Myth: Systemic steroids cause pustular psoriasis

The advent of biologic therapy for psoriasis has changed the landscape of treatments offered to patients. Nevertheless, systemic therapies still play an important role, according to the American Academy of Dermatology psoriasis treatment guidelines, due to their oral route of administration and low cost compared to biologics. They are options for patients with moderate to severe psoriasis that is unresponsive to topical therapies or phototherapy. However, many dermatologists feel that it is inappropriate to prescribe oral steroids to psoriasis patients due to the risk for steroid-induced conversion to pustular psoriasis, the long-term side effects of steroids, and deterioration of psoriasis after withdrawal of steroids.

Pustular psoriasis appears clinically as white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. There are a number of triggers in addition to systemic steroids, such as internal medications, irritating topical agents, overexposure to UV light, and pregnancy. Stopping an oral steroid abruptly can cause serious disease flares, fatigue, and joint pain.

Westphal et al described the case of a 70-year-old woman with palmoplantar psoriasis who was diagnosed with acute generalized exanthematous pustulosis that was treated with corticotherapy by injection and then oral prednisone. She experienced improvement, but her symptoms worsened when she was in the process of reducing the prednisone dose. The dose was increased again, and the same worsening of symptoms was experienced when the dose was reduced. After completely abandoning oral steroid therapy, she developed a severe case of generalized pustular psoriasis that was treated with acitretin. This case illustrates the dangerous consequences of abruptly discontinuing oral steroids.

However, dermatologists may be using oral steroids for psoriasis more often than treatment guidelines suggest. In 2014, Al-Dabagh et al evaluated how frequently systemic corticosteroids are prescribed for psoriasis in the United States. The researchers reported, "Despite the absence or discouragement of systemic corticosteroids in psoriasis management guidelines, systemic corticosteroids are among the most common systemic treatments used for psoriasis." They found that systemic corticosteroids were prescribed at 650,000 of 21,020,000 psoriasis visits, of which 93% were visits to dermatologists. Prednisone was the most commonly prescribed systemic corticosteroid, followed by methylprednisolone and dexamethasone. To prevent rebound flares, systemic corticosteroids were prescribed with a topical corticosteroid in 45% of the visits in patients with psoriasis as the sole diagnosis. They concluded, "The striking contrast between the guidelines for psoriasis management and actual practice suggests that there is an acute need to better understand the use of systemic corticosteroids for psoriasis."

The benefits of systemic corticosteroids versus the frequency of adverse reactions should be weighed by dermatologists and patients to make evidence-based decisions about treatment. Patients should take oral steroids exactly as prescribed by physicians.

References

Al-Dabagh A, Al-Dabagh R, Davis SA, et al. Systemic corticosteroids are frequently prescribed for psoriasis. J Cutan Med Surg. 2014;18:195-199.

Delzell E. What you need to know about steroids. National Psoriasis Foundation website. https://www.psoriasis.org/advance/what-you-need-to-know-about-steroids. Published September 2, 2015. Accessed January 13, 2017.

Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61:451-485.

Pustular psoriasis. National Psoriasis Foundation website. https://www.psoriasis.org/about-psoriasis/types/pustular. Accessed January 13, 2017.

Westphal DC, Schettini APM, de Souza PP, et al. Generalized pustular psoriasis induced by systemic steroid dose reduction. An Bras Dermatol. 2016;91:664-666.

Expert Commentaries on next page

Expert Commentaries

When I was a resident, I was trained not to use systemic steroids in psoriasis patients for the reasons noted above, and I have faithfully followed these instructions 9 years into practice. However, I see many patients with severe psoriasis who are given systemic steroids by other physicians (ie, rheumatologists for psoriatic arthritis, pulmonologists for asthma). I often tell patients afterwards of the dangers of systemic steroids and to have them tell their other doctors to be cautious when giving another course of systemic steroids. However, I have yet to see a generalized pustular psoriasis outbreak or flare in psoriasis vulgaris after a course of systemic steroids. While I do not recommend systemic steroids for psoriasis patients since we have so many other systemic agents, I wonder if the risks that we were all trained about are really that high.

—Jashin J. Wu, MD (Los Angeles, California)

How bad is it to give patients with psoriasis systemic steroids? Are psoriasis patients treated with systemic steroids likely to get a pustular flare? Are patients with psoriasis who suddenly stop their corticosteroids more likely to get a pustular flare than psoriasis patients who suddenly stop other systemic psoriasis treatments? I don't have the answers to these questions. My sense is that we have a lot of dogma and strong opinions but very little hard evidence to answer these questions.

I don't typically prescribe systemic steroids to psoriasis patients, but systemic steroids are widely used. Sometimes there are problems. I have seen patients who received systemic steroids for psoriasis and who went on to have a pustular flare, but it's possible the systemic steroid was given because those patients were headed toward the pustular flare already.

I once had a psoriasis patient who came to see me with a suddenly inflamed tender joint. Not knowing what to do, I called a rheumatologist to see the patient. The rheumatologist, too busy to work the patient in, told me to give the patient a 2-week prednisone taper. I did, and nothing untoward happened with the psoriasis. This one anecdote doesn't give me much confidence that systemic steroids are safe for psoriasis patients.

Clearly, long-term steroids cause a host of problems (eg, osteoporosis, diabetes). But I'm not sure that the dogma that systemic steroids should be avoided in patients with psoriasis is well supported. Systemic steroids are being widely used, and I don't see an epidemic of pustular flares.

Is it a mistake to give systemic steroids to psoriasis patients? I just don't know.
—Steven R. Feldman, MD, PhD (Winston-Salem, North Carolina)

Myth: Systemic steroids cause pustular psoriasis

The advent of biologic therapy for psoriasis has changed the landscape of treatments offered to patients. Nevertheless, systemic therapies still play an important role, according to the American Academy of Dermatology psoriasis treatment guidelines, due to their oral route of administration and low cost compared to biologics. They are options for patients with moderate to severe psoriasis that is unresponsive to topical therapies or phototherapy. However, many dermatologists feel that it is inappropriate to prescribe oral steroids to psoriasis patients due to the risk for steroid-induced conversion to pustular psoriasis, the long-term side effects of steroids, and deterioration of psoriasis after withdrawal of steroids.

Pustular psoriasis appears clinically as white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. There are a number of triggers in addition to systemic steroids, such as internal medications, irritating topical agents, overexposure to UV light, and pregnancy. Stopping an oral steroid abruptly can cause serious disease flares, fatigue, and joint pain.

Westphal et al described the case of a 70-year-old woman with palmoplantar psoriasis who was diagnosed with acute generalized exanthematous pustulosis that was treated with corticotherapy by injection and then oral prednisone. She experienced improvement, but her symptoms worsened when she was in the process of reducing the prednisone dose. The dose was increased again, and the same worsening of symptoms was experienced when the dose was reduced. After completely abandoning oral steroid therapy, she developed a severe case of generalized pustular psoriasis that was treated with acitretin. This case illustrates the dangerous consequences of abruptly discontinuing oral steroids.

However, dermatologists may be using oral steroids for psoriasis more often than treatment guidelines suggest. In 2014, Al-Dabagh et al evaluated how frequently systemic corticosteroids are prescribed for psoriasis in the United States. The researchers reported, "Despite the absence or discouragement of systemic corticosteroids in psoriasis management guidelines, systemic corticosteroids are among the most common systemic treatments used for psoriasis." They found that systemic corticosteroids were prescribed at 650,000 of 21,020,000 psoriasis visits, of which 93% were visits to dermatologists. Prednisone was the most commonly prescribed systemic corticosteroid, followed by methylprednisolone and dexamethasone. To prevent rebound flares, systemic corticosteroids were prescribed with a topical corticosteroid in 45% of the visits in patients with psoriasis as the sole diagnosis. They concluded, "The striking contrast between the guidelines for psoriasis management and actual practice suggests that there is an acute need to better understand the use of systemic corticosteroids for psoriasis."

