LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

BOSTON – Patients with stage II or III non–small-cell lung cancer with comorbidities that make them poor candidates for surgery or chemotherapy may still benefit from accelerated hypofractionated radiation, an interim analysis of a randomized trial suggests.

Among 48 patients followed for a median of 24 months, there were no statistical differences in either overall survival (OS) or progression-free survival between patients with stage II or III NSCLC and poor performance status treated with either conventional radiation delivered over 6 weeks, or image-guided radiation therapy (IGRT) delivered over 3 weeks, reported Puneeth Iyengar, MD, PhD, of the University of Texas Southwestern in Dallas.

BOSTON – Patients with stage II or III non–small-cell lung cancer with comorbidities that make them poor candidates for surgery or chemotherapy may still benefit from accelerated hypofractionated radiation, an interim analysis of a randomized trial suggests.

Among 48 patients followed for a median of 24 months, there were no statistical differences in either overall survival (OS) or progression-free survival between patients with stage II or III NSCLC and poor performance status treated with either conventional radiation delivered over 6 weeks, or image-guided radiation therapy (IGRT) delivered over 3 weeks, reported Puneeth Iyengar, MD, PhD, of the University of Texas Southwestern in Dallas.

BOSTON – Patients with stage II or III non–small-cell lung cancer with comorbidities that make them poor candidates for surgery or chemotherapy may still benefit from accelerated hypofractionated radiation, an interim analysis of a randomized trial suggests.

Among 48 patients followed for a median of 24 months, there were no statistical differences in either overall survival (OS) or progression-free survival between patients with stage II or III NSCLC and poor performance status treated with either conventional radiation delivered over 6 weeks, or image-guided radiation therapy (IGRT) delivered over 3 weeks, reported Puneeth Iyengar, MD, PhD, of the University of Texas Southwestern in Dallas.

In a large retrospective study of patients with hidradenitis suppurativa (HS) managed with surgical procedures, excision and unroofing methods were associated with low rates of complications, moderate levels of postoperative recurrences, and low rates of reoperations for those experiencing recurrences.

“Data from this surgical series of patients with HS demonstrate that surgical management is a safe and effective treatment for advanced intractable HS disease,” concluded John J. Kohorst, MD, a resident in dermatology at the Mayo Clinic, Rochester, Minn., and his associates (Dermatol Surg. 2016;42:1030-40).

Although a variety of surgical procedures have been described as treatments for advanced, intractable HS, the efficacy and safety of specific operative methodologies have remained unclear because of the relatively small number of patients examined in previous studies, they noted.

To further elucidate the efficacy and safety of currently available surgical treatment options for patient with advanced HS, they conducted a retrospective medical chart review of 590 consecutive patients with HS who underwent excision, unroofing, or drainage operative procedures between Jan. 1, 1976, and Dec. 31, 2012. This cohort included almost three times as many patients as the largest of the previously published studies on the subject. Their mean age at the time of surgery was 41 years, and most (80.7%) had Hurley stage III disease.

The majority of patients had undergone excision (68.6%) and unroofing (28.5%) procedures.

Most of the procedures were safe and effective, according to the investigators. Only 15 of the 590 patients (2.5%) experienced postoperative complications within the first 30 days of surgery (including 9 cases of cellulitis and 2 skin graft losses). Although 144 patients (24.4%) experienced recurrence at the surgical site, only 69 of the 590 patients (11.7%) required reoperation over an average of about 25 months.

The results of the multivariate Cox proportional hazards regression analysis, used to determine factors associated with risk of recurrence, indicated that surgery at multiple sites (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5), and incision and drainage procedures (HR, 3.5; 95% CI, 1.2-10.7) were all significantly associated with higher rates of recurrence. In addition, “for each decade younger at the time of surgery, patients had a significantly increased recurrence risk,” they wrote.

In an interview, Dr. Kohorst said that there was a “significant effect of age on postoperative recurrence,” with patients under age 30 having approximately a 50% chance of recurrence, compared with a 25% chance of recurrence in patients older than 50 years of age.

Conversely, other variables they assessed including the specific surgical site(s) examined, disease severity based on the patient’s Hurley stage, gender, and the extent of the operation were not associated with an increase in recurrence rates. No difference was detected between the risk of recurrence for those undergoing excision or unroofing (HR, 1.0; 95% CI, 0.6-1.4).

Based on their overall findings, the authors concluded that “with well-planned, individualized surgical care, the likelihood of postoperative recurrence rests largely on patient age at surgical treatment and the number of surgical sites.”

They disclosed no conflicts of interest. A funding source of the study was not provided.

In a large retrospective study of patients with hidradenitis suppurativa (HS) managed with surgical procedures, excision and unroofing methods were associated with low rates of complications, moderate levels of postoperative recurrences, and low rates of reoperations for those experiencing recurrences.

“Data from this surgical series of patients with HS demonstrate that surgical management is a safe and effective treatment for advanced intractable HS disease,” concluded John J. Kohorst, MD, a resident in dermatology at the Mayo Clinic, Rochester, Minn., and his associates (Dermatol Surg. 2016;42:1030-40).

Although a variety of surgical procedures have been described as treatments for advanced, intractable HS, the efficacy and safety of specific operative methodologies have remained unclear because of the relatively small number of patients examined in previous studies, they noted.

To further elucidate the efficacy and safety of currently available surgical treatment options for patient with advanced HS, they conducted a retrospective medical chart review of 590 consecutive patients with HS who underwent excision, unroofing, or drainage operative procedures between Jan. 1, 1976, and Dec. 31, 2012. This cohort included almost three times as many patients as the largest of the previously published studies on the subject. Their mean age at the time of surgery was 41 years, and most (80.7%) had Hurley stage III disease.

The majority of patients had undergone excision (68.6%) and unroofing (28.5%) procedures.

Most of the procedures were safe and effective, according to the investigators. Only 15 of the 590 patients (2.5%) experienced postoperative complications within the first 30 days of surgery (including 9 cases of cellulitis and 2 skin graft losses). Although 144 patients (24.4%) experienced recurrence at the surgical site, only 69 of the 590 patients (11.7%) required reoperation over an average of about 25 months.

The results of the multivariate Cox proportional hazards regression analysis, used to determine factors associated with risk of recurrence, indicated that surgery at multiple sites (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5), and incision and drainage procedures (HR, 3.5; 95% CI, 1.2-10.7) were all significantly associated with higher rates of recurrence. In addition, “for each decade younger at the time of surgery, patients had a significantly increased recurrence risk,” they wrote.

In an interview, Dr. Kohorst said that there was a “significant effect of age on postoperative recurrence,” with patients under age 30 having approximately a 50% chance of recurrence, compared with a 25% chance of recurrence in patients older than 50 years of age.

