugal [published online September 30, 2016]. Acta Med Port. 2016;29:507-513.
CMV colitis mortality rates similar in both immunocompetent and immunocompromised patients
Cytomegalovirus (CMV) colitis has mortality rates similar in immunocompetent patients to that in immunocompromised patients, according to Puo-Hsien Le, MD, and associates.
In a retrospective study, the investigators analyzed data from 42 immunocompetent patients and 27 patients who were immunocompromised because of HIV infection, solid organ or bone marrow transplantation, immunosuppressive drug use, chemotherapeutic agent use within 6 months, or other reasons. In-hospital mortality was 26.2% in immunocompetent patients and 25.9% in immunocompromised patients.
While diarrhea and melena were the first presenting symptom in a similar number of patients, immunocompetent patients were more likely to present with melena while immunocompromised patients were more likely to present with diarrhea. The number of days until diagnosis was the only independent predictor of in-hospital mortality according to the analysis, with patients who were diagnosed within 9 days of admittance having a significantly higher survival rate.
“Contrary to data published up to this point, we found that CMV colitis was not rare and that it could be fatal in immunocompetent hosts, especially those patients with advanced age, specific comorbidities associated with immune dysfunction, critical illness, or IBD. ... Being alert to the different presentations can greatly help make an accurate early diagnosis and materially improve survival for CMV colitis patients,” the investigators concluded.
Find the full study in Therapeutics and Clinical Risk Management (doi: 10.2147/TCRM.S151180).
Cytomegalovirus (CMV) colitis has mortality rates similar in immunocompetent patients to that in immunocompromised patients, according to Puo-Hsien Le, MD, and associates.
In a retrospective study, the investigators analyzed data from 42 immunocompetent patients and 27 patients who were immunocompromised because of HIV infection, solid organ or bone marrow transplantation, immunosuppressive drug use, chemotherapeutic agent use within 6 months, or other reasons. In-hospital mortality was 26.2% in immunocompetent patients and 25.9% in immunocompromised patients.
While diarrhea and melena were the first presenting symptom in a similar number of patients, immunocompetent patients were more likely to present with melena while immunocompromised patients were more likely to present with diarrhea. The number of days until diagnosis was the only independent predictor of in-hospital mortality according to the analysis, with patients who were diagnosed within 9 days of admittance having a significantly higher survival rate.
“Contrary to data published up to this point, we found that CMV colitis was not rare and that it could be fatal in immunocompetent hosts, especially those patients with advanced age, specific comorbidities associated with immune dysfunction, critical illness, or IBD. ... Being alert to the different presentations can greatly help make an accurate early diagnosis and materially improve survival for CMV colitis patients,” the investigators concluded.
Find the full study in Therapeutics and Clinical Risk Management (doi: 10.2147/TCRM.S151180).
Cytomegalovirus (CMV) colitis has mortality rates similar in immunocompetent patients to that in immunocompromised patients, according to Puo-Hsien Le, MD, and associates.
In a retrospective study, the investigators analyzed data from 42 immunocompetent patients and 27 patients who were immunocompromised because of HIV infection, solid organ or bone marrow transplantation, immunosuppressive drug use, chemotherapeutic agent use within 6 months, or other reasons. In-hospital mortality was 26.2% in immunocompetent patients and 25.9% in immunocompromised patients.
While diarrhea and melena were the first presenting symptom in a similar number of patients, immunocompetent patients were more likely to present with melena while immunocompromised patients were more likely to present with diarrhea. The number of days until diagnosis was the only independent predictor of in-hospital mortality according to the analysis, with patients who were diagnosed within 9 days of admittance having a significantly higher survival rate.
“Contrary to data published up to this point, we found that CMV colitis was not rare and that it could be fatal in immunocompetent hosts, especially those patients with advanced age, specific comorbidities associated with immune dysfunction, critical illness, or IBD. ... Being alert to the different presentations can greatly help make an accurate early diagnosis and materially improve survival for CMV colitis patients,” the investigators concluded.
Find the full study in Therapeutics and Clinical Risk Management (doi: 10.2147/TCRM.S151180).
FROM THERAPEUTICS AND CLINICAL RISK MANAGEMENT
Optimal rate of flow for high-flow nasal cannula in young children
Clinical question
Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?