The benefits of systemic corticosteroids versus the frequency of adverse reactions should be weighed by dermatologists and patients to make evidence-based decisions about treatment. Patients should take oral steroids exactly as prescribed by physicians.

References

Al-Dabagh A, Al-Dabagh R, Davis SA, et al. Systemic corticosteroids are frequently prescribed for psoriasis. J Cutan Med Surg. 2014;18:195-199.

Delzell E. What you need to know about steroids. National Psoriasis Foundation website. https://www.psoriasis.org/advance/what-you-need-to-know-about-steroids. Published September 2, 2015. Accessed January 13, 2017.

Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61:451-485.

Pustular psoriasis. National Psoriasis Foundation website. https://www.psoriasis.org/about-psoriasis/types/pustular. Accessed January 13, 2017.

Westphal DC, Schettini APM, de Souza PP, et al. Generalized pustular psoriasis induced by systemic steroid dose reduction. An Bras Dermatol. 2016;91:664-666.

Expert Commentaries on next page

Expert Commentaries

When I was a resident, I was trained not to use systemic steroids in psoriasis patients for the reasons noted above, and I have faithfully followed these instructions 9 years into practice. However, I see many patients with severe psoriasis who are given systemic steroids by other physicians (ie, rheumatologists for psoriatic arthritis, pulmonologists for asthma). I often tell patients afterwards of the dangers of systemic steroids and to have them tell their other doctors to be cautious when giving another course of systemic steroids. However, I have yet to see a generalized pustular psoriasis outbreak or flare in psoriasis vulgaris after a course of systemic steroids. While I do not recommend systemic steroids for psoriasis patients since we have so many other systemic agents, I wonder if the risks that we were all trained about are really that high.

—Jashin J. Wu, MD (Los Angeles, California)

How bad is it to give patients with psoriasis systemic steroids? Are psoriasis patients treated with systemic steroids likely to get a pustular flare? Are patients with psoriasis who suddenly stop their corticosteroids more likely to get a pustular flare than psoriasis patients who suddenly stop other systemic psoriasis treatments? I don't have the answers to these questions. My sense is that we have a lot of dogma and strong opinions but very little hard evidence to answer these questions.

I don't typically prescribe systemic steroids to psoriasis patients, but systemic steroids are widely used. Sometimes there are problems. I have seen patients who received systemic steroids for psoriasis and who went on to have a pustular flare, but it's possible the systemic steroid was given because those patients were headed toward the pustular flare already.

I once had a psoriasis patient who came to see me with a suddenly inflamed tender joint. Not knowing what to do, I called a rheumatologist to see the patient. The rheumatologist, too busy to work the patient in, told me to give the patient a 2-week prednisone taper. I did, and nothing untoward happened with the psoriasis. This one anecdote doesn't give me much confidence that systemic steroids are safe for psoriasis patients.

Clearly, long-term steroids cause a host of problems (eg, osteoporosis, diabetes). But I'm not sure that the dogma that systemic steroids should be avoided in patients with psoriasis is well supported. Systemic steroids are being widely used, and I don't see an epidemic of pustular flares.

Is it a mistake to give systemic steroids to psoriasis patients? I just don't know.
—Steven R. Feldman, MD, PhD (Winston-Salem, North Carolina)

Myth: Systemic steroids cause pustular psoriasis

The advent of biologic therapy for psoriasis has changed the landscape of treatments offered to patients. Nevertheless, systemic therapies still play an important role, according to the American Academy of Dermatology psoriasis treatment guidelines, due to their oral route of administration and low cost compared to biologics. They are options for patients with moderate to severe psoriasis that is unresponsive to topical therapies or phototherapy. However, many dermatologists feel that it is inappropriate to prescribe oral steroids to psoriasis patients due to the risk for steroid-induced conversion to pustular psoriasis, the long-term side effects of steroids, and deterioration of psoriasis after withdrawal of steroids.

Pustular psoriasis appears clinically as white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. There are a number of triggers in addition to systemic steroids, such as internal medications, irritating topical agents, overexposure to UV light, and pregnancy. Stopping an oral steroid abruptly can cause serious disease flares, fatigue, and joint pain.

Westphal et al described the case of a 70-year-old woman with palmoplantar psoriasis who was diagnosed with acute generalized exanthematous pustulosis that was treated with corticotherapy by injection and then oral prednisone. She experienced improvement, but her symptoms worsened when she was in the process of reducing the prednisone dose. The dose was increased again, and the same worsening of symptoms was experienced when the dose was reduced. After completely abandoning oral steroid therapy, she developed a severe case of generalized pustular psoriasis that was treated with acitretin. This case illustrates the dangerous consequences of abruptly discontinuing oral steroids.

However, dermatologists may be using oral steroids for psoriasis more often than treatment guidelines suggest. In 2014, Al-Dabagh et al evaluated how frequently systemic corticosteroids are prescribed for psoriasis in the United States. The researchers reported, "Despite the absence or discouragement of systemic corticosteroids in psoriasis management guidelines, systemic corticosteroids are among the most common systemic treatments used for psoriasis." They found that systemic corticosteroids were prescribed at 650,000 of 21,020,000 psoriasis visits, of which 93% were visits to dermatologists. Prednisone was the most commonly prescribed systemic corticosteroid, followed by methylprednisolone and dexamethasone. To prevent rebound flares, systemic corticosteroids were prescribed with a topical corticosteroid in 45% of the visits in patients with psoriasis as the sole diagnosis. They concluded, "The striking contrast between the guidelines for psoriasis management and actual practice suggests that there is an acute need to better understand the use of systemic corticosteroids for psoriasis."

The benefits of systemic corticosteroids versus the frequency of adverse reactions should be weighed by dermatologists and patients to make evidence-based decisions about treatment. Patients should take oral steroids exactly as prescribed by physicians.

References

Al-Dabagh A, Al-Dabagh R, Davis SA, et al. Systemic corticosteroids are frequently prescribed for psoriasis. J Cutan Med Surg. 2014;18:195-199.

Delzell E. What you need to know about steroids. National Psoriasis Foundation website. https://www.psoriasis.org/advance/what-you-need-to-know-about-steroids. Published September 2, 2015. Accessed January 13, 2017.

Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61:451-485.

Pustular psoriasis. National Psoriasis Foundation website. https://www.psoriasis.org/about-psoriasis/types/pustular. Accessed January 13, 2017.

Westphal DC, Schettini APM, de Souza PP, et al. Generalized pustular psoriasis induced by systemic steroid dose reduction. An Bras Dermatol. 2016;91:664-666.

Expert Commentaries on next page

Expert Commentaries

When I was a resident, I was trained not to use systemic steroids in psoriasis patients for the reasons noted above, and I have faithfully followed these instructions 9 years into practice. However, I see many patients with severe psoriasis who are given systemic steroids by other physicians (ie, rheumatologists for psoriatic arthritis, pulmonologists for asthma). I often tell patients afterwards of the dangers of systemic steroids and to have them tell their other doctors to be cautious when giving another course of systemic steroids. However, I have yet to see a generalized pustular psoriasis outbreak or flare in psoriasis vulgaris after a course of systemic steroids. While I do not recommend systemic steroids for psoriasis patients since we have so many other systemic agents, I wonder if the risks that we were all trained about are really that high.