Conversely, other variables they assessed including the specific surgical site(s) examined, disease severity based on the patient’s Hurley stage, gender, and the extent of the operation were not associated with an increase in recurrence rates. No difference was detected between the risk of recurrence for those undergoing excision or unroofing (HR, 1.0; 95% CI, 0.6-1.4).

Based on their overall findings, the authors concluded that “with well-planned, individualized surgical care, the likelihood of postoperative recurrence rests largely on patient age at surgical treatment and the number of surgical sites.”

They disclosed no conflicts of interest. A funding source of the study was not provided.

In a large retrospective study of patients with hidradenitis suppurativa (HS) managed with surgical procedures, excision and unroofing methods were associated with low rates of complications, moderate levels of postoperative recurrences, and low rates of reoperations for those experiencing recurrences.

“Data from this surgical series of patients with HS demonstrate that surgical management is a safe and effective treatment for advanced intractable HS disease,” concluded John J. Kohorst, MD, a resident in dermatology at the Mayo Clinic, Rochester, Minn., and his associates (Dermatol Surg. 2016;42:1030-40).

Although a variety of surgical procedures have been described as treatments for advanced, intractable HS, the efficacy and safety of specific operative methodologies have remained unclear because of the relatively small number of patients examined in previous studies, they noted.

To further elucidate the efficacy and safety of currently available surgical treatment options for patient with advanced HS, they conducted a retrospective medical chart review of 590 consecutive patients with HS who underwent excision, unroofing, or drainage operative procedures between Jan. 1, 1976, and Dec. 31, 2012. This cohort included almost three times as many patients as the largest of the previously published studies on the subject. Their mean age at the time of surgery was 41 years, and most (80.7%) had Hurley stage III disease.

The majority of patients had undergone excision (68.6%) and unroofing (28.5%) procedures.

Most of the procedures were safe and effective, according to the investigators. Only 15 of the 590 patients (2.5%) experienced postoperative complications within the first 30 days of surgery (including 9 cases of cellulitis and 2 skin graft losses). Although 144 patients (24.4%) experienced recurrence at the surgical site, only 69 of the 590 patients (11.7%) required reoperation over an average of about 25 months.

The results of the multivariate Cox proportional hazards regression analysis, used to determine factors associated with risk of recurrence, indicated that surgery at multiple sites (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5), and incision and drainage procedures (HR, 3.5; 95% CI, 1.2-10.7) were all significantly associated with higher rates of recurrence. In addition, “for each decade younger at the time of surgery, patients had a significantly increased recurrence risk,” they wrote.

In an interview, Dr. Kohorst said that there was a “significant effect of age on postoperative recurrence,” with patients under age 30 having approximately a 50% chance of recurrence, compared with a 25% chance of recurrence in patients older than 50 years of age.

Conversely, other variables they assessed including the specific surgical site(s) examined, disease severity based on the patient’s Hurley stage, gender, and the extent of the operation were not associated with an increase in recurrence rates. No difference was detected between the risk of recurrence for those undergoing excision or unroofing (HR, 1.0; 95% CI, 0.6-1.4).

Based on their overall findings, the authors concluded that “with well-planned, individualized surgical care, the likelihood of postoperative recurrence rests largely on patient age at surgical treatment and the number of surgical sites.”

They disclosed no conflicts of interest. A funding source of the study was not provided.

Several simple, inexpensive operational interventions substantially improve care for viral hepatitis, according to a report published in the Lancet.

Recent advances in treatment for chronic hepatitis B and chronic hepatitis C have the potential to halt or even reverse the progression of associated liver disease and to reduce related mortality, reported Kali Zhou, MD, of the division of gastroenterology, University of California, San Francisco, and her associates. But they can do so only if affected individuals are engaged and retained in the relatively long continuum of care, from diagnosis through viral suppression or cure.

To assess the usefulness of interventions that promote such patient engagement and retention, Dr. Zhou and her colleagues reviewed the scientific literature and performed a meta-analysis of 56 studies. They examined 15 studies on HBV care, 38 on HCV care, and 3 on both types of hepatitis (Lancet Infect Dis. 2016 Sep 5. doi: 10.1016/S1473-3099[16]30208-0).

Among their findings:

• Educating a single lay health worker to improve knowledge about the disease in his or her community and to promote diagnostic testing nearly tripled the testing rate (relative risk, 2.68), compared with no such intervention.

• Clinician reminders during regular office visits to consider hepatitis testing – such as prompts in the patients’ electronic medical records or stickers on their charts – nearly quadrupled the testing rate (RR, 3.70), compared with no clinician reminders.

• Providing guided referral to a hepatitis specialist for people at risk for the disorder markedly improved the rate of visits to such specialists (RR, 1.57), compared with no such referrals.

• Providing psychological counseling and motivational therapy for mental health and/or substance misuse problems along with medical care for hepatitis dramatically increased the number of patients treated (OR, 3.42) and raised the rate of treatment completion (RR, 1.14).

• Combining mental health, substance misuse, and hepatitis treatment services at one location increased the rate of treatment initiation (RR, 1.36), treatment adherence (RR, 1.22), and cure as measured by sustained virologic response rate (RR, 1.21), compared with usual care.These interventions might be useful in augmenting hepatitis treatment programs worldwide, Dr. Zhou and her associates said.

The World Health Organization and the U.S. Fulbright Program supported the study. Dr. Zhou and her associates reported having no relevant financial disclosures.

 

Several simple, inexpensive operational interventions substantially improve care for viral hepatitis, according to a report published in the Lancet.

Recent advances in treatment for chronic hepatitis B and chronic hepatitis C have the potential to halt or even reverse the progression of associated liver disease and to reduce related mortality, reported Kali Zhou, MD, of the division of gastroenterology, University of California, San Francisco, and her associates. But they can do so only if affected individuals are engaged and retained in the relatively long continuum of care, from diagnosis through viral suppression or cure.

To assess the usefulness of interventions that promote such patient engagement and retention, Dr. Zhou and her colleagues reviewed the scientific literature and performed a meta-analysis of 56 studies. They examined 15 studies on HBV care, 38 on HCV care, and 3 on both types of hepatitis (Lancet Infect Dis. 2016 Sep 5. doi: 10.1016/S1473-3099[16]30208-0).

Among their findings:

• Educating a single lay health worker to improve knowledge about the disease in his or her community and to promote diagnostic testing nearly tripled the testing rate (relative risk, 2.68), compared with no such intervention.

• Clinician reminders during regular office visits to consider hepatitis testing – such as prompts in the patients’ electronic medical records or stickers on their charts – nearly quadrupled the testing rate (RR, 3.70), compared with no clinician reminders.

• Providing guided referral to a hepatitis specialist for people at risk for the disorder markedly improved the rate of visits to such specialists (RR, 1.57), compared with no such referrals.

• Providing psychological counseling and motivational therapy for mental health and/or substance misuse problems along with medical care for hepatitis dramatically increased the number of patients treated (OR, 3.42) and raised the rate of treatment completion (RR, 1.14).

