NEWPORT BEACH, CALIF. – Current treatment of autoimmune blistering diseases is not backed by evidence-based medicine and solid randomized, controlled trials, according to David T. Woodley, MD.

“These are rare diseases; there’s no consensus on the treatment of choice,” Dr. Woodley said at the annual meeting of the Pacific Dermatologic Association.

Dr. Woodley, professor of dermatology at the University of Southern California, Los Angeles, limited his discussion to pemphigus vulgaris (PV), pemphigus foliaceus (PF), and bullous pemphigoid (BP). The histologic hallmark of PV and PF is acantholysis. “Because these are intraepidermal blistering diseases, you don’t see the blister very often; maybe you’ll have a few intact loose sacklike blisters, but you mostly see erosions and crusting,” he said. “PV often only begins with mouth lesions.”

Work-up for a suspected autoimmune blistering disease includes a physical exam, histology, direct and indirect immunofluorescence, and serologic tests. The diagnosis should be based on the target autoantigen in the skin. PV and PF can appear identical on direct immunofluorescence, even though the blister cleavage plane is very high in PF and usually just above the basal keratinocytes in PV. “PF can have an intercellular keratinocyte cell surface staining pattern throughout the full epidermis or sometimes only the upper epidermal layers,” Dr. Woodley said.

At an international meeting on pemphigus in 2015, Dr. Woodley and his associates presented results from an ongoing study that is following 44 pemphigus patients at Keck Hospital of USC (a private university health care system) and 40 patients at Los Angeles County and USC Medical Center (a public safety net health care system). “The question we asked was, When the same doctors treat patients with a serious complicated disease requiring lots of details and follow-up at two very different health care systems, were there any differences in the outcomes of these patients?”

They found that the rates of clinical and immunologic remission were identical at both hospitals. However, at the county hospital, there was a higher incidence of relapses (59% vs. 30%). In addition, complications between the county and private hospitals differed in terms of hyperglycemia (38% vs. 11%, respectively), infections (79% vs. 37%), deaths (1 vs. none), medication dosage nonadherence (68% vs. 22%), and inappropriate discontinuation of one or more medications (68% vs. 15%). “Current research goals are to determine what factors cause medication compliance and noncompliance,” he said.

Dr. Woodley noted that one autoimmune blistering disease can evolve into another because of the phenomenon of epitope spreading. “The concept is that inflammation from one autoimmune blistering disease creates skin injury and reveals new neoautoantigens that get recognized by the patient’s immune system,” he said.

For example, a patient who had PF and high-titer autoantibodies to desmoglein 1 after a couple of years began to have blisters and erosions in her mouth, which is not supposed to happen in PF. Immunologic testing of this patient showed that in addition to antibodies against desmoglein 1, she began making high-titer autoantibodies against desmoglein 3 and had transformed into PV.

Bullous pemphigoid is another well-characterized autoimmune bullous disease that usually occurs in elderly patients. The blister is beneath the epidermis at the dermal-epidermal junction. These patients may have oral involvement. BP is characterized by tense subepidermal bullae on inflammatory bases. Histology reveals epidermal-dermal separation, many eosinophils and mast cells, and sometimes many polymorphonuclear leukocytes. “Many of these patients have very high IgE antibodies as well as IgG,” he said.

Features of BP include IgG and C3 deposits at the dermal-epidermal junction by direct immunofluorescence and by indirect immunofluorescence. “On salt-split human skin substrate, these antibodies bind to the epidermal roof of the separation and not to the dermal floor,” Dr. Woodley said. “You can send off the patient’s serum for ELISA [enzyme-linked immunosorbent assay] testing to detect autoantibodies against the BP230 antigen and the BP180 antigen to confirm the diagnosis. Autoantibodies to the BP180 antigen often correlate with the patient’s disease activity. The sensitivity of indirect immunofluorescence and ELISA are both above 95%.”

BP can present with urticarial plaques and pruritus and without blisters. Also, recent research has demonstrated that BP can present with just pruritus and no skin lesions. “So that’s something to keep in mind in refractory pruritus patients,” he said.

The incidence of BP seems to be increasing, from an estimated 7 cases per million in 1995 to 43 cases per million in 2008, Dr. Woodley said. “It may be that it is associated with some drugs like loop diuretics and spironolactone, but the precise reason is not known,” he said. “If your patient has dementia or Parkinson’s disease, he or she has a fourfold increased chance that they will have BP, because the BP180 and BP230 antigens are also in neuronal cells. Parkinson’s patients are known to make antibodies to the BP180 antigen, but not to the NC16A domain of the BP180 antigen. The development of BP in a Parkinson’s patient occurs when he or she begins to also make autoantibodies against the NC16A domain.”

The standard of treatment for autoimmune blistering diseases is prednisone 0.7-2 mg/kg. Nonsteroidal immunosuppressive agents are also helpful, including methotrexate, azathioprine, cyclophosphamide, and mycophenolate mofetil. Emerging evidence suggests that rituximab is the drug of choice for PV and PF, and should be the first-line therapy. Rituximab is a chimeric monoclonal antibody that targets CD20–positive B lymphocytes. “It removes cells that are ready to transform into autoantibody-producing short-lived plasma cells,” Dr. Woodley said. “The depletion lasts 6-12 months.”

Another new development in BP is the use of omalizumab, a monoclonal antibody to IgE. “Omalizumab inhibits the IgE antibody binding to the BP180,” Dr. Woodley said.

“It’s thought that the BP180 antigen is released from basal keratinocytes into the high papillary dermis. In BP patients, there are numerous mast cells at that location. IgE binds to the mast cells, which have IgE receptors on their surface, and in the presence of the BP180 antigen, forms dimers on the mast cells, and causes them to release inflammatory cytokines, some of which recruit eosinophils. This is likely why BP is such an inflammatory disorder. You cannot follow the IgE levels; you have to follow the eosinophils. The IgE is still high, but it’s nullified and inactive.”

Other biologics that have been successfully used in PV, PF, and BP include tumor necrosis factor–alpha inhibitors and rituximab (Rituxan). Common dosing for rituximab is 325 mg/m² per week for 4 weeks. Infusion reactions are the most common side effect, he said, but other reported adverse reactions include infections, transient hypogammaglobulinemia, neutropenia, deep vein thrombosis, and pulmonary embolism. “The incidence of side effects seems to be going down, because we are now premedicating patients with antihistamines and IV hydrocortisone before giving them rituximab,” Dr. Woodley noted.

The development of progressive multifocal leukoencephalopathy has also been reported with the use of rituximab. “This is exceedingly rare with rituximab but has been described, and this is what keeps doctors who use this drug awake at night,” he said.

Elderly patients with mild BP sometimes can get by without using immunosuppressive agents to manage their disease. One option is potent topical steroids plus niacinamide 0.5-2 g after each meal as an anti-inflammatory B vitamin. “Doxycycline 100 mg b.i.d. also works to inhibit neutrophils,” he said. “Antihistamines can also be helpful, and some French dermatologists have found total body clobetasol to be useful.”