—Jashin J. Wu, MD (Los Angeles, California)

How bad is it to give patients with psoriasis systemic steroids? Are psoriasis patients treated with systemic steroids likely to get a pustular flare? Are patients with psoriasis who suddenly stop their corticosteroids more likely to get a pustular flare than psoriasis patients who suddenly stop other systemic psoriasis treatments? I don't have the answers to these questions. My sense is that we have a lot of dogma and strong opinions but very little hard evidence to answer these questions.

I don't typically prescribe systemic steroids to psoriasis patients, but systemic steroids are widely used. Sometimes there are problems. I have seen patients who received systemic steroids for psoriasis and who went on to have a pustular flare, but it's possible the systemic steroid was given because those patients were headed toward the pustular flare already.

I once had a psoriasis patient who came to see me with a suddenly inflamed tender joint. Not knowing what to do, I called a rheumatologist to see the patient. The rheumatologist, too busy to work the patient in, told me to give the patient a 2-week prednisone taper. I did, and nothing untoward happened with the psoriasis. This one anecdote doesn't give me much confidence that systemic steroids are safe for psoriasis patients.

Clearly, long-term steroids cause a host of problems (eg, osteoporosis, diabetes). But I'm not sure that the dogma that systemic steroids should be avoided in patients with psoriasis is well supported. Systemic steroids are being widely used, and I don't see an epidemic of pustular flares.

Is it a mistake to give systemic steroids to psoriasis patients? I just don't know.
—Steven R. Feldman, MD, PhD (Winston-Salem, North Carolina)

The U.S. Department of Veterans Affairs MRSA Prevention Initiative, implemented in October 2007, has shown progress at limiting health care–associated infections of methicillin-resistant Staphylococcus aureus through 2011 and 2012.

A new report published in the January 2017 issue of the American Journal of Infection Control tracks continued declines in infection through September 2015.

©Photo Researchers/NHGRI

[email protected]

The U.S. Department of Veterans Affairs MRSA Prevention Initiative, implemented in October 2007, has shown progress at limiting health care–associated infections of methicillin-resistant Staphylococcus aureus through 2011 and 2012.

A new report published in the January 2017 issue of the American Journal of Infection Control tracks continued declines in infection through September 2015.

©Photo Researchers/NHGRI

[email protected]

The U.S. Department of Veterans Affairs MRSA Prevention Initiative, implemented in October 2007, has shown progress at limiting health care–associated infections of methicillin-resistant Staphylococcus aureus through 2011 and 2012.

A new report published in the January 2017 issue of the American Journal of Infection Control tracks continued declines in infection through September 2015.

©Photo Researchers/NHGRI

[email protected]

Clinical question: Does emergency department management of patients with febrile neutropenia (FN) follow current guidelines?

Background: Chemotherapy-related FN is an oncologic emergency frequently leading to hospitalization and intravenous antibiotics. Familiarity with FN guidelines allows risk stratification for inpatient versus outpatient therapy.

Study design: Single-center, retrospective, cohort study.

Setting: Large, urban, tertiary-care academic hospital.

Synopsis: Of 173 patient visits, 25% were risk stratified as eligible for outpatient treatment and 75% as inpatient care. All patient care was assessed for guideline concordance at the time of ED disposition and therapy.

Primary outcome analysis demonstrated management was guideline discordant in 98% of low-risk patients versus 7% of high-risk patients. Secondary 30-day clinical outcomes showed high-risk patients were more likely to have positive blood cultures (54%), sepsis-induced hypotension (9.3%), and death (5.4%). Seventeen percent of all patients who received IV antibiotics were prescribed vancomycin without guideline support.

Bottom line: Low-risk FN patients in the ED received more aggressive treatment than recommended. Further research is needed to strategize means of better aligning FN management with standards of care.

Citation: Baugh CW, Wang TJ, Caterino JM, et al. ED management of patients with febrile neutropenia: guideline concordant or overly aggressive [published online ahead of print Sept. 9, 2016]? Acad Emerg Med. doi: 10.1111/acem.13079.

Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does emergency department management of patients with febrile neutropenia (FN) follow current guidelines?

Background: Chemotherapy-related FN is an oncologic emergency frequently leading to hospitalization and intravenous antibiotics. Familiarity with FN guidelines allows risk stratification for inpatient versus outpatient therapy.

Study design: Single-center, retrospective, cohort study.

Setting: Large, urban, tertiary-care academic hospital.

Synopsis: Of 173 patient visits, 25% were risk stratified as eligible for outpatient treatment and 75% as inpatient care. All patient care was assessed for guideline concordance at the time of ED disposition and therapy.

Primary outcome analysis demonstrated management was guideline discordant in 98% of low-risk patients versus 7% of high-risk patients. Secondary 30-day clinical outcomes showed high-risk patients were more likely to have positive blood cultures (54%), sepsis-induced hypotension (9.3%), and death (5.4%). Seventeen percent of all patients who received IV antibiotics were prescribed vancomycin without guideline support.

Bottom line: Low-risk FN patients in the ED received more aggressive treatment than recommended. Further research is needed to strategize means of better aligning FN management with standards of care.

Citation: Baugh CW, Wang TJ, Caterino JM, et al. ED management of patients with febrile neutropenia: guideline concordant or overly aggressive [published online ahead of print Sept. 9, 2016]? Acad Emerg Med. doi: 10.1111/acem.13079.

Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does emergency department management of patients with febrile neutropenia (FN) follow current guidelines?

Background: Chemotherapy-related FN is an oncologic emergency frequently leading to hospitalization and intravenous antibiotics. Familiarity with FN guidelines allows risk stratification for inpatient versus outpatient therapy.

Study design: Single-center, retrospective, cohort study.

Setting: Large, urban, tertiary-care academic hospital.

Synopsis: Of 173 patient visits, 25% were risk stratified as eligible for outpatient treatment and 75% as inpatient care. All patient care was assessed for guideline concordance at the time of ED disposition and therapy.

Primary outcome analysis demonstrated management was guideline discordant in 98% of low-risk patients versus 7% of high-risk patients. Secondary 30-day clinical outcomes showed high-risk patients were more likely to have positive blood cultures (54%), sepsis-induced hypotension (9.3%), and death (5.4%). Seventeen percent of all patients who received IV antibiotics were prescribed vancomycin without guideline support.

Bottom line: Low-risk FN patients in the ED received more aggressive treatment than recommended. Further research is needed to strategize means of better aligning FN management with standards of care.

Citation: Baugh CW, Wang TJ, Caterino JM, et al. ED management of patients with febrile neutropenia: guideline concordant or overly aggressive [published online ahead of print Sept. 9, 2016]? Acad Emerg Med. doi: 10.1111/acem.13079.

Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

NEW ORLEANS – Children with congenital heart defects have a five- to sixfold increased risk of developing pediatric cancer, Matthew Oster, MD, reported at the American Heart Association scientific sessions.

“The absolute risk is small, but it’s still a five- to sixfold risk compared to the general pediatric population, and it does warrant monitoring and a high index of suspicion in our children with congenital heart defects,” said Dr. Oster of Children’s Healthcare of Atlanta.

[email protected]

NEW ORLEANS – Children with congenital heart defects have a five- to sixfold increased risk of developing pediatric cancer, Matthew Oster, MD, reported at the American Heart Association scientific sessions.

“The absolute risk is small, but it’s still a five- to sixfold risk compared to the general pediatric population, and it does warrant monitoring and a high index of suspicion in our children with congenital heart defects,” said Dr. Oster of Children’s Healthcare of Atlanta.

[email protected]

NEW ORLEANS – Children with congenital heart defects have a five- to sixfold increased risk of developing pediatric cancer, Matthew Oster, MD, reported at the American Heart Association scientific sessions.