Background
High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.
Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.1 An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
Study design
Single-center prospective observational trial.
Setting
24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.
Synopsis
A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.
Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.
A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).
Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
Bottom line
The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.
Citation
Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.
Reference
1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.
Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.
Clinical question
Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?
Background
High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.
Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.1 An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
Study design
Single-center prospective observational trial.
Setting
24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.
Synopsis
A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.
Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.
A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).
Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
Bottom line
The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.
Citation
Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.
Reference
1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.
Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.
Clinical question
Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?
Background
High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.
Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.1 An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
Study design
Single-center prospective observational trial.
Setting
24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.
Synopsis
A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.
Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.
A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).
Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
Bottom line
The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.
Citation
Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.
Reference
1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.
Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.
Best of 2017: Top News Articles
VA Central California Improves Access to Clinical Trials
The Hematology and Oncology Department at the VA Central California Health Care System (VACCHCS) in Fresno, California, is developing multiple programs to increase access to clinical trials for veterans. The department secured funding for an investigator-initiated supportive care clinical trial, which looks at the feasibility of using olanzapine to replace dexamethasone in elderly patients with diabetes who are undergoing moderate-intensity chemotherapy for prevention of nausea and vomiting. The department received a grant from the Southwest Oncology Group (SWOG) HOPE Foundation to help its clinical trials research team become members of SWOG. Currently, VACCHCS Fresno has 4 active industry-sponsored clinical trials to offer to veterans with myelodysplastic syndrome/acute myeloid leukemia, lung, prostate, and bladder cancers. They are in the process of getting another 4 clinical trials in the next 6 months.
“Our primary responsibility is to provide timely and excellent care to our veterans,” said Sachdev P. Thomas, MD, Chief of Hematology/Oncology at Fresno VACCHCS. “Wait time for new patients in our Hematology/Oncology clinic is less than 7 business days. We also have a walk-in clinic. Before we initiated our Clinical Trial program, we ensured that this metric for timely care was in place.”
Through the Association of VA Hematology/Oncology (AVAHO), Fresno VACCHCS oncologists and a team at the Richmond VAMC in, Virginia are currently working with the National Institutes of Health, to create a VA-specific cancer clinical trials’ filter at the website Clinicaltrials.gov. This VA-specific filter will enable, any VA physician, nationwide to easily search for available clinical trials for any cancer type, throughout the VHA.
The Hematology and Oncology Department at the VA Central California Health Care System (VACCHCS) in Fresno, California, is developing multiple programs to increase access to clinical trials for veterans. The department secured funding for an investigator-initiated supportive care clinical trial, which looks at the feasibility of using olanzapine to replace dexamethasone in elderly patients with diabetes who are undergoing moderate-intensity chemotherapy for prevention of nausea and vomiting. The department received a grant from the Southwest Oncology Group (SWOG) HOPE Foundation to help its clinical trials research team become members of SWOG. Currently, VACCHCS Fresno has 4 active industry-sponsored clinical trials to offer to veterans with myelodysplastic syndrome/acute myeloid leukemia, lung, prostate, and bladder cancers. They are in the process of getting another 4 clinical trials in the next 6 months.
“Our primary responsibility is to provide timely and excellent care to our veterans,” said Sachdev P. Thomas, MD, Chief of Hematology/Oncology at Fresno VACCHCS. “Wait time for new patients in our Hematology/Oncology clinic is less than 7 business days. We also have a walk-in clinic. Before we initiated our Clinical Trial program, we ensured that this metric for timely care was in place.”
Through the Association of VA Hematology/Oncology (AVAHO), Fresno VACCHCS oncologists and a team at the Richmond VAMC in, Virginia are currently working with the National Institutes of Health, to create a VA-specific cancer clinical trials’ filter at the website Clinicaltrials.gov. This VA-specific filter will enable, any VA physician, nationwide to easily search for available clinical trials for any cancer type, throughout the VHA.