• Combining mental health, substance misuse, and hepatitis treatment services at one location increased the rate of treatment initiation (RR, 1.36), treatment adherence (RR, 1.22), and cure as measured by sustained virologic response rate (RR, 1.21), compared with usual care.These interventions might be useful in augmenting hepatitis treatment programs worldwide, Dr. Zhou and her associates said.

The World Health Organization and the U.S. Fulbright Program supported the study. Dr. Zhou and her associates reported having no relevant financial disclosures.

 

Several simple, inexpensive operational interventions substantially improve care for viral hepatitis, according to a report published in the Lancet.

Recent advances in treatment for chronic hepatitis B and chronic hepatitis C have the potential to halt or even reverse the progression of associated liver disease and to reduce related mortality, reported Kali Zhou, MD, of the division of gastroenterology, University of California, San Francisco, and her associates. But they can do so only if affected individuals are engaged and retained in the relatively long continuum of care, from diagnosis through viral suppression or cure.

To assess the usefulness of interventions that promote such patient engagement and retention, Dr. Zhou and her colleagues reviewed the scientific literature and performed a meta-analysis of 56 studies. They examined 15 studies on HBV care, 38 on HCV care, and 3 on both types of hepatitis (Lancet Infect Dis. 2016 Sep 5. doi: 10.1016/S1473-3099[16]30208-0).

Among their findings:

• Educating a single lay health worker to improve knowledge about the disease in his or her community and to promote diagnostic testing nearly tripled the testing rate (relative risk, 2.68), compared with no such intervention.

• Clinician reminders during regular office visits to consider hepatitis testing – such as prompts in the patients’ electronic medical records or stickers on their charts – nearly quadrupled the testing rate (RR, 3.70), compared with no clinician reminders.

• Providing guided referral to a hepatitis specialist for people at risk for the disorder markedly improved the rate of visits to such specialists (RR, 1.57), compared with no such referrals.

• Providing psychological counseling and motivational therapy for mental health and/or substance misuse problems along with medical care for hepatitis dramatically increased the number of patients treated (OR, 3.42) and raised the rate of treatment completion (RR, 1.14).

• Combining mental health, substance misuse, and hepatitis treatment services at one location increased the rate of treatment initiation (RR, 1.36), treatment adherence (RR, 1.22), and cure as measured by sustained virologic response rate (RR, 1.21), compared with usual care.These interventions might be useful in augmenting hepatitis treatment programs worldwide, Dr. Zhou and her associates said.

The World Health Organization and the U.S. Fulbright Program supported the study. Dr. Zhou and her associates reported having no relevant financial disclosures.

 

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

LAS VEGAS – Patients with systemic sclerosis, mixed connective tissue disease, and Ehlers-Danlos syndrome who have a gastrointestinal symptom cluster that includes bloating, early satiety, and postprandial “brain fog” may be suffering from small intestine bacterial overgrowth, or SIBO.

This treatable condition occurs when enteric flora from the colon creep north into the small intestine, which is usually a relatively sterile environment. In addition to the bloating, dyspepsia, and nausea that SIBO can cause, patients may have an erratic bowel movement pattern, and can occasionally suffer from vitamin deficiencies and weight loss, Ali Rezaie, MD, said at the annual Perspectives in Rheumatic Diseases held by the Global Academy for Medical Education.

“SIBO is not a primary disease,” said Dr. Rezaie, professor of gastroenterology at Cedars-Sinai Medical Center, Los Angeles, and lead author of a 2016 review on the diagnosis and treatment of SIBO (Curr Gastroenterol Rep. 2016 Feb;18[2]:8).

For patients with scleroderma or mixed connective tissue diseases as well as hypermobility disorders such as Ehlers-Danlos syndrome, the small bowel dysmotility associated with their conditions is often the primary disease. However, diabetes-associated gastroparesis and the presence of anti-vinculin and anti-CdtB antibodies in irritable bowel syndrome patients can also cause dysmotility, provoking SIBO.

Surgical procedures that can set patients up for SIBO include gastric bypass and ileocecal resection; medications such as opioids and anticholinergic or antidiarrheal medications also can be SIBO risk factors. Finally, chronic proton pump inhibitor use, autoimmune gastritis, and gastrectomy can all reduce gastric acid secretion, permitting bacterial overgrowth in the small intestine.

Normally, jejunal contents have around 100 colony-forming units (CFU) per mL, with Lactobacillus and Streptococcus predominating. However, in SIBO, there are more bacteria in the small intestine – greater than 1,000 CFU/mL – and enteric flora predominate.

Depending on the species predominating, an excess of hydrogen or methane may be produced during bacterial fermentation of food in the small intestine, Dr. Rezaie said. Though the preferred method for diagnosis is small-bowel aspiration, “this is an invasive, costly, and time-consuming procedure,” he said.

By contrast, breath testing is noninvasive and inexpensive, and detects excess levels of hydrogen or methane on the breath when performed at a fixed time after the patient is fed a bolus of lactulose or glucose. The test is diagnostic for SIBO because “the sole source of methane and hydrogen [as H₂] in our body is from the bacterial metabolism,” Dr. Rezaie said.

SIBO breath testing is considered positive if there are 10 or greater parts per million of methane at any time point, or if hydrogen levels rise by at least 20 parts per million within 90 minutes of the bolus feed.

The treatment for SIBO can be thought of in three phases, Dr. Rezaie said in an interview, referencing the consensus statement. The three treatment stages include induction of remission, maintenance of remission, and treatment of recurrence, should it recur.

Therapy for induction of remission is guided by the breath test results. If excessive methane production is not detected, then a broad-spectrum antibiotic such as amoxicillin, ciprofloxacin, trimethoprim-sulfamethoxazole, or rifaximin can be given for 14 days. If excess methane is detected, then the broad spectrum antibiotic should be combined with neomycin 500 mg by mouth for 14 days as well.

If a clinical response occurs, then a maintenance strategy can include restricting highly fermentable foods, using promotility drugs such as low-dose macrolides, tegaserod, or other 5HT₄ agonists, and ongoing vigilance for recurrent symptoms. If there’s a primary cause that can be remedied – for example, stopping a proton pump inhibitor or lysing identifiable intestinal lesions – then those factors can be addressed during remission as well.

For patients who can’t be brought into remission with one antibiotic course, another course of alternative antibiotics can be considered. Some patients may benefit from an elemental diet.

Managing recurrences involves further rounds of antibiotics together with optimizing motility and addressing other risk factors.

In terms of how SIBO affects management of the primary rheumatologic disease, patients should try to avoid frequent use of nonsteroidal anti-inflammatory drugs because of the potential for further untoward effects on a disrupted gut. However, there’s no reason to alter medical therapy otherwise, and biologic therapy “is generally well-tolerated in patients with small intestine bacterial overgrowth,” Dr. Rezaie said.