“The absolute risk is small, but it’s still a five- to sixfold risk compared to the general pediatric population, and it does warrant monitoring and a high index of suspicion in our children with congenital heart defects,” said Dr. Oster of Children’s Healthcare of Atlanta.

[email protected]

In December 2016, Federal Practitioner sat down with Shereef M. Elnahal, MD, MBA, VHA chief quality & safety officer, to discuss the VA Diffusion of Excellence (VADOE) program, which seeks to change VA culture and reward employees who have developed innovative programs that increase patient satisfaction, access to care, and clinical results, among other VA priorities. A recent JAMA article by Dr. Elnahal, VA Secretary Nominee David Shulkin, MD, and Deputy Under Secretary for Health for Organizational Excellence Carolyn Clancy, MD, highlights how VADOE can be a model for excellence at other large-scale health care systems.  

According to Dr. Elnahal, in 1 year, more than 400 VADOE programs have been submitted, more than 20 have been replicated at multiple sites, and 8 are targeted nationally, including a virtual tumor board and clinical pharmacy best practices. “We really empower and recognize the frontline employees who not only contribute the best practices but who replicate them,” Dr. Elnahal told Federal Practitioner. “Essentially, we give them a systemwide leadership role… This is part of many different initiatives that are trying to recognize and elevate the great work that physicians do and really improve their morale and reduce burnout.”

In December 2016, Federal Practitioner sat down with Shereef M. Elnahal, MD, MBA, VHA chief quality & safety officer, to discuss the VA Diffusion of Excellence (VADOE) program, which seeks to change VA culture and reward employees who have developed innovative programs that increase patient satisfaction, access to care, and clinical results, among other VA priorities. A recent JAMA article by Dr. Elnahal, VA Secretary Nominee David Shulkin, MD, and Deputy Under Secretary for Health for Organizational Excellence Carolyn Clancy, MD, highlights how VADOE can be a model for excellence at other large-scale health care systems.  

According to Dr. Elnahal, in 1 year, more than 400 VADOE programs have been submitted, more than 20 have been replicated at multiple sites, and 8 are targeted nationally, including a virtual tumor board and clinical pharmacy best practices. “We really empower and recognize the frontline employees who not only contribute the best practices but who replicate them,” Dr. Elnahal told Federal Practitioner. “Essentially, we give them a systemwide leadership role… This is part of many different initiatives that are trying to recognize and elevate the great work that physicians do and really improve their morale and reduce burnout.”

In December 2016, Federal Practitioner sat down with Shereef M. Elnahal, MD, MBA, VHA chief quality & safety officer, to discuss the VA Diffusion of Excellence (VADOE) program, which seeks to change VA culture and reward employees who have developed innovative programs that increase patient satisfaction, access to care, and clinical results, among other VA priorities. A recent JAMA article by Dr. Elnahal, VA Secretary Nominee David Shulkin, MD, and Deputy Under Secretary for Health for Organizational Excellence Carolyn Clancy, MD, highlights how VADOE can be a model for excellence at other large-scale health care systems.  

According to Dr. Elnahal, in 1 year, more than 400 VADOE programs have been submitted, more than 20 have been replicated at multiple sites, and 8 are targeted nationally, including a virtual tumor board and clinical pharmacy best practices. “We really empower and recognize the frontline employees who not only contribute the best practices but who replicate them,” Dr. Elnahal told Federal Practitioner. “Essentially, we give them a systemwide leadership role… This is part of many different initiatives that are trying to recognize and elevate the great work that physicians do and really improve their morale and reduce burnout.”

Blood donor
Photo by Marja Helander

The Irish Blood Transfusion Service (IBTS) has lifted the lifetime ban on blood donations from men who have sex with men (MSM).

However, prospective MSM blood donors are still subject to deferral.

Now, MSMs are allowed to donate blood in Ireland if it has been more than 12 months since their last sexual contact with a man and if they meet the other blood donor selection criteria.

The IBTS has also introduced new regulations relating to individuals with a history of specific, notifiable sexually transmitted infections (STIs).

These individuals are now allowed to donate blood 5 years after they have completed treatment for their STIs.

“In June of last year, I accepted the recommendations of the IBTS to change their blood donation deferral policies for men who have sex with men, as well as for donors who have had a sexually transmitted infection,” said Ireland’s Health Minister, Simon Harris.

“I would like to take this opportunity to thank the IBTS for their work over the past 6 months, which, today, sees these recommendations brought to fruition within the timescale agreed. [T]he IBTS will continue to keep all deferral policies under active review in the light of scientific evidence, emerging infections, and international experience.”

MSM deferral

The change in deferral policy relating to MSMs follows a 2-year review of the issues by the IBTS.

The agency hosted an international symposium on the topic in April 2016. Experts from 7 countries who had either lifted, or were in the process of lifting, their lifetime ban on MSM blood donors presented their respective stances, research, and the rationale behind their decisions.

The IBTS said its change to a 1-year deferral period for MSMs is supported by the most current scientific evidence available and brings Ireland into line with similar policies in the UK, Canada, and the US.

STI-related deferral

The IBTS said the 1-year deferral policy for MSMs will protect against the risk of HIV transmission. However, there is concern that it may not be sufficient to deal with an emerging infection. 

Therefore, the board of the IBTS decided that individuals who have had a notifiable STI, such as chlamydia or genital herpes, should be deferred from donating blood for 5 years after completing treatment for that STI.  

Individuals who have had syphilis, gonorrhea, lymphogranuloma venereum, or granuloma inguinale are (and have been) permanently banned from donating blood.

Individuals who have taken medication to prevent HIV infection are also deferred from donating blood for 5 years after they take the medication.

Safety of the blood supply

“The IBTS provides a safe, reliable, and robust blood service to the Irish health system and has the necessary program and procedures in place to protect both donors and recipients of blood and blood products,” Harris said.

All prospective blood donors in Ireland undergo nucleic acid testing for a number of diseases, including HIV, hepatitis B, and hepatitis C. This is the most sensitive method of testing available.

The risk of transmitted infection of blood is at its highest when individuals donate blood during the 5- to 15-day period following exposure to a virus.

There is no biological measure to detect infectivity during this period and, as a consequence, the IBTS temporarily or permanently defers, on average, 1 in 10 people from giving blood.

Blood donor
Photo by Marja Helander

The Irish Blood Transfusion Service (IBTS) has lifted the lifetime ban on blood donations from men who have sex with men (MSM).

However, prospective MSM blood donors are still subject to deferral.

Now, MSMs are allowed to donate blood in Ireland if it has been more than 12 months since their last sexual contact with a man and if they meet the other blood donor selection criteria.

The IBTS has also introduced new regulations relating to individuals with a history of specific, notifiable sexually transmitted infections (STIs).

These individuals are now allowed to donate blood 5 years after they have completed treatment for their STIs.

“In June of last year, I accepted the recommendations of the IBTS to change their blood donation deferral policies for men who have sex with men, as well as for donors who have had a sexually transmitted infection,” said Ireland’s Health Minister, Simon Harris.

“I would like to take this opportunity to thank the IBTS for their work over the past 6 months, which, today, sees these recommendations brought to fruition within the timescale agreed. [T]he IBTS will continue to keep all deferral policies under active review in the light of scientific evidence, emerging infections, and international experience.”

MSM deferral

The change in deferral policy relating to MSMs follows a 2-year review of the issues by the IBTS.

The agency hosted an international symposium on the topic in April 2016. Experts from 7 countries who had either lifted, or were in the process of lifting, their lifetime ban on MSM blood donors presented their respective stances, research, and the rationale behind their decisions.

The IBTS said its change to a 1-year deferral period for MSMs is supported by the most current scientific evidence available and brings Ireland into line with similar policies in the UK, Canada, and the US.