Dr. Woodley disclosed that he holds patents on human recombinant type VII collagen. He is also a consultant for Shire Pharmaceuticals and a speaker for Biofusion.

[email protected]

NEWPORT BEACH, CALIF. – Current treatment of autoimmune blistering diseases is not backed by evidence-based medicine and solid randomized, controlled trials, according to David T. Woodley, MD.

“These are rare diseases; there’s no consensus on the treatment of choice,” Dr. Woodley said at the annual meeting of the Pacific Dermatologic Association.

Dr. Woodley, professor of dermatology at the University of Southern California, Los Angeles, limited his discussion to pemphigus vulgaris (PV), pemphigus foliaceus (PF), and bullous pemphigoid (BP). The histologic hallmark of PV and PF is acantholysis. “Because these are intraepidermal blistering diseases, you don’t see the blister very often; maybe you’ll have a few intact loose sacklike blisters, but you mostly see erosions and crusting,” he said. “PV often only begins with mouth lesions.”

Work-up for a suspected autoimmune blistering disease includes a physical exam, histology, direct and indirect immunofluorescence, and serologic tests. The diagnosis should be based on the target autoantigen in the skin. PV and PF can appear identical on direct immunofluorescence, even though the blister cleavage plane is very high in PF and usually just above the basal keratinocytes in PV. “PF can have an intercellular keratinocyte cell surface staining pattern throughout the full epidermis or sometimes only the upper epidermal layers,” Dr. Woodley said.

At an international meeting on pemphigus in 2015, Dr. Woodley and his associates presented results from an ongoing study that is following 44 pemphigus patients at Keck Hospital of USC (a private university health care system) and 40 patients at Los Angeles County and USC Medical Center (a public safety net health care system). “The question we asked was, When the same doctors treat patients with a serious complicated disease requiring lots of details and follow-up at two very different health care systems, were there any differences in the outcomes of these patients?”

They found that the rates of clinical and immunologic remission were identical at both hospitals. However, at the county hospital, there was a higher incidence of relapses (59% vs. 30%). In addition, complications between the county and private hospitals differed in terms of hyperglycemia (38% vs. 11%, respectively), infections (79% vs. 37%), deaths (1 vs. none), medication dosage nonadherence (68% vs. 22%), and inappropriate discontinuation of one or more medications (68% vs. 15%). “Current research goals are to determine what factors cause medication compliance and noncompliance,” he said.

Dr. Woodley noted that one autoimmune blistering disease can evolve into another because of the phenomenon of epitope spreading. “The concept is that inflammation from one autoimmune blistering disease creates skin injury and reveals new neoautoantigens that get recognized by the patient’s immune system,” he said.

For example, a patient who had PF and high-titer autoantibodies to desmoglein 1 after a couple of years began to have blisters and erosions in her mouth, which is not supposed to happen in PF. Immunologic testing of this patient showed that in addition to antibodies against desmoglein 1, she began making high-titer autoantibodies against desmoglein 3 and had transformed into PV.

Bullous pemphigoid is another well-characterized autoimmune bullous disease that usually occurs in elderly patients. The blister is beneath the epidermis at the dermal-epidermal junction. These patients may have oral involvement. BP is characterized by tense subepidermal bullae on inflammatory bases. Histology reveals epidermal-dermal separation, many eosinophils and mast cells, and sometimes many polymorphonuclear leukocytes. “Many of these patients have very high IgE antibodies as well as IgG,” he said.

Features of BP include IgG and C3 deposits at the dermal-epidermal junction by direct immunofluorescence and by indirect immunofluorescence. “On salt-split human skin substrate, these antibodies bind to the epidermal roof of the separation and not to the dermal floor,” Dr. Woodley said. “You can send off the patient’s serum for ELISA [enzyme-linked immunosorbent assay] testing to detect autoantibodies against the BP230 antigen and the BP180 antigen to confirm the diagnosis. Autoantibodies to the BP180 antigen often correlate with the patient’s disease activity. The sensitivity of indirect immunofluorescence and ELISA are both above 95%.”

BP can present with urticarial plaques and pruritus and without blisters. Also, recent research has demonstrated that BP can present with just pruritus and no skin lesions. “So that’s something to keep in mind in refractory pruritus patients,” he said.

The incidence of BP seems to be increasing, from an estimated 7 cases per million in 1995 to 43 cases per million in 2008, Dr. Woodley said. “It may be that it is associated with some drugs like loop diuretics and spironolactone, but the precise reason is not known,” he said. “If your patient has dementia or Parkinson’s disease, he or she has a fourfold increased chance that they will have BP, because the BP180 and BP230 antigens are also in neuronal cells. Parkinson’s patients are known to make antibodies to the BP180 antigen, but not to the NC16A domain of the BP180 antigen. The development of BP in a Parkinson’s patient occurs when he or she begins to also make autoantibodies against the NC16A domain.”

The standard of treatment for autoimmune blistering diseases is prednisone 0.7-2 mg/kg. Nonsteroidal immunosuppressive agents are also helpful, including methotrexate, azathioprine, cyclophosphamide, and mycophenolate mofetil. Emerging evidence suggests that rituximab is the drug of choice for PV and PF, and should be the first-line therapy. Rituximab is a chimeric monoclonal antibody that targets CD20–positive B lymphocytes. “It removes cells that are ready to transform into autoantibody-producing short-lived plasma cells,” Dr. Woodley said. “The depletion lasts 6-12 months.”

Another new development in BP is the use of omalizumab, a monoclonal antibody to IgE. “Omalizumab inhibits the IgE antibody binding to the BP180,” Dr. Woodley said.

“It’s thought that the BP180 antigen is released from basal keratinocytes into the high papillary dermis. In BP patients, there are numerous mast cells at that location. IgE binds to the mast cells, which have IgE receptors on their surface, and in the presence of the BP180 antigen, forms dimers on the mast cells, and causes them to release inflammatory cytokines, some of which recruit eosinophils. This is likely why BP is such an inflammatory disorder. You cannot follow the IgE levels; you have to follow the eosinophils. The IgE is still high, but it’s nullified and inactive.”

Other biologics that have been successfully used in PV, PF, and BP include tumor necrosis factor–alpha inhibitors and rituximab (Rituxan). Common dosing for rituximab is 325 mg/m² per week for 4 weeks. Infusion reactions are the most common side effect, he said, but other reported adverse reactions include infections, transient hypogammaglobulinemia, neutropenia, deep vein thrombosis, and pulmonary embolism. “The incidence of side effects seems to be going down, because we are now premedicating patients with antihistamines and IV hydrocortisone before giving them rituximab,” Dr. Woodley noted.

The development of progressive multifocal leukoencephalopathy has also been reported with the use of rituximab. “This is exceedingly rare with rituximab but has been described, and this is what keeps doctors who use this drug awake at night,” he said.

Elderly patients with mild BP sometimes can get by without using immunosuppressive agents to manage their disease. One option is potent topical steroids plus niacinamide 0.5-2 g after each meal as an anti-inflammatory B vitamin. “Doxycycline 100 mg b.i.d. also works to inhibit neutrophils,” he said. “Antihistamines can also be helpful, and some French dermatologists have found total body clobetasol to be useful.”