He pointed out that rheumatology patients can have so many medical issues that gastrointestinal symptoms may not rise to the surface, so a thorough review of systems should include careful questioning about digestive health. “Rheumatologists need to incorporate this knowledge into the management of their patients,” he said. “It’s a quality of life issue.”

Dr. Rezaie reported having received honoraria and consulted for Valeant Pharmaceuticals. Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with systemic sclerosis, mixed connective tissue disease, and Ehlers-Danlos syndrome who have a gastrointestinal symptom cluster that includes bloating, early satiety, and postprandial “brain fog” may be suffering from small intestine bacterial overgrowth, or SIBO.

This treatable condition occurs when enteric flora from the colon creep north into the small intestine, which is usually a relatively sterile environment. In addition to the bloating, dyspepsia, and nausea that SIBO can cause, patients may have an erratic bowel movement pattern, and can occasionally suffer from vitamin deficiencies and weight loss, Ali Rezaie, MD, said at the annual Perspectives in Rheumatic Diseases held by the Global Academy for Medical Education.

“SIBO is not a primary disease,” said Dr. Rezaie, professor of gastroenterology at Cedars-Sinai Medical Center, Los Angeles, and lead author of a 2016 review on the diagnosis and treatment of SIBO (Curr Gastroenterol Rep. 2016 Feb;18[2]:8).

For patients with scleroderma or mixed connective tissue diseases as well as hypermobility disorders such as Ehlers-Danlos syndrome, the small bowel dysmotility associated with their conditions is often the primary disease. However, diabetes-associated gastroparesis and the presence of anti-vinculin and anti-CdtB antibodies in irritable bowel syndrome patients can also cause dysmotility, provoking SIBO.

Surgical procedures that can set patients up for SIBO include gastric bypass and ileocecal resection; medications such as opioids and anticholinergic or antidiarrheal medications also can be SIBO risk factors. Finally, chronic proton pump inhibitor use, autoimmune gastritis, and gastrectomy can all reduce gastric acid secretion, permitting bacterial overgrowth in the small intestine.

Normally, jejunal contents have around 100 colony-forming units (CFU) per mL, with Lactobacillus and Streptococcus predominating. However, in SIBO, there are more bacteria in the small intestine – greater than 1,000 CFU/mL – and enteric flora predominate.

Depending on the species predominating, an excess of hydrogen or methane may be produced during bacterial fermentation of food in the small intestine, Dr. Rezaie said. Though the preferred method for diagnosis is small-bowel aspiration, “this is an invasive, costly, and time-consuming procedure,” he said.

By contrast, breath testing is noninvasive and inexpensive, and detects excess levels of hydrogen or methane on the breath when performed at a fixed time after the patient is fed a bolus of lactulose or glucose. The test is diagnostic for SIBO because “the sole source of methane and hydrogen [as H₂] in our body is from the bacterial metabolism,” Dr. Rezaie said.

SIBO breath testing is considered positive if there are 10 or greater parts per million of methane at any time point, or if hydrogen levels rise by at least 20 parts per million within 90 minutes of the bolus feed.

The treatment for SIBO can be thought of in three phases, Dr. Rezaie said in an interview, referencing the consensus statement. The three treatment stages include induction of remission, maintenance of remission, and treatment of recurrence, should it recur.

Therapy for induction of remission is guided by the breath test results. If excessive methane production is not detected, then a broad-spectrum antibiotic such as amoxicillin, ciprofloxacin, trimethoprim-sulfamethoxazole, or rifaximin can be given for 14 days. If excess methane is detected, then the broad spectrum antibiotic should be combined with neomycin 500 mg by mouth for 14 days as well.

If a clinical response occurs, then a maintenance strategy can include restricting highly fermentable foods, using promotility drugs such as low-dose macrolides, tegaserod, or other 5HT₄ agonists, and ongoing vigilance for recurrent symptoms. If there’s a primary cause that can be remedied – for example, stopping a proton pump inhibitor or lysing identifiable intestinal lesions – then those factors can be addressed during remission as well.

For patients who can’t be brought into remission with one antibiotic course, another course of alternative antibiotics can be considered. Some patients may benefit from an elemental diet.

Managing recurrences involves further rounds of antibiotics together with optimizing motility and addressing other risk factors.

In terms of how SIBO affects management of the primary rheumatologic disease, patients should try to avoid frequent use of nonsteroidal anti-inflammatory drugs because of the potential for further untoward effects on a disrupted gut. However, there’s no reason to alter medical therapy otherwise, and biologic therapy “is generally well-tolerated in patients with small intestine bacterial overgrowth,” Dr. Rezaie said.

He pointed out that rheumatology patients can have so many medical issues that gastrointestinal symptoms may not rise to the surface, so a thorough review of systems should include careful questioning about digestive health. “Rheumatologists need to incorporate this knowledge into the management of their patients,” he said. “It’s a quality of life issue.”

Dr. Rezaie reported having received honoraria and consulted for Valeant Pharmaceuticals. Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with systemic sclerosis, mixed connective tissue disease, and Ehlers-Danlos syndrome who have a gastrointestinal symptom cluster that includes bloating, early satiety, and postprandial “brain fog” may be suffering from small intestine bacterial overgrowth, or SIBO.

This treatable condition occurs when enteric flora from the colon creep north into the small intestine, which is usually a relatively sterile environment. In addition to the bloating, dyspepsia, and nausea that SIBO can cause, patients may have an erratic bowel movement pattern, and can occasionally suffer from vitamin deficiencies and weight loss, Ali Rezaie, MD, said at the annual Perspectives in Rheumatic Diseases held by the Global Academy for Medical Education.

“SIBO is not a primary disease,” said Dr. Rezaie, professor of gastroenterology at Cedars-Sinai Medical Center, Los Angeles, and lead author of a 2016 review on the diagnosis and treatment of SIBO (Curr Gastroenterol Rep. 2016 Feb;18[2]:8).

For patients with scleroderma or mixed connective tissue diseases as well as hypermobility disorders such as Ehlers-Danlos syndrome, the small bowel dysmotility associated with their conditions is often the primary disease. However, diabetes-associated gastroparesis and the presence of anti-vinculin and anti-CdtB antibodies in irritable bowel syndrome patients can also cause dysmotility, provoking SIBO.

Surgical procedures that can set patients up for SIBO include gastric bypass and ileocecal resection; medications such as opioids and anticholinergic or antidiarrheal medications also can be SIBO risk factors. Finally, chronic proton pump inhibitor use, autoimmune gastritis, and gastrectomy can all reduce gastric acid secretion, permitting bacterial overgrowth in the small intestine.

Normally, jejunal contents have around 100 colony-forming units (CFU) per mL, with Lactobacillus and Streptococcus predominating. However, in SIBO, there are more bacteria in the small intestine – greater than 1,000 CFU/mL – and enteric flora predominate.