STI-related deferral

The IBTS said the 1-year deferral policy for MSMs will protect against the risk of HIV transmission. However, there is concern that it may not be sufficient to deal with an emerging infection. 

Therefore, the board of the IBTS decided that individuals who have had a notifiable STI, such as chlamydia or genital herpes, should be deferred from donating blood for 5 years after completing treatment for that STI.  

Individuals who have had syphilis, gonorrhea, lymphogranuloma venereum, or granuloma inguinale are (and have been) permanently banned from donating blood.

Individuals who have taken medication to prevent HIV infection are also deferred from donating blood for 5 years after they take the medication.

Safety of the blood supply

“The IBTS provides a safe, reliable, and robust blood service to the Irish health system and has the necessary program and procedures in place to protect both donors and recipients of blood and blood products,” Harris said.

All prospective blood donors in Ireland undergo nucleic acid testing for a number of diseases, including HIV, hepatitis B, and hepatitis C. This is the most sensitive method of testing available.

The risk of transmitted infection of blood is at its highest when individuals donate blood during the 5- to 15-day period following exposure to a virus.

There is no biological measure to detect infectivity during this period and, as a consequence, the IBTS temporarily or permanently defers, on average, 1 in 10 people from giving blood.

Blood donor
Photo by Marja Helander

The Irish Blood Transfusion Service (IBTS) has lifted the lifetime ban on blood donations from men who have sex with men (MSM).

However, prospective MSM blood donors are still subject to deferral.

Now, MSMs are allowed to donate blood in Ireland if it has been more than 12 months since their last sexual contact with a man and if they meet the other blood donor selection criteria.

The IBTS has also introduced new regulations relating to individuals with a history of specific, notifiable sexually transmitted infections (STIs).

These individuals are now allowed to donate blood 5 years after they have completed treatment for their STIs.

“In June of last year, I accepted the recommendations of the IBTS to change their blood donation deferral policies for men who have sex with men, as well as for donors who have had a sexually transmitted infection,” said Ireland’s Health Minister, Simon Harris.

“I would like to take this opportunity to thank the IBTS for their work over the past 6 months, which, today, sees these recommendations brought to fruition within the timescale agreed. [T]he IBTS will continue to keep all deferral policies under active review in the light of scientific evidence, emerging infections, and international experience.”

MSM deferral

The change in deferral policy relating to MSMs follows a 2-year review of the issues by the IBTS.

The agency hosted an international symposium on the topic in April 2016. Experts from 7 countries who had either lifted, or were in the process of lifting, their lifetime ban on MSM blood donors presented their respective stances, research, and the rationale behind their decisions.

The IBTS said its change to a 1-year deferral period for MSMs is supported by the most current scientific evidence available and brings Ireland into line with similar policies in the UK, Canada, and the US.

STI-related deferral

The IBTS said the 1-year deferral policy for MSMs will protect against the risk of HIV transmission. However, there is concern that it may not be sufficient to deal with an emerging infection. 

Therefore, the board of the IBTS decided that individuals who have had a notifiable STI, such as chlamydia or genital herpes, should be deferred from donating blood for 5 years after completing treatment for that STI.  

Individuals who have had syphilis, gonorrhea, lymphogranuloma venereum, or granuloma inguinale are (and have been) permanently banned from donating blood.

Individuals who have taken medication to prevent HIV infection are also deferred from donating blood for 5 years after they take the medication.

Safety of the blood supply

“The IBTS provides a safe, reliable, and robust blood service to the Irish health system and has the necessary program and procedures in place to protect both donors and recipients of blood and blood products,” Harris said.

All prospective blood donors in Ireland undergo nucleic acid testing for a number of diseases, including HIV, hepatitis B, and hepatitis C. This is the most sensitive method of testing available.

The risk of transmitted infection of blood is at its highest when individuals donate blood during the 5- to 15-day period following exposure to a virus.

There is no biological measure to detect infectivity during this period and, as a consequence, the IBTS temporarily or permanently defers, on average, 1 in 10 people from giving blood.

Umbilical cord clamping
Photo by Meutia Chaerani
and Indradi Soemardjan

Delaying umbilical cord clamping by a few minutes can reduce the risk of anemia several months after birth, according to research published in JAMA Pediatrics.

A randomized clinical trial showed that delaying cord clamping by 3 minutes or more after birth—rather than clamping within 1 minute of birth—reduced the prevalence of anemia, iron deficiency, and iron deficiency anemia in infants at 8 months and 12 months of age.

Ola Andersson, MD, PhD, of Uppsala University in Uppsala, Sweden, and his colleagues conducted this research in Nepal, a country with a high prevalence of anemia.

The study included 540 infants—281 boys and 259 girls—with a mean gestational age of 39.2 weeks. Half of the subjects were randomized to delayed cord clamping (3 minutes or more after birth) or early cord clamping (within 1 minute of birth).

At 8 months of age, 78.5% of infants from the delayed clamping group and 69.6% from the early clamping group returned for blood sampling.

Results showed that infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.4 g/dL and 10.2 g/dL, respectively (P=0.008).

Infants in the delayed clamping group also had a lower incidence of:

• Anemia (hemoglobin level <11.0 g/dL)—73.0% and 82.2%, respectively (P=0.01)
• Iron deficiency—22.2% and 38.1%, respectively (P<0.001)
• Iron deficiency anemia—19.3% and 33.3%, respectively (P<0.001).

The relative risk (RR) of anemia was 0.89, the RR of iron deficiency was 0.58, and the RR of iron deficiency anemia was 0.58.

Results were similar when the infants reached 12 months of age, although all the between-group differences were not statistically significant.

Again, infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.3 g/dL and 10.1 g/dL, respectively (P=0.02).

And infants in the delayed clamping group had a lower incidence of:

• Anemia—77.8% and 85.9%, respectively (P=0.02)
• Iron deficiency—35.6% and 43%, respectively (P=0.09)
• Iron deficiency anemia—30.4% and 37.8%, respectively (P=0.08).

The RR of anemia was 0.91, the RR of iron deficiency was 0.83, and the RR of iron deficiency anemia was 0.80.

The researchers said this study shows that delayed cord clamping was an effective intervention to reduce anemia in a high-risk population, with minimal cost and without apparent adverse effects.

The team believes that, if this intervention were implemented on a global scale, this could translate to 5 million fewer infants with anemia at 8 months of age.

Umbilical cord clamping
Photo by Meutia Chaerani
and Indradi Soemardjan

Delaying umbilical cord clamping by a few minutes can reduce the risk of anemia several months after birth, according to research published in JAMA Pediatrics.

A randomized clinical trial showed that delaying cord clamping by 3 minutes or more after birth—rather than clamping within 1 minute of birth—reduced the prevalence of anemia, iron deficiency, and iron deficiency anemia in infants at 8 months and 12 months of age.

Ola Andersson, MD, PhD, of Uppsala University in Uppsala, Sweden, and his colleagues conducted this research in Nepal, a country with a high prevalence of anemia.

The study included 540 infants—281 boys and 259 girls—with a mean gestational age of 39.2 weeks. Half of the subjects were randomized to delayed cord clamping (3 minutes or more after birth) or early cord clamping (within 1 minute of birth).

At 8 months of age, 78.5% of infants from the delayed clamping group and 69.6% from the early clamping group returned for blood sampling.

Results showed that infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.4 g/dL and 10.2 g/dL, respectively (P=0.008).

Infants in the delayed clamping group also had a lower incidence of:

• Anemia (hemoglobin level <11.0 g/dL)—73.0% and 82.2%, respectively (P=0.01)
• Iron deficiency—22.2% and 38.1%, respectively (P<0.001)
• Iron deficiency anemia—19.3% and 33.3%, respectively (P<0.001).