The Hematology and Oncology Department at the VA Central California Health Care System (VACCHCS) in Fresno, California, is developing multiple programs to increase access to clinical trials for veterans. The department secured funding for an investigator-initiated supportive care clinical trial, which looks at the feasibility of using olanzapine to replace dexamethasone in elderly patients with diabetes who are undergoing moderate-intensity chemotherapy for prevention of nausea and vomiting. The department received a grant from the Southwest Oncology Group (SWOG) HOPE Foundation to help its clinical trials research team become members of SWOG. Currently, VACCHCS Fresno has 4 active industry-sponsored clinical trials to offer to veterans with myelodysplastic syndrome/acute myeloid leukemia, lung, prostate, and bladder cancers. They are in the process of getting another 4 clinical trials in the next 6 months.
“Our primary responsibility is to provide timely and excellent care to our veterans,” said Sachdev P. Thomas, MD, Chief of Hematology/Oncology at Fresno VACCHCS. “Wait time for new patients in our Hematology/Oncology clinic is less than 7 business days. We also have a walk-in clinic. Before we initiated our Clinical Trial program, we ensured that this metric for timely care was in place.”
Through the Association of VA Hematology/Oncology (AVAHO), Fresno VACCHCS oncologists and a team at the Richmond VAMC in, Virginia are currently working with the National Institutes of Health, to create a VA-specific cancer clinical trials’ filter at the website Clinicaltrials.gov. This VA-specific filter will enable, any VA physician, nationwide to easily search for available clinical trials for any cancer type, throughout the VHA.
Is the VA Ready for New Veterans?
Beginning in less than 90 days, new veterans will become eligible for VA mental health care as soon as they leave military service. More than 250,000 service members transition out of the military each year. On Tuesday, the President signed an executive order that gives the DoD, Department of Homeland Security, and VA just 60 days to develop a plan for handling the influx of new patients into the system.
“As service members transition to veteran status, they face higher risk of suicide and mental health difficulties,” said VA Secretary David Shulkin, MD. “During this critical phase, many transitioning service members may not qualify for enrollment in health care. The focus of this executive order is to coordinate federal assets to close that gap.”
How the VA will meet the increased demand remains to be seen. As an executive order, the mandate does not come with additional funds. And in October testimony, Secretary Shulkin admitted that the VA already was having difficulty hiring and training enough mental health care providers to meet existing demand.
The executive order is focused on the 60% of new veterans who are not immediately eligible for VA health care benefits. According to Secretary Shulkin, in the first year postseparation, often before VA eligibility is determined, these new veterans are especially at risk for suicide. “That 12-month period after you leave service is the highest risk for suicide,” Secretary Shulkin noted. Veterans during that period face almost one and a half to 2 times the risk of suicide in that first 12 months when they leave the service.
The VA outlined 3 approaches that would be implemented to meet the mental health needs for transitioning veterans. Peer counseling will play a particularly important role in the new services. First, the VA will expand its peer community outreach and group session offers and the VA whole health patient-centered care initiative. Currently, the VA Whole Health program is in 18 facilities, but it will be expanded to all facilities. The program focuses on wellness and establishing individual health goals.
In addition, the DoD “Be There Peer Support Call and Outreach Center” services will be expanded. The program will begin to offer peer support for veterans in the year following separation from the uniformed service.
Most consequently, the executive order will expand the DoD Military OneSource, which currently provides free mental health care counseling to active-duty service members and their families. The program will be expanded to include recently transitioned veterans as well. And according to a report in Military Times, Military OneSource care also may be available to the families of new veterans.
Beginning in less than 90 days, new veterans will become eligible for VA mental health care as soon as they leave military service. More than 250,000 service members transition out of the military each year. On Tuesday, the President signed an executive order that gives the DoD, Department of Homeland Security, and VA just 60 days to develop a plan for handling the influx of new patients into the system.
“As service members transition to veteran status, they face higher risk of suicide and mental health difficulties,” said VA Secretary David Shulkin, MD. “During this critical phase, many transitioning service members may not qualify for enrollment in health care. The focus of this executive order is to coordinate federal assets to close that gap.”
How the VA will meet the increased demand remains to be seen. As an executive order, the mandate does not come with additional funds. And in October testimony, Secretary Shulkin admitted that the VA already was having difficulty hiring and training enough mental health care providers to meet existing demand.