Dr. Woodley disclosed that he holds patents on human recombinant type VII collagen. He is also a consultant for Shire Pharmaceuticals and a speaker for Biofusion.

[email protected]

NEWPORT BEACH, CALIF. – Current treatment of autoimmune blistering diseases is not backed by evidence-based medicine and solid randomized, controlled trials, according to David T. Woodley, MD.

“These are rare diseases; there’s no consensus on the treatment of choice,” Dr. Woodley said at the annual meeting of the Pacific Dermatologic Association.

Dr. Woodley, professor of dermatology at the University of Southern California, Los Angeles, limited his discussion to pemphigus vulgaris (PV), pemphigus foliaceus (PF), and bullous pemphigoid (BP). The histologic hallmark of PV and PF is acantholysis. “Because these are intraepidermal blistering diseases, you don’t see the blister very often; maybe you’ll have a few intact loose sacklike blisters, but you mostly see erosions and crusting,” he said. “PV often only begins with mouth lesions.”

Work-up for a suspected autoimmune blistering disease includes a physical exam, histology, direct and indirect immunofluorescence, and serologic tests. The diagnosis should be based on the target autoantigen in the skin. PV and PF can appear identical on direct immunofluorescence, even though the blister cleavage plane is very high in PF and usually just above the basal keratinocytes in PV. “PF can have an intercellular keratinocyte cell surface staining pattern throughout the full epidermis or sometimes only the upper epidermal layers,” Dr. Woodley said.

At an international meeting on pemphigus in 2015, Dr. Woodley and his associates presented results from an ongoing study that is following 44 pemphigus patients at Keck Hospital of USC (a private university health care system) and 40 patients at Los Angeles County and USC Medical Center (a public safety net health care system). “The question we asked was, When the same doctors treat patients with a serious complicated disease requiring lots of details and follow-up at two very different health care systems, were there any differences in the outcomes of these patients?”

They found that the rates of clinical and immunologic remission were identical at both hospitals. However, at the county hospital, there was a higher incidence of relapses (59% vs. 30%). In addition, complications between the county and private hospitals differed in terms of hyperglycemia (38% vs. 11%, respectively), infections (79% vs. 37%), deaths (1 vs. none), medication dosage nonadherence (68% vs. 22%), and inappropriate discontinuation of one or more medications (68% vs. 15%). “Current research goals are to determine what factors cause medication compliance and noncompliance,” he said.

Dr. Woodley noted that one autoimmune blistering disease can evolve into another because of the phenomenon of epitope spreading. “The concept is that inflammation from one autoimmune blistering disease creates skin injury and reveals new neoautoantigens that get recognized by the patient’s immune system,” he said.

For example, a patient who had PF and high-titer autoantibodies to desmoglein 1 after a couple of years began to have blisters and erosions in her mouth, which is not supposed to happen in PF. Immunologic testing of this patient showed that in addition to antibodies against desmoglein 1, she began making high-titer autoantibodies against desmoglein 3 and had transformed into PV.

Bullous pemphigoid is another well-characterized autoimmune bullous disease that usually occurs in elderly patients. The blister is beneath the epidermis at the dermal-epidermal junction. These patients may have oral involvement. BP is characterized by tense subepidermal bullae on inflammatory bases. Histology reveals epidermal-dermal separation, many eosinophils and mast cells, and sometimes many polymorphonuclear leukocytes. “Many of these patients have very high IgE antibodies as well as IgG,” he said.

Features of BP include IgG and C3 deposits at the dermal-epidermal junction by direct immunofluorescence and by indirect immunofluorescence. “On salt-split human skin substrate, these antibodies bind to the epidermal roof of the separation and not to the dermal floor,” Dr. Woodley said. “You can send off the patient’s serum for ELISA [enzyme-linked immunosorbent assay] testing to detect autoantibodies against the BP230 antigen and the BP180 antigen to confirm the diagnosis. Autoantibodies to the BP180 antigen often correlate with the patient’s disease activity. The sensitivity of indirect immunofluorescence and ELISA are both above 95%.”

BP can present with urticarial plaques and pruritus and without blisters. Also, recent research has demonstrated that BP can present with just pruritus and no skin lesions. “So that’s something to keep in mind in refractory pruritus patients,” he said.

The incidence of BP seems to be increasing, from an estimated 7 cases per million in 1995 to 43 cases per million in 2008, Dr. Woodley said. “It may be that it is associated with some drugs like loop diuretics and spironolactone, but the precise reason is not known,” he said. “If your patient has dementia or Parkinson’s disease, he or she has a fourfold increased chance that they will have BP, because the BP180 and BP230 antigens are also in neuronal cells. Parkinson’s patients are known to make antibodies to the BP180 antigen, but not to the NC16A domain of the BP180 antigen. The development of BP in a Parkinson’s patient occurs when he or she begins to also make autoantibodies against the NC16A domain.”

The standard of treatment for autoimmune blistering diseases is prednisone 0.7-2 mg/kg. Nonsteroidal immunosuppressive agents are also helpful, including methotrexate, azathioprine, cyclophosphamide, and mycophenolate mofetil. Emerging evidence suggests that rituximab is the drug of choice for PV and PF, and should be the first-line therapy. Rituximab is a chimeric monoclonal antibody that targets CD20–positive B lymphocytes. “It removes cells that are ready to transform into autoantibody-producing short-lived plasma cells,” Dr. Woodley said. “The depletion lasts 6-12 months.”

Another new development in BP is the use of omalizumab, a monoclonal antibody to IgE. “Omalizumab inhibits the IgE antibody binding to the BP180,” Dr. Woodley said.

“It’s thought that the BP180 antigen is released from basal keratinocytes into the high papillary dermis. In BP patients, there are numerous mast cells at that location. IgE binds to the mast cells, which have IgE receptors on their surface, and in the presence of the BP180 antigen, forms dimers on the mast cells, and causes them to release inflammatory cytokines, some of which recruit eosinophils. This is likely why BP is such an inflammatory disorder. You cannot follow the IgE levels; you have to follow the eosinophils. The IgE is still high, but it’s nullified and inactive.”

Other biologics that have been successfully used in PV, PF, and BP include tumor necrosis factor–alpha inhibitors and rituximab (Rituxan). Common dosing for rituximab is 325 mg/m² per week for 4 weeks. Infusion reactions are the most common side effect, he said, but other reported adverse reactions include infections, transient hypogammaglobulinemia, neutropenia, deep vein thrombosis, and pulmonary embolism. “The incidence of side effects seems to be going down, because we are now premedicating patients with antihistamines and IV hydrocortisone before giving them rituximab,” Dr. Woodley noted.

The development of progressive multifocal leukoencephalopathy has also been reported with the use of rituximab. “This is exceedingly rare with rituximab but has been described, and this is what keeps doctors who use this drug awake at night,” he said.