The relative risk (RR) of anemia was 0.89, the RR of iron deficiency was 0.58, and the RR of iron deficiency anemia was 0.58.

Results were similar when the infants reached 12 months of age, although all the between-group differences were not statistically significant.

Again, infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.3 g/dL and 10.1 g/dL, respectively (P=0.02).

And infants in the delayed clamping group had a lower incidence of:

• Anemia—77.8% and 85.9%, respectively (P=0.02)
• Iron deficiency—35.6% and 43%, respectively (P=0.09)
• Iron deficiency anemia—30.4% and 37.8%, respectively (P=0.08).

The RR of anemia was 0.91, the RR of iron deficiency was 0.83, and the RR of iron deficiency anemia was 0.80.

The researchers said this study shows that delayed cord clamping was an effective intervention to reduce anemia in a high-risk population, with minimal cost and without apparent adverse effects.

The team believes that, if this intervention were implemented on a global scale, this could translate to 5 million fewer infants with anemia at 8 months of age.

Umbilical cord clamping
Photo by Meutia Chaerani
and Indradi Soemardjan

Delaying umbilical cord clamping by a few minutes can reduce the risk of anemia several months after birth, according to research published in JAMA Pediatrics.

A randomized clinical trial showed that delaying cord clamping by 3 minutes or more after birth—rather than clamping within 1 minute of birth—reduced the prevalence of anemia, iron deficiency, and iron deficiency anemia in infants at 8 months and 12 months of age.

Ola Andersson, MD, PhD, of Uppsala University in Uppsala, Sweden, and his colleagues conducted this research in Nepal, a country with a high prevalence of anemia.

The study included 540 infants—281 boys and 259 girls—with a mean gestational age of 39.2 weeks. Half of the subjects were randomized to delayed cord clamping (3 minutes or more after birth) or early cord clamping (within 1 minute of birth).

At 8 months of age, 78.5% of infants from the delayed clamping group and 69.6% from the early clamping group returned for blood sampling.

Results showed that infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.4 g/dL and 10.2 g/dL, respectively (P=0.008).

Infants in the delayed clamping group also had a lower incidence of:

• Anemia (hemoglobin level <11.0 g/dL)—73.0% and 82.2%, respectively (P=0.01)
• Iron deficiency—22.2% and 38.1%, respectively (P<0.001)
• Iron deficiency anemia—19.3% and 33.3%, respectively (P<0.001).

The relative risk (RR) of anemia was 0.89, the RR of iron deficiency was 0.58, and the RR of iron deficiency anemia was 0.58.

Results were similar when the infants reached 12 months of age, although all the between-group differences were not statistically significant.

Again, infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.3 g/dL and 10.1 g/dL, respectively (P=0.02).

And infants in the delayed clamping group had a lower incidence of:

• Anemia—77.8% and 85.9%, respectively (P=0.02)
• Iron deficiency—35.6% and 43%, respectively (P=0.09)
• Iron deficiency anemia—30.4% and 37.8%, respectively (P=0.08).

The RR of anemia was 0.91, the RR of iron deficiency was 0.83, and the RR of iron deficiency anemia was 0.80.

The researchers said this study shows that delayed cord clamping was an effective intervention to reduce anemia in a high-risk population, with minimal cost and without apparent adverse effects.

The team believes that, if this intervention were implemented on a global scale, this could translate to 5 million fewer infants with anemia at 8 months of age.

Micrograph showing
multiple myeloma

Preclinical research published in Oncotarget has provided new insights regarding how the protein EZH2 affects the development of multiple myeloma (MM) and reinforces the idea that EZH2 inhibition may be a way to treat MM.

Previous research by the same group suggested that EZH2 is a potential therapeutic target in MM.

With the current study, the group further investigated the anti-myeloma mechanisms mediated by EZH2 inhibition.

They found that targeting EZH2 with an agent known as UNC1999 reduces the expression of 4 MM-associated oncogenes—IRF-4, XBP-1, PRDM1/BLIMP-1, and c-MYC.

“The role of oncogenes in the development of cancer is to potentiate the survival of the cancer cell, which, instead of undergoing cell death, as is usually the case when the cell is not functioning properly, continues to divide and proliferate,” said study author Helena Jernberg-Wiklund, PhD, of Uppsala University in Uppsala, Sweden.

“In our study, we identified 4 oncogenes that showed lower activity in cells treated with the EZH2 inhibitor as compared to control-treated cells. All 4 genes have previously been shown to be associated with the development of multiple myeloma. This confirms our previous findings that inhibition of EZH2 could be used as a means to treat multiple myeloma.”

However, the researchers were puzzled by the fact that inhibition of EZH2 could decrease the activity of the oncogenes.

The chemical histone modification performed by EZH2 leads to decreased activity of affected genes. Therefore, inhibition of EZH2 should result in a reduced level of chemical modifications, which, in turn, should result in increased gene activity.

“The answer is that there are other genetic factors involved, called microRNAs,” Dr Jernberg-Wiklund said. “In the cells treated with the EZH2 inhibitor, we found 2 microRNA genes with increased activity, and we believe that the oncogenes are regulated by these microRNAs.”

“What happens then is that, when EZH2 is inhibited, there is a reduced histone modification at the microRNA genes. This leads to an increased synthesis of the microRNAs, which, in turn, decreases the activity of the oncogenes. This is a completely new mechanism for EZH2 action.”

The microRNAs the researchers identified are miR-125a-3p and miR-320c. The team found that miR-125a-3p and miR-320c were targets of EZH2 and H3K27me3 in MM cell lines and primary cells.

The researchers said these results support their previous work suggesting EZH2 could be a therapeutic target in MM.

Micrograph showing
multiple myeloma

Preclinical research published in Oncotarget has provided new insights regarding how the protein EZH2 affects the development of multiple myeloma (MM) and reinforces the idea that EZH2 inhibition may be a way to treat MM.

Previous research by the same group suggested that EZH2 is a potential therapeutic target in MM.

With the current study, the group further investigated the anti-myeloma mechanisms mediated by EZH2 inhibition.

They found that targeting EZH2 with an agent known as UNC1999 reduces the expression of 4 MM-associated oncogenes—IRF-4, XBP-1, PRDM1/BLIMP-1, and c-MYC.

“The role of oncogenes in the development of cancer is to potentiate the survival of the cancer cell, which, instead of undergoing cell death, as is usually the case when the cell is not functioning properly, continues to divide and proliferate,” said study author Helena Jernberg-Wiklund, PhD, of Uppsala University in Uppsala, Sweden.

“In our study, we identified 4 oncogenes that showed lower activity in cells treated with the EZH2 inhibitor as compared to control-treated cells. All 4 genes have previously been shown to be associated with the development of multiple myeloma. This confirms our previous findings that inhibition of EZH2 could be used as a means to treat multiple myeloma.”

However, the researchers were puzzled by the fact that inhibition of EZH2 could decrease the activity of the oncogenes.

The chemical histone modification performed by EZH2 leads to decreased activity of affected genes. Therefore, inhibition of EZH2 should result in a reduced level of chemical modifications, which, in turn, should result in increased gene activity.

“The answer is that there are other genetic factors involved, called microRNAs,” Dr Jernberg-Wiklund said. “In the cells treated with the EZH2 inhibitor, we found 2 microRNA genes with increased activity, and we believe that the oncogenes are regulated by these microRNAs.”

“What happens then is that, when EZH2 is inhibited, there is a reduced histone modification at the microRNA genes. This leads to an increased synthesis of the microRNAs, which, in turn, decreases the activity of the oncogenes. This is a completely new mechanism for EZH2 action.”