The executive order is focused on the 60% of new veterans who are not immediately eligible for VA health care benefits. According to Secretary Shulkin, in the first year postseparation, often before VA eligibility is determined, these new veterans are especially at risk for suicide. “That 12-month period after you leave service is the highest risk for suicide,” Secretary Shulkin noted. Veterans during that period face almost one and a half to 2 times the risk of suicide in that first 12 months when they leave the service.
The VA outlined 3 approaches that would be implemented to meet the mental health needs for transitioning veterans. Peer counseling will play a particularly important role in the new services. First, the VA will expand its peer community outreach and group session offers and the VA whole health patient-centered care initiative. Currently, the VA Whole Health program is in 18 facilities, but it will be expanded to all facilities. The program focuses on wellness and establishing individual health goals.
In addition, the DoD “Be There Peer Support Call and Outreach Center” services will be expanded. The program will begin to offer peer support for veterans in the year following separation from the uniformed service.
Most consequently, the executive order will expand the DoD Military OneSource, which currently provides free mental health care counseling to active-duty service members and their families. The program will be expanded to include recently transitioned veterans as well. And according to a report in Military Times, Military OneSource care also may be available to the families of new veterans.
Beginning in less than 90 days, new veterans will become eligible for VA mental health care as soon as they leave military service. More than 250,000 service members transition out of the military each year. On Tuesday, the President signed an executive order that gives the DoD, Department of Homeland Security, and VA just 60 days to develop a plan for handling the influx of new patients into the system.
“As service members transition to veteran status, they face higher risk of suicide and mental health difficulties,” said VA Secretary David Shulkin, MD. “During this critical phase, many transitioning service members may not qualify for enrollment in health care. The focus of this executive order is to coordinate federal assets to close that gap.”
How the VA will meet the increased demand remains to be seen. As an executive order, the mandate does not come with additional funds. And in October testimony, Secretary Shulkin admitted that the VA already was having difficulty hiring and training enough mental health care providers to meet existing demand.
The executive order is focused on the 60% of new veterans who are not immediately eligible for VA health care benefits. According to Secretary Shulkin, in the first year postseparation, often before VA eligibility is determined, these new veterans are especially at risk for suicide. “That 12-month period after you leave service is the highest risk for suicide,” Secretary Shulkin noted. Veterans during that period face almost one and a half to 2 times the risk of suicide in that first 12 months when they leave the service.
The VA outlined 3 approaches that would be implemented to meet the mental health needs for transitioning veterans. Peer counseling will play a particularly important role in the new services. First, the VA will expand its peer community outreach and group session offers and the VA whole health patient-centered care initiative. Currently, the VA Whole Health program is in 18 facilities, but it will be expanded to all facilities. The program focuses on wellness and establishing individual health goals.
In addition, the DoD “Be There Peer Support Call and Outreach Center” services will be expanded. The program will begin to offer peer support for veterans in the year following separation from the uniformed service.
Most consequently, the executive order will expand the DoD Military OneSource, which currently provides free mental health care counseling to active-duty service members and their families. The program will be expanded to include recently transitioned veterans as well. And according to a report in Military Times, Military OneSource care also may be available to the families of new veterans.
Alopecia tied to nearly fivefold increase in fibroids in African American women
based on data from more than 400,000 women.
In a study published in JAMA Dermatology, researchers reviewed data from 487,104 black women seen at a single center between Aug. 1, 2013, and Aug. 1, 2017. Overall, 14% of women with central centrifugal cicatricial alopecia (CCCA) also had a history of uterine fibroids, compared with 3% percent of black women without CCCA.
“Alopecia is more than just a cosmetic problem. … It could signal an increased risk of developing other conditions,” corresponding author Crystal Aguh, MD, of Johns Hopkins University in Baltimore said in an interview. “To our knowledge, this is the first time that an association has been noted between these two conditions. We believe that the fact that both are related to excess scarring and fibrous tissue deposition may reflect similarities in how both [conditions] develop, but this is still unknown.” 
Overall, 62 of 447 women who met criteria for CCCA also had fibroids, representing a nearly fivefold increase in fibroid risk for women with CCCA.
“I was definitely surprised by the findings,” said Dr. Aguh. “I thought it would be interesting to look at any possible correlation between the two diseases, but did not expect to see such a large difference between black women with and without this form of hair loss,” she noted.