Elderly patients with mild BP sometimes can get by without using immunosuppressive agents to manage their disease. One option is potent topical steroids plus niacinamide 0.5-2 g after each meal as an anti-inflammatory B vitamin. “Doxycycline 100 mg b.i.d. also works to inhibit neutrophils,” he said. “Antihistamines can also be helpful, and some French dermatologists have found total body clobetasol to be useful.”

Dr. Woodley disclosed that he holds patents on human recombinant type VII collagen. He is also a consultant for Shire Pharmaceuticals and a speaker for Biofusion.

[email protected]

The number of people adhering to a gluten-free diet more than tripled between 2009 and 2014, despite the fact that the prevalence of celiac disease has remained largely stable over the same period, according to data from the National Health and Nutrition Examination Survey.

Hyun-seok Kim, MD, MPH, and colleagues from Rutgers New Jersey Medical School noted that there is a popular trend of people choosing gluten-free diets, which exceeds the numbers that would be solely attributable to an increasing prevalence of celiac disease.

In a report published online Sept. 6 in JAMA Internal Medicine, the researchers noted that of 22,278 persons aged 6 years or older for whom data were available on celiac disease status and gluten-free diet status, 106 (0.69%) had a diagnosis of celiac disease, and 213 (1.08%) followed a gluten-free diet but did not have celiac disease.

At a U.S. population level, this would correspond to an estimated 1.76 million individuals with celiac disease, and 2.7 million individuals without celiac disease who follow a gluten-free diet.

The prevalence of celiac disease ranged from 0.70% during 2009-2010, to 0.77% during 2011-2012, and 0.58% during 2013-2014 (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5254).

In contrast, the prevalence of a gluten-free diet without celiac disease increased from 0.52% during 2009-2010 to 0.99% during 2011-2012 and 1.69% during 2013-2014, although the increase was even greater among non-Hispanic whites.

“The two trends may be related because gluten consumption has been identified as a risk factor of celiac disease, such that steady or even decreasing gluten consumption may be contributing to a plateau in celiac disease,” they reported.

The authors suggested that there were a number of reasons why individuals without celiac disease might choose to follow a gluten-free diet. “The public perception is that gluten-free diets are healthier and may provide benefits to nonspecific gastrointestinal symptoms,” they wrote, pointing out that gluten-free products are now also more widely available in supermarkets and online.

“There is also an increasing number of individuals with self-diagnosed gluten sensitivity but not the typical enteropathic or serologic features of celiac disease who have improved gastrointestinal health after avoidance of gluten-containing products.”

They stressed that the numbers of individuals in the survey with celiac disease or adhering to a gluten-free diet were relatively small, and that a diagnosis of celiac disease was not confirmed by intestinal biopsy, relying instead on serological tests and prior diagnosis by a health professional.

No conflicts of interest were declared.

The number of people adhering to a gluten-free diet more than tripled between 2009 and 2014, despite the fact that the prevalence of celiac disease has remained largely stable over the same period, according to data from the National Health and Nutrition Examination Survey.

Hyun-seok Kim, MD, MPH, and colleagues from Rutgers New Jersey Medical School noted that there is a popular trend of people choosing gluten-free diets, which exceeds the numbers that would be solely attributable to an increasing prevalence of celiac disease.

In a report published online Sept. 6 in JAMA Internal Medicine, the researchers noted that of 22,278 persons aged 6 years or older for whom data were available on celiac disease status and gluten-free diet status, 106 (0.69%) had a diagnosis of celiac disease, and 213 (1.08%) followed a gluten-free diet but did not have celiac disease.

At a U.S. population level, this would correspond to an estimated 1.76 million individuals with celiac disease, and 2.7 million individuals without celiac disease who follow a gluten-free diet.

The prevalence of celiac disease ranged from 0.70% during 2009-2010, to 0.77% during 2011-2012, and 0.58% during 2013-2014 (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5254).

In contrast, the prevalence of a gluten-free diet without celiac disease increased from 0.52% during 2009-2010 to 0.99% during 2011-2012 and 1.69% during 2013-2014, although the increase was even greater among non-Hispanic whites.

“The two trends may be related because gluten consumption has been identified as a risk factor of celiac disease, such that steady or even decreasing gluten consumption may be contributing to a plateau in celiac disease,” they reported.

The authors suggested that there were a number of reasons why individuals without celiac disease might choose to follow a gluten-free diet. “The public perception is that gluten-free diets are healthier and may provide benefits to nonspecific gastrointestinal symptoms,” they wrote, pointing out that gluten-free products are now also more widely available in supermarkets and online.

“There is also an increasing number of individuals with self-diagnosed gluten sensitivity but not the typical enteropathic or serologic features of celiac disease who have improved gastrointestinal health after avoidance of gluten-containing products.”

They stressed that the numbers of individuals in the survey with celiac disease or adhering to a gluten-free diet were relatively small, and that a diagnosis of celiac disease was not confirmed by intestinal biopsy, relying instead on serological tests and prior diagnosis by a health professional.

No conflicts of interest were declared.

The number of people adhering to a gluten-free diet more than tripled between 2009 and 2014, despite the fact that the prevalence of celiac disease has remained largely stable over the same period, according to data from the National Health and Nutrition Examination Survey.

Hyun-seok Kim, MD, MPH, and colleagues from Rutgers New Jersey Medical School noted that there is a popular trend of people choosing gluten-free diets, which exceeds the numbers that would be solely attributable to an increasing prevalence of celiac disease.

In a report published online Sept. 6 in JAMA Internal Medicine, the researchers noted that of 22,278 persons aged 6 years or older for whom data were available on celiac disease status and gluten-free diet status, 106 (0.69%) had a diagnosis of celiac disease, and 213 (1.08%) followed a gluten-free diet but did not have celiac disease.

At a U.S. population level, this would correspond to an estimated 1.76 million individuals with celiac disease, and 2.7 million individuals without celiac disease who follow a gluten-free diet.

The prevalence of celiac disease ranged from 0.70% during 2009-2010, to 0.77% during 2011-2012, and 0.58% during 2013-2014 (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5254).

In contrast, the prevalence of a gluten-free diet without celiac disease increased from 0.52% during 2009-2010 to 0.99% during 2011-2012 and 1.69% during 2013-2014, although the increase was even greater among non-Hispanic whites.

“The two trends may be related because gluten consumption has been identified as a risk factor of celiac disease, such that steady or even decreasing gluten consumption may be contributing to a plateau in celiac disease,” they reported.

The authors suggested that there were a number of reasons why individuals without celiac disease might choose to follow a gluten-free diet. “The public perception is that gluten-free diets are healthier and may provide benefits to nonspecific gastrointestinal symptoms,” they wrote, pointing out that gluten-free products are now also more widely available in supermarkets and online.

“There is also an increasing number of individuals with self-diagnosed gluten sensitivity but not the typical enteropathic or serologic features of celiac disease who have improved gastrointestinal health after avoidance of gluten-containing products.”

They stressed that the numbers of individuals in the survey with celiac disease or adhering to a gluten-free diet were relatively small, and that a diagnosis of celiac disease was not confirmed by intestinal biopsy, relying instead on serological tests and prior diagnosis by a health professional.