The microRNAs the researchers identified are miR-125a-3p and miR-320c. The team found that miR-125a-3p and miR-320c were targets of EZH2 and H3K27me3 in MM cell lines and primary cells.

The researchers said these results support their previous work suggesting EZH2 could be a therapeutic target in MM.

Micrograph showing
multiple myeloma

Preclinical research published in Oncotarget has provided new insights regarding how the protein EZH2 affects the development of multiple myeloma (MM) and reinforces the idea that EZH2 inhibition may be a way to treat MM.

Previous research by the same group suggested that EZH2 is a potential therapeutic target in MM.

With the current study, the group further investigated the anti-myeloma mechanisms mediated by EZH2 inhibition.

They found that targeting EZH2 with an agent known as UNC1999 reduces the expression of 4 MM-associated oncogenes—IRF-4, XBP-1, PRDM1/BLIMP-1, and c-MYC.

“The role of oncogenes in the development of cancer is to potentiate the survival of the cancer cell, which, instead of undergoing cell death, as is usually the case when the cell is not functioning properly, continues to divide and proliferate,” said study author Helena Jernberg-Wiklund, PhD, of Uppsala University in Uppsala, Sweden.

“In our study, we identified 4 oncogenes that showed lower activity in cells treated with the EZH2 inhibitor as compared to control-treated cells. All 4 genes have previously been shown to be associated with the development of multiple myeloma. This confirms our previous findings that inhibition of EZH2 could be used as a means to treat multiple myeloma.”

However, the researchers were puzzled by the fact that inhibition of EZH2 could decrease the activity of the oncogenes.

The chemical histone modification performed by EZH2 leads to decreased activity of affected genes. Therefore, inhibition of EZH2 should result in a reduced level of chemical modifications, which, in turn, should result in increased gene activity.

“The answer is that there are other genetic factors involved, called microRNAs,” Dr Jernberg-Wiklund said. “In the cells treated with the EZH2 inhibitor, we found 2 microRNA genes with increased activity, and we believe that the oncogenes are regulated by these microRNAs.”

“What happens then is that, when EZH2 is inhibited, there is a reduced histone modification at the microRNA genes. This leads to an increased synthesis of the microRNAs, which, in turn, decreases the activity of the oncogenes. This is a completely new mechanism for EZH2 action.”

The microRNAs the researchers identified are miR-125a-3p and miR-320c. The team found that miR-125a-3p and miR-320c were targets of EZH2 and H3K27me3 in MM cell lines and primary cells.

The researchers said these results support their previous work suggesting EZH2 could be a therapeutic target in MM.

Cows in Karnataka, India
Photo by Ilya Mauter

The goal of eliminating malaria in countries like India could be more achievable if mosquito-control efforts take into account the relationship between mosquitoes and cattle, according to an international team of researchers.

The group analyzed 2 mosquito

species found in Odisha, the state with the highest number of malaria cases in

India, and found that both species fed on cattle as well as humans.

“In many parts of the world, the mosquitoes responsible for transmitting malaria are specialist feeders on humans and often rest within human houses,” said Matthew Thomas, PhD, of Pennsylvania State University in University Park, Pennsylvania.

“We found that, in an area of India that has a high burden of malaria, most of the mosquitoes that are known to transmit malaria rest in cattle sheds and feed on both cows and humans.”

Dr Thomas and his colleagues reported these findings in Scientific Reports.

According to the researchers, cattle sheds in India are often next to, and sometimes even share a wall with, human houses. However, current malaria control efforts are restricted to domestic dwellings only.

“Given this cattle-shed ‘refuge’ for mosquitoes, focusing only on humans with regard to malaria control is a bit like treating the tip of an iceberg,” said study author Jessica Waite, PhD, also of Pennsylvania State University.

She, Dr Thomas, and their colleagues determined the importance of cows in the malaria-control problem by capturing adult mosquitoes in different habitats within 6 villages in Odisha state—which has the highest number of malaria cases in the country—and noting where the mosquitoes had been resting.

The team then used molecular techniques to determine which species of mosquitoes had been captured and which hosts they had been feeding on.

The researchers collected 1774 Anopheles culicifacies mosquitoes and 169 Anopheles fluviatilis mosquitoes across all study sites.

Both species were denser in cattle sheds than in human dwellings, and both were feeding on humans as well as cattle.

Next, the researchers used their field-collected data to help build a computer model that simulated the life of an adult mosquito. The team used the model to explore how best to control the mosquitoes to have maximum impact on malaria transmission in these villages.

“Our model analysis suggests that conventional control tools—such as insecticide-treated bed nets and indoor insecticide sprays—are less effective when mosquitoes exhibit ‘zoophilic’ behaviors (having an attraction to nonhuman animals),” Dr Thomas said.

“However, extending controls to better target the zoophilic mosquitoes—for example, by broadening coverage of non-repellant insecticide sprays to include cattle sheds—could help reduce transmission dramatically.”

Dr Waite added that the model suggests very little cattle-based vector control effort would be required to drive malaria transmission in the region to elimination.

“We show that directing even modest amounts of effort to specifically increase mosquito mortality associated with zoophilic behavior can shift the balance towards elimination,” she said.

“Understanding the dynamic between humans, cattle, and mosquitoes could have major implications for malaria control policy and practice, not only in India, but in other areas where transmission is sustained by zoophilic vectors,” Dr Thomas said.

“Specifically, optimizing use of existing tools will be essential to achieving the ambitious 2030 elimination target set by the World Health Organization, which aims to decrease malaria cases globally by 90% compared to 2015 levels and eliminate malaria in at least 35 additional countries by 2030.”

Cows in Karnataka, India
Photo by Ilya Mauter

The goal of eliminating malaria in countries like India could be more achievable if mosquito-control efforts take into account the relationship between mosquitoes and cattle, according to an international team of researchers.

The group analyzed 2 mosquito

species found in Odisha, the state with the highest number of malaria cases in

India, and found that both species fed on cattle as well as humans.

“In many parts of the world, the mosquitoes responsible for transmitting malaria are specialist feeders on humans and often rest within human houses,” said Matthew Thomas, PhD, of Pennsylvania State University in University Park, Pennsylvania.

“We found that, in an area of India that has a high burden of malaria, most of the mosquitoes that are known to transmit malaria rest in cattle sheds and feed on both cows and humans.”

Dr Thomas and his colleagues reported these findings in Scientific Reports.

According to the researchers, cattle sheds in India are often next to, and sometimes even share a wall with, human houses. However, current malaria control efforts are restricted to domestic dwellings only.

“Given this cattle-shed ‘refuge’ for mosquitoes, focusing only on humans with regard to malaria control is a bit like treating the tip of an iceberg,” said study author Jessica Waite, PhD, also of Pennsylvania State University.

She, Dr Thomas, and their colleagues determined the importance of cows in the malaria-control problem by capturing adult mosquitoes in different habitats within 6 villages in Odisha state—which has the highest number of malaria cases in the country—and noting where the mosquitoes had been resting.

The team then used molecular techniques to determine which species of mosquitoes had been captured and which hosts they had been feeding on.

The researchers collected 1774 Anopheles culicifacies mosquitoes and 169 Anopheles fluviatilis mosquitoes across all study sites.

Both species were denser in cattle sheds than in human dwellings, and both were feeding on humans as well as cattle.

Next, the researchers used their field-collected data to help build a computer model that simulated the life of an adult mosquito. The team used the model to explore how best to control the mosquitoes to have maximum impact on malaria transmission in these villages.

“Our model analysis suggests that conventional control tools—such as insecticide-treated bed nets and indoor insecticide sprays—are less effective when mosquitoes exhibit ‘zoophilic’ behaviors (having an attraction to nonhuman animals),” Dr Thomas said.