As fibroids are often asymptomatic, “physicians should screen their patients with CCCA for symptoms of fibroids such as painful menstrual cycles, heavy bleeding, unexplained anemia, or difficulty conceiving,” said Dr. Aguh. “In those patients who may not know they have fibroids, early recognition that allows for treatment will be especially beneficial.”
The findings were limited by the retrospective nature of the study. “I believe that larger studies are warranted to help us fully understand how these two conditions are connected,” Dr. Aguh said.
Lead author Yemisi Dina of Meharry Medical College, Nashville, Tenn., is supported in part by a grant from the National Institutes of Health. The other researchers had no financial conflicts to disclose.
SOURCE: Dina Y et al. JAMA Dermatol. 2017 Dec 27. doi: 10.1001/jamadermatol.2017.5163
based on data from more than 400,000 women.
In a study published in JAMA Dermatology, researchers reviewed data from 487,104 black women seen at a single center between Aug. 1, 2013, and Aug. 1, 2017. Overall, 14% of women with central centrifugal cicatricial alopecia (CCCA) also had a history of uterine fibroids, compared with 3% percent of black women without CCCA.
“Alopecia is more than just a cosmetic problem. … It could signal an increased risk of developing other conditions,” corresponding author Crystal Aguh, MD, of Johns Hopkins University in Baltimore said in an interview. “To our knowledge, this is the first time that an association has been noted between these two conditions. We believe that the fact that both are related to excess scarring and fibrous tissue deposition may reflect similarities in how both [conditions] develop, but this is still unknown.”
Overall, 62 of 447 women who met criteria for CCCA also had fibroids, representing a nearly fivefold increase in fibroid risk for women with CCCA.
“I was definitely surprised by the findings,” said Dr. Aguh. “I thought it would be interesting to look at any possible correlation between the two diseases, but did not expect to see such a large difference between black women with and without this form of hair loss,” she noted.
As fibroids are often asymptomatic, “physicians should screen their patients with CCCA for symptoms of fibroids such as painful menstrual cycles, heavy bleeding, unexplained anemia, or difficulty conceiving,” said Dr. Aguh. “In those patients who may not know they have fibroids, early recognition that allows for treatment will be especially beneficial.”
The findings were limited by the retrospective nature of the study. “I believe that larger studies are warranted to help us fully understand how these two conditions are connected,” Dr. Aguh said.
Lead author Yemisi Dina of Meharry Medical College, Nashville, Tenn., is supported in part by a grant from the National Institutes of Health. The other researchers had no financial conflicts to disclose.
SOURCE: Dina Y et al. JAMA Dermatol. 2017 Dec 27. doi: 10.1001/jamadermatol.2017.5163
based on data from more than 400,000 women.
In a study published in JAMA Dermatology, researchers reviewed data from 487,104 black women seen at a single center between Aug. 1, 2013, and Aug. 1, 2017. Overall, 14% of women with central centrifugal cicatricial alopecia (CCCA) also had a history of uterine fibroids, compared with 3% percent of black women without CCCA.
“Alopecia is more than just a cosmetic problem. … It could signal an increased risk of developing other conditions,” corresponding author Crystal Aguh, MD, of Johns Hopkins University in Baltimore said in an interview. “To our knowledge, this is the first time that an association has been noted between these two conditions. We believe that the fact that both are related to excess scarring and fibrous tissue deposition may reflect similarities in how both [conditions] develop, but this is still unknown.”
Overall, 62 of 447 women who met criteria for CCCA also had fibroids, representing a nearly fivefold increase in fibroid risk for women with CCCA.
“I was definitely surprised by the findings,” said Dr. Aguh. “I thought it would be interesting to look at any possible correlation between the two diseases, but did not expect to see such a large difference between black women with and without this form of hair loss,” she noted.
As fibroids are often asymptomatic, “physicians should screen their patients with CCCA for symptoms of fibroids such as painful menstrual cycles, heavy bleeding, unexplained anemia, or difficulty conceiving,” said Dr. Aguh. “In those patients who may not know they have fibroids, early recognition that allows for treatment will be especially beneficial.”
The findings were limited by the retrospective nature of the study. “I believe that larger studies are warranted to help us fully understand how these two conditions are connected,” Dr. Aguh said.