No conflicts of interest were declared.

NEWPORT BEACH, CALIF. – As the health care delivery landscape continues to evolve, expect the use of telemedicine to expand in dermatology.

“We have a robust evidence base that this is a valid way to deliver health care that can significantly improve patient access and offer comparable diagnostic and therapeutic outcomes, compared with in-person dermatology,” Ivy A. Lee, MD, said at the annual meeting of the Pacific Dermatologic Association. “This is an efficient way to improve access to our small and mighty workforce.”

Many factors are driving teledermatology’s rise in popularity, including patient access issues. “These are getting more prominent and more prevalent, not only in the uninsured and the underinsured, but also in our insured population,” said Dr. Lee, a Pasadena, Calif.–based dermatologist who also chairs the American Academy of Dermatology’s Telemedicine Task Force. “In my private practice, it’s about a 6- to 8-week wait for a new patient appointment, and this is in an affluent part of Los Angeles.”

Then there’s the increasing expectations of today’s health care consumers, who “want a better medical experience,” she said. “They don’t want to spend all their day in our waiting room, and they want to be able to get in touch with their physicians and not play phone tag with the front office staff. There’s also omnipresent technology. We have devices in our office, in our home, and in our hand – in every aspect of our lives. That’s also affecting our experience and expectations of medicine and health.”

Current forms of telemedicine range from “store and forward” (which refers to the submission of clinical images and history to a remote provider who reviews the material and sends a recommendation at a different time), “live interactive” (which uses synchronous video technology similar to FaceTime or Skype where you’re interacting with the patient or with the patient’s provider at the same time, even though you are separated by space), and “hybrid” (a combination of the two forms).

Dr. Lee said that store and forward currently is the predominant form of teledermatology “because of the convenience and ease of use. We’re a lot more efficient with that modality. We’ve used it predominantly for care delivery in a consultative practice model (provider interacts with another provider for consultation or triage of a patient). But, we also see an increasing interest and practice of direct-to-patient or direct-to-consumer care where providers interact with patients. This trend is predominantly led by telemedicine companies as a response to increasing patient demand for convenience, but also we see this practice model being adopted by larger health care systems and private practices.”

In the past, she continued, most telemedicine technology has consisted of stand-alone software platforms. The new focus is integration, asking software platforms to be more interoperable with EHRs. “Also, some EHRs are offering telemedicine capabilities,” she said. Recent interest in value-based medicine, especially since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also plays a role in the growing adoption of telemedicine. “The focus on value and data collection is increasingly imposed upon us by multiple sources,” Dr. Lee said.

Reimbursement remains a barrier for wide adoption of teledermatology. Current models include volume-based (fee-for-service) and value-based models such as capitation, bundled payments, and pay for performance. Advances in the volume-based realm include increasing adoption of parity laws for private insurers (29 states hold such laws, which call for telemedicine services to be covered to the same extent and in a similar manner as in-person services).

In this era of higher-deductible insurance plans and narrowing networks, patients are also paying for their own care out of pocket or by using flexible savings accounts, to the tune of $30-$200 per teledermatology encounter. “We also have seen some progress with government payers in the fee-for-service models: Medicare, and less so with Medicaid,” she said. Telemedicine payments from Medicare have increased, from about $5 million in 2011 to about $18 million in 2015, but it currently reimburses live video with geographic restrictions and reimburses for store-and-forward technologies only in Alaska and Hawaii.

Medicaid “lags behind other payers,” Dr. Lee said. “Few states reimburse for store and forward, and reimbursement depends on distance requirements, eligible patient populations and health care providers, authorized technologies, and patient consent. Currently, reimbursement varies significantly across the country; it varies by state and, within each state, by payer. With the passage of MACRA, we have to start thinking about how we will practice and measure the value-based care we deliver and whether we as dermatologists will implement an alternative payment model or a merit-based incentive system. There are a lot of legislative changes in terms of getting properly paid for these services.”

On the legislative front, the Federation of State Medical Boards Interstate Medical Licensure Compact should help promote the adoption of teledermatology. This is proposed legislation to provide expedited and streamlined processes for physicians to obtain a multistate license to provide care. It’s been enacted by 17 states and proposed by 9 states and will go into effect in 2017.

“For teledermatology, this is an exciting time full of changes in practice, utilization, reimbursement, regulation, and research,” Dr. Lee concluded. “We see telemedicine increasingly integrated into mainstream medicine and health maintenance, and the outlook for dermatology is very positive.”

She reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – As the health care delivery landscape continues to evolve, expect the use of telemedicine to expand in dermatology.

“We have a robust evidence base that this is a valid way to deliver health care that can significantly improve patient access and offer comparable diagnostic and therapeutic outcomes, compared with in-person dermatology,” Ivy A. Lee, MD, said at the annual meeting of the Pacific Dermatologic Association. “This is an efficient way to improve access to our small and mighty workforce.”

Many factors are driving teledermatology’s rise in popularity, including patient access issues. “These are getting more prominent and more prevalent, not only in the uninsured and the underinsured, but also in our insured population,” said Dr. Lee, a Pasadena, Calif.–based dermatologist who also chairs the American Academy of Dermatology’s Telemedicine Task Force. “In my private practice, it’s about a 6- to 8-week wait for a new patient appointment, and this is in an affluent part of Los Angeles.”

Then there’s the increasing expectations of today’s health care consumers, who “want a better medical experience,” she said. “They don’t want to spend all their day in our waiting room, and they want to be able to get in touch with their physicians and not play phone tag with the front office staff. There’s also omnipresent technology. We have devices in our office, in our home, and in our hand – in every aspect of our lives. That’s also affecting our experience and expectations of medicine and health.”

Current forms of telemedicine range from “store and forward” (which refers to the submission of clinical images and history to a remote provider who reviews the material and sends a recommendation at a different time), “live interactive” (which uses synchronous video technology similar to FaceTime or Skype where you’re interacting with the patient or with the patient’s provider at the same time, even though you are separated by space), and “hybrid” (a combination of the two forms).

Dr. Lee said that store and forward currently is the predominant form of teledermatology “because of the convenience and ease of use. We’re a lot more efficient with that modality. We’ve used it predominantly for care delivery in a consultative practice model (provider interacts with another provider for consultation or triage of a patient). But, we also see an increasing interest and practice of direct-to-patient or direct-to-consumer care where providers interact with patients. This trend is predominantly led by telemedicine companies as a response to increasing patient demand for convenience, but also we see this practice model being adopted by larger health care systems and private practices.”

In the past, she continued, most telemedicine technology has consisted of stand-alone software platforms. The new focus is integration, asking software platforms to be more interoperable with EHRs. “Also, some EHRs are offering telemedicine capabilities,” she said. Recent interest in value-based medicine, especially since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also plays a role in the growing adoption of telemedicine. “The focus on value and data collection is increasingly imposed upon us by multiple sources,” Dr. Lee said.

Reimbursement remains a barrier for wide adoption of teledermatology. Current models include volume-based (fee-for-service) and value-based models such as capitation, bundled payments, and pay for performance. Advances in the volume-based realm include increasing adoption of parity laws for private insurers (29 states hold such laws, which call for telemedicine services to be covered to the same extent and in a similar manner as in-person services).