“However, extending controls to better target the zoophilic mosquitoes—for example, by broadening coverage of non-repellant insecticide sprays to include cattle sheds—could help reduce transmission dramatically.”

Dr Waite added that the model suggests very little cattle-based vector control effort would be required to drive malaria transmission in the region to elimination.

“We show that directing even modest amounts of effort to specifically increase mosquito mortality associated with zoophilic behavior can shift the balance towards elimination,” she said.

“Understanding the dynamic between humans, cattle, and mosquitoes could have major implications for malaria control policy and practice, not only in India, but in other areas where transmission is sustained by zoophilic vectors,” Dr Thomas said.

“Specifically, optimizing use of existing tools will be essential to achieving the ambitious 2030 elimination target set by the World Health Organization, which aims to decrease malaria cases globally by 90% compared to 2015 levels and eliminate malaria in at least 35 additional countries by 2030.”

Cows in Karnataka, India
Photo by Ilya Mauter

The goal of eliminating malaria in countries like India could be more achievable if mosquito-control efforts take into account the relationship between mosquitoes and cattle, according to an international team of researchers.

The group analyzed 2 mosquito

species found in Odisha, the state with the highest number of malaria cases in

India, and found that both species fed on cattle as well as humans.

“In many parts of the world, the mosquitoes responsible for transmitting malaria are specialist feeders on humans and often rest within human houses,” said Matthew Thomas, PhD, of Pennsylvania State University in University Park, Pennsylvania.

“We found that, in an area of India that has a high burden of malaria, most of the mosquitoes that are known to transmit malaria rest in cattle sheds and feed on both cows and humans.”

Dr Thomas and his colleagues reported these findings in Scientific Reports.

According to the researchers, cattle sheds in India are often next to, and sometimes even share a wall with, human houses. However, current malaria control efforts are restricted to domestic dwellings only.

“Given this cattle-shed ‘refuge’ for mosquitoes, focusing only on humans with regard to malaria control is a bit like treating the tip of an iceberg,” said study author Jessica Waite, PhD, also of Pennsylvania State University.

She, Dr Thomas, and their colleagues determined the importance of cows in the malaria-control problem by capturing adult mosquitoes in different habitats within 6 villages in Odisha state—which has the highest number of malaria cases in the country—and noting where the mosquitoes had been resting.

The team then used molecular techniques to determine which species of mosquitoes had been captured and which hosts they had been feeding on.

The researchers collected 1774 Anopheles culicifacies mosquitoes and 169 Anopheles fluviatilis mosquitoes across all study sites.

Both species were denser in cattle sheds than in human dwellings, and both were feeding on humans as well as cattle.

Next, the researchers used their field-collected data to help build a computer model that simulated the life of an adult mosquito. The team used the model to explore how best to control the mosquitoes to have maximum impact on malaria transmission in these villages.

“Our model analysis suggests that conventional control tools—such as insecticide-treated bed nets and indoor insecticide sprays—are less effective when mosquitoes exhibit ‘zoophilic’ behaviors (having an attraction to nonhuman animals),” Dr Thomas said.

“However, extending controls to better target the zoophilic mosquitoes—for example, by broadening coverage of non-repellant insecticide sprays to include cattle sheds—could help reduce transmission dramatically.”

Dr Waite added that the model suggests very little cattle-based vector control effort would be required to drive malaria transmission in the region to elimination.

“We show that directing even modest amounts of effort to specifically increase mosquito mortality associated with zoophilic behavior can shift the balance towards elimination,” she said.

“Understanding the dynamic between humans, cattle, and mosquitoes could have major implications for malaria control policy and practice, not only in India, but in other areas where transmission is sustained by zoophilic vectors,” Dr Thomas said.

“Specifically, optimizing use of existing tools will be essential to achieving the ambitious 2030 elimination target set by the World Health Organization, which aims to decrease malaria cases globally by 90% compared to 2015 levels and eliminate malaria in at least 35 additional countries by 2030.”

People in the military are somewhat nomadic by necessity: They move around a lot, and their medical records should be just as mobile, says Army Brig. Gen. John Cho, deputy chief of staff for support for the Army’s Medical Command, in an article for Health.mil. Cho is the functional champion on development of MHS Genesis, the new electronic health record that is replacing less agile DoD legacy systems.

Related: IHS Pilots Improved Version of Health Records

Developed with input from more than 850 experts in the field around the world, MHS Genesis is intended to fix shortcomings in the current system. It will integrate medical and dental records throughout the continuum of care, from point of injury to the military treatment facility where the care is provided.

Benefits include the ability to monitor a beneficiary’s health status through health data, tracking, and alerting capabilities; improved ability to monitor patient safety, outcomes, and operational and medical readiness; improved access to integrated, evidence-based health care delivery and decision-making; and increased sharing of health information across the spectrum of military operations, the VA, and civilian health care organizations.

Related: How Safe Are Patients’ Electronic Records?

MHS Genesis will support the availability of electronic health records for > 9.4 million DoD beneficiaries and approximately 205,000 MHS personnel globally. The new system is currently being tested, with rollout in the Pacific Northwest scheduled for early 2017. The system expected to be ready throughout the MHS in 5 years.

People in the military are somewhat nomadic by necessity: They move around a lot, and their medical records should be just as mobile, says Army Brig. Gen. John Cho, deputy chief of staff for support for the Army’s Medical Command, in an article for Health.mil. Cho is the functional champion on development of MHS Genesis, the new electronic health record that is replacing less agile DoD legacy systems.

Related: IHS Pilots Improved Version of Health Records

Developed with input from more than 850 experts in the field around the world, MHS Genesis is intended to fix shortcomings in the current system. It will integrate medical and dental records throughout the continuum of care, from point of injury to the military treatment facility where the care is provided.

Benefits include the ability to monitor a beneficiary’s health status through health data, tracking, and alerting capabilities; improved ability to monitor patient safety, outcomes, and operational and medical readiness; improved access to integrated, evidence-based health care delivery and decision-making; and increased sharing of health information across the spectrum of military operations, the VA, and civilian health care organizations.

Related: How Safe Are Patients’ Electronic Records?

MHS Genesis will support the availability of electronic health records for > 9.4 million DoD beneficiaries and approximately 205,000 MHS personnel globally. The new system is currently being tested, with rollout in the Pacific Northwest scheduled for early 2017. The system expected to be ready throughout the MHS in 5 years.

People in the military are somewhat nomadic by necessity: They move around a lot, and their medical records should be just as mobile, says Army Brig. Gen. John Cho, deputy chief of staff for support for the Army’s Medical Command, in an article for Health.mil. Cho is the functional champion on development of MHS Genesis, the new electronic health record that is replacing less agile DoD legacy systems.

Related: IHS Pilots Improved Version of Health Records

Developed with input from more than 850 experts in the field around the world, MHS Genesis is intended to fix shortcomings in the current system. It will integrate medical and dental records throughout the continuum of care, from point of injury to the military treatment facility where the care is provided.

Benefits include the ability to monitor a beneficiary’s health status through health data, tracking, and alerting capabilities; improved ability to monitor patient safety, outcomes, and operational and medical readiness; improved access to integrated, evidence-based health care delivery and decision-making; and increased sharing of health information across the spectrum of military operations, the VA, and civilian health care organizations.

Related: How Safe Are Patients’ Electronic Records?

MHS Genesis will support the availability of electronic health records for > 9.4 million DoD beneficiaries and approximately 205,000 MHS personnel globally. The new system is currently being tested, with rollout in the Pacific Northwest scheduled for early 2017. The system expected to be ready throughout the MHS in 5 years.