Depending on the species predominating, an excess of hydrogen or methane may be produced during bacterial fermentation of food in the small intestine, Dr. Rezaie said. Though the preferred method for diagnosis is small-bowel aspiration, “this is an invasive, costly, and time-consuming procedure,” he said.

By contrast, breath testing is noninvasive and inexpensive, and detects excess levels of hydrogen or methane on the breath when performed at a fixed time after the patient is fed a bolus of lactulose or glucose. The test is diagnostic for SIBO because “the sole source of methane and hydrogen [as H₂] in our body is from the bacterial metabolism,” Dr. Rezaie said.

SIBO breath testing is considered positive if there are 10 or greater parts per million of methane at any time point, or if hydrogen levels rise by at least 20 parts per million within 90 minutes of the bolus feed.

The treatment for SIBO can be thought of in three phases, Dr. Rezaie said in an interview, referencing the consensus statement. The three treatment stages include induction of remission, maintenance of remission, and treatment of recurrence, should it recur.

Therapy for induction of remission is guided by the breath test results. If excessive methane production is not detected, then a broad-spectrum antibiotic such as amoxicillin, ciprofloxacin, trimethoprim-sulfamethoxazole, or rifaximin can be given for 14 days. If excess methane is detected, then the broad spectrum antibiotic should be combined with neomycin 500 mg by mouth for 14 days as well.

If a clinical response occurs, then a maintenance strategy can include restricting highly fermentable foods, using promotility drugs such as low-dose macrolides, tegaserod, or other 5HT₄ agonists, and ongoing vigilance for recurrent symptoms. If there’s a primary cause that can be remedied – for example, stopping a proton pump inhibitor or lysing identifiable intestinal lesions – then those factors can be addressed during remission as well.

For patients who can’t be brought into remission with one antibiotic course, another course of alternative antibiotics can be considered. Some patients may benefit from an elemental diet.

Managing recurrences involves further rounds of antibiotics together with optimizing motility and addressing other risk factors.

In terms of how SIBO affects management of the primary rheumatologic disease, patients should try to avoid frequent use of nonsteroidal anti-inflammatory drugs because of the potential for further untoward effects on a disrupted gut. However, there’s no reason to alter medical therapy otherwise, and biologic therapy “is generally well-tolerated in patients with small intestine bacterial overgrowth,” Dr. Rezaie said.

He pointed out that rheumatology patients can have so many medical issues that gastrointestinal symptoms may not rise to the surface, so a thorough review of systems should include careful questioning about digestive health. “Rheumatologists need to incorporate this knowledge into the management of their patients,” he said. “It’s a quality of life issue.”

Dr. Rezaie reported having received honoraria and consulted for Valeant Pharmaceuticals. Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

OnabotulinumtoxinA decreased daily episodes of urinary incontinence by a small amount, compared with sacral neuromodulation, but did not appear to impact several quality of life measures and raised the rates of urinary tract infection and self-catheterization, according to findings from a comparative effectiveness study.

In an open-label randomized trial directly comparing the two approaches for refractory urgency incontinence, onabotulinumtoxinA showed a statistically significant advantage over sacral neuromodulation, but whether this translates into a clinically significant difference is unclear.

“Overall, these findings make it uncertain whether onabotulinumtoxinA provides a clinically important net benefit, compared with sacral neuromodulation,” said Cindy L. Amundsen, MD, of Duke University, Durham N.C., and her associates.

Noting that a recent systematic review of the literature found insufficient evidence to recommend one of these treatments over the other, the investigators performed their study at nine medical centers participating in the National Institutes of Health’s Pelvic Floor Disorder Network. Study participants included 386 women who had a minimum of six urgency incontinence episodes per day and whose symptoms persisted despite treatment with at least one behavioral or physical therapy intervention and at least two medical therapies. They were followed up at 6 months.

In the intention-to-treat analysis, the 190 women who received a single injection of onabotulinumtoxinA showed a mean reduction of 3.9 daily episodes of urinary incontinence, compared with a reduction of 3.3 episodes for the 174 women who underwent sacral neuromodulation. The onabotulinumtoxinA group also showed slightly greater improvement on the Overactive Bladder Short Form score for symptom bother and on the Overactive Bladder Satisfaction of Treatment questionnaire, Dr. Amundsen and her associates reported (JAMA. 2016;316[13]:1366-1374).

However, there were no significant differences between the two study groups in measures of convenience, adverse effects, treatment preference, or other quality of life factors. And onabotulinumtoxinA was associated with a higher rate of urinary tract infection (35% vs. 11%) and of intermittent self-catheterization (8% vs. 0% at 1 month).

This study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Office of Research on Women’s Health. Dr. Amundsen reported having no relevant financial disclosures; two of her associates reported ties to Pfizer, Medtronic (maker of the InterStim sacral neuromodulation device), Allergan (maker of Botox), and Axonics.

OnabotulinumtoxinA decreased daily episodes of urinary incontinence by a small amount, compared with sacral neuromodulation, but did not appear to impact several quality of life measures and raised the rates of urinary tract infection and self-catheterization, according to findings from a comparative effectiveness study.

In an open-label randomized trial directly comparing the two approaches for refractory urgency incontinence, onabotulinumtoxinA showed a statistically significant advantage over sacral neuromodulation, but whether this translates into a clinically significant difference is unclear.

“Overall, these findings make it uncertain whether onabotulinumtoxinA provides a clinically important net benefit, compared with sacral neuromodulation,” said Cindy L. Amundsen, MD, of Duke University, Durham N.C., and her associates.

Noting that a recent systematic review of the literature found insufficient evidence to recommend one of these treatments over the other, the investigators performed their study at nine medical centers participating in the National Institutes of Health’s Pelvic Floor Disorder Network. Study participants included 386 women who had a minimum of six urgency incontinence episodes per day and whose symptoms persisted despite treatment with at least one behavioral or physical therapy intervention and at least two medical therapies. They were followed up at 6 months.

In the intention-to-treat analysis, the 190 women who received a single injection of onabotulinumtoxinA showed a mean reduction of 3.9 daily episodes of urinary incontinence, compared with a reduction of 3.3 episodes for the 174 women who underwent sacral neuromodulation. The onabotulinumtoxinA group also showed slightly greater improvement on the Overactive Bladder Short Form score for symptom bother and on the Overactive Bladder Satisfaction of Treatment questionnaire, Dr. Amundsen and her associates reported (JAMA. 2016;316[13]:1366-1374).

However, there were no significant differences between the two study groups in measures of convenience, adverse effects, treatment preference, or other quality of life factors. And onabotulinumtoxinA was associated with a higher rate of urinary tract infection (35% vs. 11%) and of intermittent self-catheterization (8% vs. 0% at 1 month).