In this era of higher-deductible insurance plans and narrowing networks, patients are also paying for their own care out of pocket or by using flexible savings accounts, to the tune of $30-$200 per teledermatology encounter. “We also have seen some progress with government payers in the fee-for-service models: Medicare, and less so with Medicaid,” she said. Telemedicine payments from Medicare have increased, from about $5 million in 2011 to about $18 million in 2015, but it currently reimburses live video with geographic restrictions and reimburses for store-and-forward technologies only in Alaska and Hawaii.

Medicaid “lags behind other payers,” Dr. Lee said. “Few states reimburse for store and forward, and reimbursement depends on distance requirements, eligible patient populations and health care providers, authorized technologies, and patient consent. Currently, reimbursement varies significantly across the country; it varies by state and, within each state, by payer. With the passage of MACRA, we have to start thinking about how we will practice and measure the value-based care we deliver and whether we as dermatologists will implement an alternative payment model or a merit-based incentive system. There are a lot of legislative changes in terms of getting properly paid for these services.”

On the legislative front, the Federation of State Medical Boards Interstate Medical Licensure Compact should help promote the adoption of teledermatology. This is proposed legislation to provide expedited and streamlined processes for physicians to obtain a multistate license to provide care. It’s been enacted by 17 states and proposed by 9 states and will go into effect in 2017.

“For teledermatology, this is an exciting time full of changes in practice, utilization, reimbursement, regulation, and research,” Dr. Lee concluded. “We see telemedicine increasingly integrated into mainstream medicine and health maintenance, and the outlook for dermatology is very positive.”

She reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – As the health care delivery landscape continues to evolve, expect the use of telemedicine to expand in dermatology.

“We have a robust evidence base that this is a valid way to deliver health care that can significantly improve patient access and offer comparable diagnostic and therapeutic outcomes, compared with in-person dermatology,” Ivy A. Lee, MD, said at the annual meeting of the Pacific Dermatologic Association. “This is an efficient way to improve access to our small and mighty workforce.”

Many factors are driving teledermatology’s rise in popularity, including patient access issues. “These are getting more prominent and more prevalent, not only in the uninsured and the underinsured, but also in our insured population,” said Dr. Lee, a Pasadena, Calif.–based dermatologist who also chairs the American Academy of Dermatology’s Telemedicine Task Force. “In my private practice, it’s about a 6- to 8-week wait for a new patient appointment, and this is in an affluent part of Los Angeles.”

Then there’s the increasing expectations of today’s health care consumers, who “want a better medical experience,” she said. “They don’t want to spend all their day in our waiting room, and they want to be able to get in touch with their physicians and not play phone tag with the front office staff. There’s also omnipresent technology. We have devices in our office, in our home, and in our hand – in every aspect of our lives. That’s also affecting our experience and expectations of medicine and health.”

Current forms of telemedicine range from “store and forward” (which refers to the submission of clinical images and history to a remote provider who reviews the material and sends a recommendation at a different time), “live interactive” (which uses synchronous video technology similar to FaceTime or Skype where you’re interacting with the patient or with the patient’s provider at the same time, even though you are separated by space), and “hybrid” (a combination of the two forms).

Dr. Lee said that store and forward currently is the predominant form of teledermatology “because of the convenience and ease of use. We’re a lot more efficient with that modality. We’ve used it predominantly for care delivery in a consultative practice model (provider interacts with another provider for consultation or triage of a patient). But, we also see an increasing interest and practice of direct-to-patient or direct-to-consumer care where providers interact with patients. This trend is predominantly led by telemedicine companies as a response to increasing patient demand for convenience, but also we see this practice model being adopted by larger health care systems and private practices.”

In the past, she continued, most telemedicine technology has consisted of stand-alone software platforms. The new focus is integration, asking software platforms to be more interoperable with EHRs. “Also, some EHRs are offering telemedicine capabilities,” she said. Recent interest in value-based medicine, especially since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also plays a role in the growing adoption of telemedicine. “The focus on value and data collection is increasingly imposed upon us by multiple sources,” Dr. Lee said.

Reimbursement remains a barrier for wide adoption of teledermatology. Current models include volume-based (fee-for-service) and value-based models such as capitation, bundled payments, and pay for performance. Advances in the volume-based realm include increasing adoption of parity laws for private insurers (29 states hold such laws, which call for telemedicine services to be covered to the same extent and in a similar manner as in-person services).

In this era of higher-deductible insurance plans and narrowing networks, patients are also paying for their own care out of pocket or by using flexible savings accounts, to the tune of $30-$200 per teledermatology encounter. “We also have seen some progress with government payers in the fee-for-service models: Medicare, and less so with Medicaid,” she said. Telemedicine payments from Medicare have increased, from about $5 million in 2011 to about $18 million in 2015, but it currently reimburses live video with geographic restrictions and reimburses for store-and-forward technologies only in Alaska and Hawaii.

Medicaid “lags behind other payers,” Dr. Lee said. “Few states reimburse for store and forward, and reimbursement depends on distance requirements, eligible patient populations and health care providers, authorized technologies, and patient consent. Currently, reimbursement varies significantly across the country; it varies by state and, within each state, by payer. With the passage of MACRA, we have to start thinking about how we will practice and measure the value-based care we deliver and whether we as dermatologists will implement an alternative payment model or a merit-based incentive system. There are a lot of legislative changes in terms of getting properly paid for these services.”

On the legislative front, the Federation of State Medical Boards Interstate Medical Licensure Compact should help promote the adoption of teledermatology. This is proposed legislation to provide expedited and streamlined processes for physicians to obtain a multistate license to provide care. It’s been enacted by 17 states and proposed by 9 states and will go into effect in 2017.

“For teledermatology, this is an exciting time full of changes in practice, utilization, reimbursement, regulation, and research,” Dr. Lee concluded. “We see telemedicine increasingly integrated into mainstream medicine and health maintenance, and the outlook for dermatology is very positive.”

She reported having no relevant financial disclosures.

[email protected]

• Awards of Excellence: www.hospitalmedicine.org/awards
• Board of Directors: www.hospitalmedicine.org/boardelection
• Committee nominations: www.hospitalmedicine.org/committee
• Masters of Hospital Medicine: www.hospitalmedicine.org/masters

• Awards of Excellence: www.hospitalmedicine.org/awards
• Board of Directors: www.hospitalmedicine.org/boardelection
• Committee nominations: www.hospitalmedicine.org/committee
• Masters of Hospital Medicine: www.hospitalmedicine.org/masters

• Awards of Excellence: www.hospitalmedicine.org/awards
• Board of Directors: www.hospitalmedicine.org/boardelection
• Committee nominations: www.hospitalmedicine.org/committee
• Masters of Hospital Medicine: www.hospitalmedicine.org/masters

If you applied for early decision on or before September 15, you’ll hear back on or before October 28, 2016. The regular decision application will remain open through November 30, with a decision on or before December 31, 2016. Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

If you applied for early decision on or before September 15, you’ll hear back on or before October 28, 2016. The regular decision application will remain open through November 30, with a decision on or before December 31, 2016. Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

If you applied for early decision on or before September 15, you’ll hear back on or before October 28, 2016. The regular decision application will remain open through November 30, with a decision on or before December 31, 2016. Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

Busy clinical services and multiple demands on hospitalists’ time make it difficult to prepare brief talks to give to residents and students. The SHM Education Committee has created SHM Clinical Quick Talks, a bank of short prepared lectures on the SHM website. SHM Clinical Quick Talks are designed to be given in fewer than 10 minutes and are intended for use during teaching rounds, for a brief sit-down, or whenever time allows.