Lead author Yemisi Dina of Meharry Medical College, Nashville, Tenn., is supported in part by a grant from the National Institutes of Health. The other researchers had no financial conflicts to disclose.
SOURCE: Dina Y et al. JAMA Dermatol. 2017 Dec 27. doi: 10.1001/jamadermatol.2017.5163
FROM JAMA DERMATOLOGY
Key clinical point: Dermatologists should screen patients with central centrifugal cicatricial alopecia for potential fibroids.
Major finding: Women with CCCA were nearly five times more likely to have fibroids, compared with controls.
Data source: The data come from a review of 487,104 black women seen at a single center between Aug. 1, 2013, and Aug. 1, 2017.
Disclosures: Lead author Yemisi Dina of Meharry Medical College, Nashville, Tenn., is supported in part by a grant from the National Institutes of Health. The other researchers had no financial conflicts to disclose.
Source: Dina Y et al. JAMA Dermatol. 2017 Dec 27. doi: 10.1001/jamadermatol.2017.5163.
Risk of Diabetes Climbs Among Veterans
More veterans are developing diabetes, say researchers from East Tennessee University in Johnson City, Tennessee. The rise is linked to a similar climb in obesity rates.
The researchers analyzed data from 5 cycles of the National Health and Nutrition Examination Survey (NHANES). The survey sample sizes ranged from 472 to 685.
Diabetes prevalence rose from 15.5% in 2005-2006 to 20.5% in 2013-2014, and rose significantly among men, from 16.5% in 2005-2006 to 22% in 2013-2014. Diabetes was most prevalent among veterans who were aged > 65 years, had more than 12 years of education, and had an income below the 100% federal poverty level. Those same subgroups had the highest prevalence of obesity except for the age subgroup. Obesity was more prevalent among veterans aged 45 to 64 years. Hispanic veterans had the highest prevalence of both obesity and diabetes.
The researchers note that some factors limited the accuracy of the estimated prevalence of diabetes among U.S. veterans when using VA databases. One is that in fiscal year 2014, < 30% of the total veteran population sought VA health care, and > 70% sought care outside the VA system even though some were enrolled.
More veterans are developing diabetes, say researchers from East Tennessee University in Johnson City, Tennessee. The rise is linked to a similar climb in obesity rates.
The researchers analyzed data from 5 cycles of the National Health and Nutrition Examination Survey (NHANES). The survey sample sizes ranged from 472 to 685.
Diabetes prevalence rose from 15.5% in 2005-2006 to 20.5% in 2013-2014, and rose significantly among men, from 16.5% in 2005-2006 to 22% in 2013-2014. Diabetes was most prevalent among veterans who were aged > 65 years, had more than 12 years of education, and had an income below the 100% federal poverty level. Those same subgroups had the highest prevalence of obesity except for the age subgroup. Obesity was more prevalent among veterans aged 45 to 64 years. Hispanic veterans had the highest prevalence of both obesity and diabetes.
The researchers note that some factors limited the accuracy of the estimated prevalence of diabetes among U.S. veterans when using VA databases. One is that in fiscal year 2014, < 30% of the total veteran population sought VA health care, and > 70% sought care outside the VA system even though some were enrolled.
More veterans are developing diabetes, say researchers from East Tennessee University in Johnson City, Tennessee. The rise is linked to a similar climb in obesity rates.
The researchers analyzed data from 5 cycles of the National Health and Nutrition Examination Survey (NHANES). The survey sample sizes ranged from 472 to 685.
Diabetes prevalence rose from 15.5% in 2005-2006 to 20.5% in 2013-2014, and rose significantly among men, from 16.5% in 2005-2006 to 22% in 2013-2014. Diabetes was most prevalent among veterans who were aged > 65 years, had more than 12 years of education, and had an income below the 100% federal poverty level. Those same subgroups had the highest prevalence of obesity except for the age subgroup. Obesity was more prevalent among veterans aged 45 to 64 years. Hispanic veterans had the highest prevalence of both obesity and diabetes.
The researchers note that some factors limited the accuracy of the estimated prevalence of diabetes among U.S. veterans when using VA databases. One is that in fiscal year 2014, < 30% of the total veteran population sought VA health care, and > 70% sought care outside the VA system even though some were enrolled.