This study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Office of Research on Women’s Health. Dr. Amundsen reported having no relevant financial disclosures; two of her associates reported ties to Pfizer, Medtronic (maker of the InterStim sacral neuromodulation device), Allergan (maker of Botox), and Axonics.

OnabotulinumtoxinA decreased daily episodes of urinary incontinence by a small amount, compared with sacral neuromodulation, but did not appear to impact several quality of life measures and raised the rates of urinary tract infection and self-catheterization, according to findings from a comparative effectiveness study.

In an open-label randomized trial directly comparing the two approaches for refractory urgency incontinence, onabotulinumtoxinA showed a statistically significant advantage over sacral neuromodulation, but whether this translates into a clinically significant difference is unclear.

“Overall, these findings make it uncertain whether onabotulinumtoxinA provides a clinically important net benefit, compared with sacral neuromodulation,” said Cindy L. Amundsen, MD, of Duke University, Durham N.C., and her associates.

Noting that a recent systematic review of the literature found insufficient evidence to recommend one of these treatments over the other, the investigators performed their study at nine medical centers participating in the National Institutes of Health’s Pelvic Floor Disorder Network. Study participants included 386 women who had a minimum of six urgency incontinence episodes per day and whose symptoms persisted despite treatment with at least one behavioral or physical therapy intervention and at least two medical therapies. They were followed up at 6 months.

In the intention-to-treat analysis, the 190 women who received a single injection of onabotulinumtoxinA showed a mean reduction of 3.9 daily episodes of urinary incontinence, compared with a reduction of 3.3 episodes for the 174 women who underwent sacral neuromodulation. The onabotulinumtoxinA group also showed slightly greater improvement on the Overactive Bladder Short Form score for symptom bother and on the Overactive Bladder Satisfaction of Treatment questionnaire, Dr. Amundsen and her associates reported (JAMA. 2016;316[13]:1366-1374).

However, there were no significant differences between the two study groups in measures of convenience, adverse effects, treatment preference, or other quality of life factors. And onabotulinumtoxinA was associated with a higher rate of urinary tract infection (35% vs. 11%) and of intermittent self-catheterization (8% vs. 0% at 1 month).

This study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Office of Research on Women’s Health. Dr. Amundsen reported having no relevant financial disclosures; two of her associates reported ties to Pfizer, Medtronic (maker of the InterStim sacral neuromodulation device), Allergan (maker of Botox), and Axonics.

Nonalcoholic fatty liver disease (NAFLD) is estimated to affect over 64 million people each year in the United States, leading to medical costs of more than $100 billion, according to a new analysis.

Using a steady-state prevalence model, Zobair M. Younossi, MD, MPH, from the Center for Liver Diseases at Inova Fairfax (Va.) Hospital, and his coauthors, sought to estimate the prevalence and economic burden of NAFLD in the United States, Germany, France, Italy, and the United Kingdom.

Copyright sndr/istockphoto

Nonalcoholic fatty liver disease (NAFLD) is estimated to affect over 64 million people each year in the United States, leading to medical costs of more than $100 billion, according to a new analysis.

Using a steady-state prevalence model, Zobair M. Younossi, MD, MPH, from the Center for Liver Diseases at Inova Fairfax (Va.) Hospital, and his coauthors, sought to estimate the prevalence and economic burden of NAFLD in the United States, Germany, France, Italy, and the United Kingdom.

Copyright sndr/istockphoto

Nonalcoholic fatty liver disease (NAFLD) is estimated to affect over 64 million people each year in the United States, leading to medical costs of more than $100 billion, according to a new analysis.

Using a steady-state prevalence model, Zobair M. Younossi, MD, MPH, from the Center for Liver Diseases at Inova Fairfax (Va.) Hospital, and his coauthors, sought to estimate the prevalence and economic burden of NAFLD in the United States, Germany, France, Italy, and the United Kingdom.

Copyright sndr/istockphoto

I would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.

Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.

What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.

Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.

So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.

At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.

For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

I would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.

Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.

What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.

Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.

So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.

At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.

For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

I would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.

Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.

What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.

Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.

So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.

At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.

For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

TORONTO—Approximately 80% of elderly people with dementia in nursing homes do not have a reemergence of behavioral symptoms after cessation of antipsychotic drugs, according to research presented at the Alzheimer’s Association International Conference. The results may indicate that the antipsychotics are not necessary in these patients.

Many residents of nursing homes receive antipsychotics, but the drugs’ effect size is modest, said Henry Brodaty, MD, DSc, Professor of Aging and Mental Health and Codirector of the Center for Healthy Brain Aging at the University of New South Wales in Sydney. Antipsychotics can cause extrapyramidal side effects, falls, anticholinergic side effects such as worse cognition, urinary outflow difficulties and constipation, and orthostatic hypotension. The medicines also are associated with increased rates of stroke and death. In a UK study, Ballard and colleagues found no difference in the reemergence of behavioral symptoms between patients on continuous antipsychotics who were randomized to withdrawal and patients who continued their antipsychotics. However, Devenand and colleagues reported reemergence of behavioral symptoms when patients ceased antipsychotics.

Nurses Used Behavioral Strategies

To investigate the matter further, Dr. Brodaty and colleagues initiated the Halting Antipsychotics in Long-Term Care (HALT) study. The single-arm, 12-month, longitudinal study took place in 23 nursing homes in the Australian state of New South Wales. A nurse at each nursing home was named a “nurse champion” and identified residents who were receiving continuous antipsychotics. The researchers obtained permission from the nursing homes, the patients’ families, and the patients’ physicians to include the patients in the study.

During three days of training, each nurse champion learned how to manage behavioral symptoms and how to use person-centered care and behavioral strategies. These nurse champions subsequently trained the other nurses at their respective facilities in these techniques. Next, investigators monitored the patients for a month to establish their baseline conditions. Antipsychotics were stopped for all patients according to a protocol, and the researchers reassessed participants three, six, and 12 months later.

Participants’ mean age was about 85, and approximately two-thirds of patients were female. More than half of the sample was separated, widowed, or divorced. Approximately one-third of participants were married. About half of the sample had a high level of education, and half had a low level. A chart review indicated that one-third of patients had Alzheimer’s disease, and less than one-third had unspecified dementia. Smaller portions of the population had vascular or other dementias.

Participants received an average of 2.3 psychotropic medications and an average of nine medications for other indications. The total of about 11 medications per person was “about average,” said Dr. Brodaty. The most common antipsychotic was risperidone, followed by quetiapine, olanzapine, and haloperidol. Participants had been taking their antipsychotics for about two years and their current doses for at least one year. More than half of participants started antipsychotic medication after admission to the nursing home. About 20% of participants started antipsychotics during hospitalization before transfer to the nursing home, and 8% started antipsychotics in the community. For others, this information was not available.