SHM is looking for additional authors for this series of micro-lectures. Read more and learn how to submit at connect.hospitalmedicine.org/clinicalquicktalks.

Busy clinical services and multiple demands on hospitalists’ time make it difficult to prepare brief talks to give to residents and students. The SHM Education Committee has created SHM Clinical Quick Talks, a bank of short prepared lectures on the SHM website. SHM Clinical Quick Talks are designed to be given in fewer than 10 minutes and are intended for use during teaching rounds, for a brief sit-down, or whenever time allows.

SHM is looking for additional authors for this series of micro-lectures. Read more and learn how to submit at connect.hospitalmedicine.org/clinicalquicktalks.

Busy clinical services and multiple demands on hospitalists’ time make it difficult to prepare brief talks to give to residents and students. The SHM Education Committee has created SHM Clinical Quick Talks, a bank of short prepared lectures on the SHM website. SHM Clinical Quick Talks are designed to be given in fewer than 10 minutes and are intended for use during teaching rounds, for a brief sit-down, or whenever time allows.

SHM is looking for additional authors for this series of micro-lectures. Read more and learn how to submit at connect.hospitalmedicine.org/clinicalquicktalks.

Approximately 86% of middle school students were vaccinated against HPV in a school setting in a review of data from a service project involving more than 8,000 students.

“School-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments,” wrote Dr. Amy Middleman of the University of Oklahoma Health Science Center, Oklahoma City, and her colleagues. Data from previous studies suggest reluctance on the part of parents to allow their children to receive the human papillomavirus vaccine (HPV) in a school setting, but such data may not reflect parents’ opinions when a school-based program is actually available, the researchers noted.

©xrender/Thinkstock

The researchers tested SLVPs at eight middle schools including 8,333 students; 80% were Hispanic, 17% were black, 1% were white, and the remainder of students’ ethnicities were not identified (Human Vaccines & Immunotherapeutics. 2016 Aug. doi: 10.1080/21645515.2016.1208326).

School-based vaccinations were scheduled for three times: September/October 2012, March/April 2013, and September/October 2013; the findings reflect the first two visits.

The SLVPs included the following vaccines: HPV, influenza, Tdap, meningococcal conjugate vaccine (MCV₄), hepatitis A, varicella, and MMR. A total of 1,674 vaccines were administered in the fall of 2012, and 532 were administered in the spring of 2013. Overall, 449 of 524 (86%) students in the fall program and 161 of 188 (86%) in the spring program received the HPV vaccine.

The study was limited by several factors including the descriptive nature of the service project and the inability to obtain the vaccination status of all enrolled students. In addition, the schools were located in lower income areas, which might limit the generalizability of the findings, the researchers noted. However, the results suggest that “SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing,” they said.

The study was supported by the Society for Adolescent Health through a grant from Merck. One study coauthor previously received salary support from Merck.

Approximately 86% of middle school students were vaccinated against HPV in a school setting in a review of data from a service project involving more than 8,000 students.

“School-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments,” wrote Dr. Amy Middleman of the University of Oklahoma Health Science Center, Oklahoma City, and her colleagues. Data from previous studies suggest reluctance on the part of parents to allow their children to receive the human papillomavirus vaccine (HPV) in a school setting, but such data may not reflect parents’ opinions when a school-based program is actually available, the researchers noted.

©xrender/Thinkstock

The researchers tested SLVPs at eight middle schools including 8,333 students; 80% were Hispanic, 17% were black, 1% were white, and the remainder of students’ ethnicities were not identified (Human Vaccines & Immunotherapeutics. 2016 Aug. doi: 10.1080/21645515.2016.1208326).

School-based vaccinations were scheduled for three times: September/October 2012, March/April 2013, and September/October 2013; the findings reflect the first two visits.

The SLVPs included the following vaccines: HPV, influenza, Tdap, meningococcal conjugate vaccine (MCV₄), hepatitis A, varicella, and MMR. A total of 1,674 vaccines were administered in the fall of 2012, and 532 were administered in the spring of 2013. Overall, 449 of 524 (86%) students in the fall program and 161 of 188 (86%) in the spring program received the HPV vaccine.

The study was limited by several factors including the descriptive nature of the service project and the inability to obtain the vaccination status of all enrolled students. In addition, the schools were located in lower income areas, which might limit the generalizability of the findings, the researchers noted. However, the results suggest that “SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing,” they said.

The study was supported by the Society for Adolescent Health through a grant from Merck. One study coauthor previously received salary support from Merck.

Approximately 86% of middle school students were vaccinated against HPV in a school setting in a review of data from a service project involving more than 8,000 students.

“School-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments,” wrote Dr. Amy Middleman of the University of Oklahoma Health Science Center, Oklahoma City, and her colleagues. Data from previous studies suggest reluctance on the part of parents to allow their children to receive the human papillomavirus vaccine (HPV) in a school setting, but such data may not reflect parents’ opinions when a school-based program is actually available, the researchers noted.

©xrender/Thinkstock

The researchers tested SLVPs at eight middle schools including 8,333 students; 80% were Hispanic, 17% were black, 1% were white, and the remainder of students’ ethnicities were not identified (Human Vaccines & Immunotherapeutics. 2016 Aug. doi: 10.1080/21645515.2016.1208326).

School-based vaccinations were scheduled for three times: September/October 2012, March/April 2013, and September/October 2013; the findings reflect the first two visits.

The SLVPs included the following vaccines: HPV, influenza, Tdap, meningococcal conjugate vaccine (MCV₄), hepatitis A, varicella, and MMR. A total of 1,674 vaccines were administered in the fall of 2012, and 532 were administered in the spring of 2013. Overall, 449 of 524 (86%) students in the fall program and 161 of 188 (86%) in the spring program received the HPV vaccine.

The study was limited by several factors including the descriptive nature of the service project and the inability to obtain the vaccination status of all enrolled students. In addition, the schools were located in lower income areas, which might limit the generalizability of the findings, the researchers noted. However, the results suggest that “SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing,” they said.

The study was supported by the Society for Adolescent Health through a grant from Merck. One study coauthor previously received salary support from Merck.

Q) I work in a cardiology practice. Recently, a patient on dialysis mentioned that her nephrology practitioner recommended either home therapy or nocturnal dialysis. Why would someone recommend these, and what are the differences between home, nocturnal, and regular daytime dialysis?