Neuropsychiatric Symptoms Did Not Change

In all, 150 participants completed the prebaseline assessment, 139 completed the baseline assessment, 133 participants completed the three-month follow-up, and 118 participants completed the six-month follow-up. The 12-month follow-up was incomplete at the time of the presentation.

Of the 125 patients who had stopped their antipsychotics, the drugs were represcribed to 15 patients during the first three months. At six months, 10 of 118 patients for whom data were available had antipsychotics represcribed. In the final six months of the study, one patient had an antipsychotic represcribed. “In other words, almost 80% remained deprescribed, usually completely ceased,” said Dr. Brodaty. Many physicians wrote prn prescriptions, mainly for oxazepam as rescue medication, but the investigators have not analyzed the data to determine whether they were filled.

Despite the cessation of antipsychotics for most of the residents, there was no significant change in participants’ total Neuropsychiatric Inventory (NPI) score over the five follow-up visits, nor in their agitation (as measured by the Cohen Mansfield Agitation Inventory), aggression (as measured by the NPI), delusions, or hallucinations.

Should Standard of Care Change?

It was difficult to recruit patients for the study, said Dr. Brodaty. The investigators approached 58 nursing homes, and more than half declined to participate. Nurse champions also may not have included all patients on antipsychotics in the study. The results thus may have been influenced by selection bias. Staff at the nursing homes, physicians, and families appeared to be ignorant about the potential benefits of stopping antipsychotics such as preventing anticholinergic and other side effects.

“Inappropriate use of antipsychotics is an old story, yet we are still talking about it,” said Dr. Brodaty. “We have the knowledge and now we have to build on this knowledge and change practice. As a side issue, informed consent was pretty well lacking, and there is a lack of accountability about getting informed consent.”

Incentives for the owners, managers, and staff of nursing homes, as well as education for patients’ families, could promote person-centered care and reduce the inappropriate use of antipsychotics.

“Our next steps are to look at the prn medication and represcribing patterns. We are curious as to why some people seemed to need the antipsychotics,” said Dr. Brodaty. Although antipsychotics may be falling from favor, “there is a place for the use of antipsychotics, and our skill as clinicians is trying to identify which patients benefit from them,” Dr. Brodaty concluded.

—Erik Greb

Suggested Reading

Ballard C, Hanney ML, Theodoulou M, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol. 2009;8(2):151-157.

Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013;(3):CD007726.

Devanand DP, Mintzer J, Schultz SK, et al. Relapse risk after discontinuation of risperidone in Alzheimer’s disease. N Engl J Med. 2012; 367(16): 1497–1507.

Rabey JM, Prokhorov T, Miniovitz A, et al. Effect of quetiapine in psychotic Parkinson’s disease patients: a double-blind labeled study of 3 months’ duration. Mov Disord. 2007;22(3):313-318.

TORONTO—Approximately 80% of elderly people with dementia in nursing homes do not have a reemergence of behavioral symptoms after cessation of antipsychotic drugs, according to research presented at the Alzheimer’s Association International Conference. The results may indicate that the antipsychotics are not necessary in these patients.

Many residents of nursing homes receive antipsychotics, but the drugs’ effect size is modest, said Henry Brodaty, MD, DSc, Professor of Aging and Mental Health and Codirector of the Center for Healthy Brain Aging at the University of New South Wales in Sydney. Antipsychotics can cause extrapyramidal side effects, falls, anticholinergic side effects such as worse cognition, urinary outflow difficulties and constipation, and orthostatic hypotension. The medicines also are associated with increased rates of stroke and death. In a UK study, Ballard and colleagues found no difference in the reemergence of behavioral symptoms between patients on continuous antipsychotics who were randomized to withdrawal and patients who continued their antipsychotics. However, Devenand and colleagues reported reemergence of behavioral symptoms when patients ceased antipsychotics.

Nurses Used Behavioral Strategies

To investigate the matter further, Dr. Brodaty and colleagues initiated the Halting Antipsychotics in Long-Term Care (HALT) study. The single-arm, 12-month, longitudinal study took place in 23 nursing homes in the Australian state of New South Wales. A nurse at each nursing home was named a “nurse champion” and identified residents who were receiving continuous antipsychotics. The researchers obtained permission from the nursing homes, the patients’ families, and the patients’ physicians to include the patients in the study.

During three days of training, each nurse champion learned how to manage behavioral symptoms and how to use person-centered care and behavioral strategies. These nurse champions subsequently trained the other nurses at their respective facilities in these techniques. Next, investigators monitored the patients for a month to establish their baseline conditions. Antipsychotics were stopped for all patients according to a protocol, and the researchers reassessed participants three, six, and 12 months later.

Participants’ mean age was about 85, and approximately two-thirds of patients were female. More than half of the sample was separated, widowed, or divorced. Approximately one-third of participants were married. About half of the sample had a high level of education, and half had a low level. A chart review indicated that one-third of patients had Alzheimer’s disease, and less than one-third had unspecified dementia. Smaller portions of the population had vascular or other dementias.

Participants received an average of 2.3 psychotropic medications and an average of nine medications for other indications. The total of about 11 medications per person was “about average,” said Dr. Brodaty. The most common antipsychotic was risperidone, followed by quetiapine, olanzapine, and haloperidol. Participants had been taking their antipsychotics for about two years and their current doses for at least one year. More than half of participants started antipsychotic medication after admission to the nursing home. About 20% of participants started antipsychotics during hospitalization before transfer to the nursing home, and 8% started antipsychotics in the community. For others, this information was not available.

Neuropsychiatric Symptoms Did Not Change

In all, 150 participants completed the prebaseline assessment, 139 completed the baseline assessment, 133 participants completed the three-month follow-up, and 118 participants completed the six-month follow-up. The 12-month follow-up was incomplete at the time of the presentation.

Of the 125 patients who had stopped their antipsychotics, the drugs were represcribed to 15 patients during the first three months. At six months, 10 of 118 patients for whom data were available had antipsychotics represcribed. In the final six months of the study, one patient had an antipsychotic represcribed. “In other words, almost 80% remained deprescribed, usually completely ceased,” said Dr. Brodaty. Many physicians wrote prn prescriptions, mainly for oxazepam as rescue medication, but the investigators have not analyzed the data to determine whether they were filled.

Despite the cessation of antipsychotics for most of the residents, there was no significant change in participants’ total Neuropsychiatric Inventory (NPI) score over the five follow-up visits, nor in their agitation (as measured by the Cohen Mansfield Agitation Inventory), aggression (as measured by the NPI), delusions, or hallucinations.

Should Standard of Care Change?

It was difficult to recruit patients for the study, said Dr. Brodaty. The investigators approached 58 nursing homes, and more than half declined to participate. Nurse champions also may not have included all patients on antipsychotics in the study. The results thus may have been influenced by selection bias. Staff at the nursing homes, physicians, and families appeared to be ignorant about the potential benefits of stopping antipsychotics such as preventing anticholinergic and other side effects.

“Inappropriate use of antipsychotics is an old story, yet we are still talking about it,” said Dr. Brodaty. “We have the knowledge and now we have to build on this knowledge and change practice. As a side issue, informed consent was pretty well lacking, and there is a lack of accountability about getting informed consent.”

Incentives for the owners, managers, and staff of nursing homes, as well as education for patients’ families, could promote person-centered care and reduce the inappropriate use of antipsychotics.

“Our next steps are to look at the prn medication and represcribing patterns. We are curious as to why some people seemed to need the antipsychotics,” said Dr. Brodaty. Although antipsychotics may be falling from favor, “there is a place for the use of antipsychotics, and our skill as clinicians is trying to identify which patients benefit from them,” Dr. Brodaty concluded.

—Erik Greb

Suggested Reading

Ballard C, Hanney ML, Theodoulou M, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol. 2009;8(2):151-157.

Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013;(3):CD007726.

Devanand DP, Mintzer J, Schultz SK, et al. Relapse risk after discontinuation of risperidone in Alzheimer’s disease. N Engl J Med. 2012; 367(16): 1497–1507.

Rabey JM, Prokhorov T, Miniovitz A, et al. Effect of quetiapine in psychotic Parkinson’s disease patients: a double-blind labeled study of 3 months’ duration. Mov Disord. 2007;22(3):313-318.

TORONTO—Approximately 80% of elderly people with dementia in nursing homes do not have a reemergence of behavioral symptoms after cessation of antipsychotic drugs, according to research presented at the Alzheimer’s Association International Conference. The results may indicate that the antipsychotics are not necessary in these patients.

Many residents of nursing homes receive antipsychotics, but the drugs’ effect size is modest, said Henry Brodaty, MD, DSc, Professor of Aging and Mental Health and Codirector of the Center for Healthy Brain Aging at the University of New South Wales in Sydney. Antipsychotics can cause extrapyramidal side effects, falls, anticholinergic side effects such as worse cognition, urinary outflow difficulties and constipation, and orthostatic hypotension. The medicines also are associated with increased rates of stroke and death. In a UK study, Ballard and colleagues found no difference in the reemergence of behavioral symptoms between patients on continuous antipsychotics who were randomized to withdrawal and patients who continued their antipsychotics. However, Devenand and colleagues reported reemergence of behavioral symptoms when patients ceased antipsychotics.

Nurses Used Behavioral Strategies

To investigate the matter further, Dr. Brodaty and colleagues initiated the Halting Antipsychotics in Long-Term Care (HALT) study. The single-arm, 12-month, longitudinal study took place in 23 nursing homes in the Australian state of New South Wales. A nurse at each nursing home was named a “nurse champion” and identified residents who were receiving continuous antipsychotics. The researchers obtained permission from the nursing homes, the patients’ families, and the patients’ physicians to include the patients in the study.

During three days of training, each nurse champion learned how to manage behavioral symptoms and how to use person-centered care and behavioral strategies. These nurse champions subsequently trained the other nurses at their respective facilities in these techniques. Next, investigators monitored the patients for a month to establish their baseline conditions. Antipsychotics were stopped for all patients according to a protocol, and the researchers reassessed participants three, six, and 12 months later.

Participants’ mean age was about 85, and approximately two-thirds of patients were female. More than half of the sample was separated, widowed, or divorced. Approximately one-third of participants were married. About half of the sample had a high level of education, and half had a low level. A chart review indicated that one-third of patients had Alzheimer’s disease, and less than one-third had unspecified dementia. Smaller portions of the population had vascular or other dementias.

Participants received an average of 2.3 psychotropic medications and an average of nine medications for other indications. The total of about 11 medications per person was “about average,” said Dr. Brodaty. The most common antipsychotic was risperidone, followed by quetiapine, olanzapine, and haloperidol. Participants had been taking their antipsychotics for about two years and their current doses for at least one year. More than half of participants started antipsychotic medication after admission to the nursing home. About 20% of participants started antipsychotics during hospitalization before transfer to the nursing home, and 8% started antipsychotics in the community. For others, this information was not available.

Neuropsychiatric Symptoms Did Not Change

In all, 150 participants completed the prebaseline assessment, 139 completed the baseline assessment, 133 participants completed the three-month follow-up, and 118 participants completed the six-month follow-up. The 12-month follow-up was incomplete at the time of the presentation.

Of the 125 patients who had stopped their antipsychotics, the drugs were represcribed to 15 patients during the first three months. At six months, 10 of 118 patients for whom data were available had antipsychotics represcribed. In the final six months of the study, one patient had an antipsychotic represcribed. “In other words, almost 80% remained deprescribed, usually completely ceased,” said Dr. Brodaty. Many physicians wrote prn prescriptions, mainly for oxazepam as rescue medication, but the investigators have not analyzed the data to determine whether they were filled.

Despite the cessation of antipsychotics for most of the residents, there was no significant change in participants’ total Neuropsychiatric Inventory (NPI) score over the five follow-up visits, nor in their agitation (as measured by the Cohen Mansfield Agitation Inventory), aggression (as measured by the NPI), delusions, or hallucinations.

Should Standard of Care Change?

It was difficult to recruit patients for the study, said Dr. Brodaty. The investigators approached 58 nursing homes, and more than half declined to participate. Nurse champions also may not have included all patients on antipsychotics in the study. The results thus may have been influenced by selection bias. Staff at the nursing homes, physicians, and families appeared to be ignorant about the potential benefits of stopping antipsychotics such as preventing anticholinergic and other side effects.

“Inappropriate use of antipsychotics is an old story, yet we are still talking about it,” said Dr. Brodaty. “We have the knowledge and now we have to build on this knowledge and change practice. As a side issue, informed consent was pretty well lacking, and there is a lack of accountability about getting informed consent.”

Incentives for the owners, managers, and staff of nursing homes, as well as education for patients’ families, could promote person-centered care and reduce the inappropriate use of antipsychotics.

“Our next steps are to look at the prn medication and represcribing patterns. We are curious as to why some people seemed to need the antipsychotics,” said Dr. Brodaty. Although antipsychotics may be falling from favor, “there is a place for the use of antipsychotics, and our skill as clinicians is trying to identify which patients benefit from them,” Dr. Brodaty concluded.

—Erik Greb

Suggested Reading

Ballard C, Hanney ML, Theodoulou M, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol. 2009;8(2):151-157.

Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013;(3):CD007726.

Devanand DP, Mintzer J, Schultz SK, et al. Relapse risk after discontinuation of risperidone in Alzheimer’s disease. N Engl J Med. 2012; 367(16): 1497–1507.

Rabey JM, Prokhorov T, Miniovitz A, et al. Effect of quetiapine in psychotic Parkinson’s disease patients: a double-blind labeled study of 3 months’ duration. Mov Disord. 2007;22(3):313-318.