Patients usually require dialysis when 90% or more of their renal function is lost.⁵ This can happen acutely or result from a chronic process. Dialysis performs many of the functions of a kidney, such as removing waste and fluid buildup that damaged kidneys cannot. It also helps maintain electrolyte balance.

There are several forms of hemodialysis including home, incenter, and nocturnal; the most frequently used is in-center hemodialysis.⁵ Patients on in-center hemodialysis visit the center three times a week, and their treatments last from three to five hours; the nationwide average is four hours. These patients have very restricted schedules and must maintain their appointments with limited flexibility. Food, drinks, and nonmedical personnel may not be allowed in the treatment area. Between treatments, patients must follow a diet that restricts fluid, sodium, and potassium intake.

Home dialysis has become a popular alternative, since it may be done in a location and at a time that is convenient for the patient. With more flexibility, many patients are able to continue working and feel like they have a more “normal” life. Types of home dialysis include home hemodialysis (HHD) or peritoneal dialysis (PD). A relative or friend may need to assist the patient during HHD, which is undergone more frequently (between five and seven days per week) and for a shorter duration of time than in-center dialysis. PD is done every day, either at night or multiple times throughout the day. Although no partner is needed for PD, a medical provider is available by phone to address any concerns that may arise during treatment.

Nocturnal hemodialysis is similar to daytime in-center hemodialysis, but it occurs while the patient is asleep. The treatment duration is longer (an average of eight hours per treatment). The slower blood flow allows for gentler dialysis. Patients who undergo nocturnal hemodialysis have higher survival and lower hospitalization rates, with better phosphorus control and blood pressure.⁶ This is attributed to the slower removal of excess fluid and more effective clearance of toxins.

So, why is your patient being encouraged to consider home or nocturnal dialysis? Studies have shown that for the cardiac patient, slower, gentler dialysis is preferable.⁷ The clinician who recommended it has the patient’s best interest in mind. —TAH

Tricia A. Howard, MHS, PA-C, DFAAPA
PA Program, South University, Savannah, Georgia

Q) I work in a cardiology practice. Recently, a patient on dialysis mentioned that her nephrology practitioner recommended either home therapy or nocturnal dialysis. Why would someone recommend these, and what are the differences between home, nocturnal, and regular daytime dialysis?

Patients usually require dialysis when 90% or more of their renal function is lost.⁵ This can happen acutely or result from a chronic process. Dialysis performs many of the functions of a kidney, such as removing waste and fluid buildup that damaged kidneys cannot. It also helps maintain electrolyte balance.

There are several forms of hemodialysis including home, incenter, and nocturnal; the most frequently used is in-center hemodialysis.⁵ Patients on in-center hemodialysis visit the center three times a week, and their treatments last from three to five hours; the nationwide average is four hours. These patients have very restricted schedules and must maintain their appointments with limited flexibility. Food, drinks, and nonmedical personnel may not be allowed in the treatment area. Between treatments, patients must follow a diet that restricts fluid, sodium, and potassium intake.

Home dialysis has become a popular alternative, since it may be done in a location and at a time that is convenient for the patient. With more flexibility, many patients are able to continue working and feel like they have a more “normal” life. Types of home dialysis include home hemodialysis (HHD) or peritoneal dialysis (PD). A relative or friend may need to assist the patient during HHD, which is undergone more frequently (between five and seven days per week) and for a shorter duration of time than in-center dialysis. PD is done every day, either at night or multiple times throughout the day. Although no partner is needed for PD, a medical provider is available by phone to address any concerns that may arise during treatment.

Nocturnal hemodialysis is similar to daytime in-center hemodialysis, but it occurs while the patient is asleep. The treatment duration is longer (an average of eight hours per treatment). The slower blood flow allows for gentler dialysis. Patients who undergo nocturnal hemodialysis have higher survival and lower hospitalization rates, with better phosphorus control and blood pressure.⁶ This is attributed to the slower removal of excess fluid and more effective clearance of toxins.

So, why is your patient being encouraged to consider home or nocturnal dialysis? Studies have shown that for the cardiac patient, slower, gentler dialysis is preferable.⁷ The clinician who recommended it has the patient’s best interest in mind. —TAH

Tricia A. Howard, MHS, PA-C, DFAAPA
PA Program, South University, Savannah, Georgia

Q) I work in a cardiology practice. Recently, a patient on dialysis mentioned that her nephrology practitioner recommended either home therapy or nocturnal dialysis. Why would someone recommend these, and what are the differences between home, nocturnal, and regular daytime dialysis?

Patients usually require dialysis when 90% or more of their renal function is lost.⁵ This can happen acutely or result from a chronic process. Dialysis performs many of the functions of a kidney, such as removing waste and fluid buildup that damaged kidneys cannot. It also helps maintain electrolyte balance.

There are several forms of hemodialysis including home, incenter, and nocturnal; the most frequently used is in-center hemodialysis.⁵ Patients on in-center hemodialysis visit the center three times a week, and their treatments last from three to five hours; the nationwide average is four hours. These patients have very restricted schedules and must maintain their appointments with limited flexibility. Food, drinks, and nonmedical personnel may not be allowed in the treatment area. Between treatments, patients must follow a diet that restricts fluid, sodium, and potassium intake.

Home dialysis has become a popular alternative, since it may be done in a location and at a time that is convenient for the patient. With more flexibility, many patients are able to continue working and feel like they have a more “normal” life. Types of home dialysis include home hemodialysis (HHD) or peritoneal dialysis (PD). A relative or friend may need to assist the patient during HHD, which is undergone more frequently (between five and seven days per week) and for a shorter duration of time than in-center dialysis. PD is done every day, either at night or multiple times throughout the day. Although no partner is needed for PD, a medical provider is available by phone to address any concerns that may arise during treatment.

Nocturnal hemodialysis is similar to daytime in-center hemodialysis, but it occurs while the patient is asleep. The treatment duration is longer (an average of eight hours per treatment). The slower blood flow allows for gentler dialysis. Patients who undergo nocturnal hemodialysis have higher survival and lower hospitalization rates, with better phosphorus control and blood pressure.⁶ This is attributed to the slower removal of excess fluid and more effective clearance of toxins.

So, why is your patient being encouraged to consider home or nocturnal dialysis? Studies have shown that for the cardiac patient, slower, gentler dialysis is preferable.⁷ The clinician who recommended it has the patient’s best interest in mind. —TAH

Tricia A. Howard, MHS, PA-C, DFAAPA
PA Program, South University, Savannah, Georgia

To improve the lives of individuals with sickle cell disease, the American Society of Hematology has launched the Sickle Cell Disease Coalition (SCDC). Creation of the coalition with 20 other organizations coincides with the release of “State of Sickle Cell Disease: 2016” – a report detailing the status of access to care for patients with sickle cell disease, gaps in the training and education of health care professionals, areas of interest for research and clinical trials, and the global state of the disease. All four of these areas need improvement, ASH officials said in a statement.

“Not only are individuals with [sickle cell disease] burdened by the pain and disability that comes with a chronic condition, but they also have very few accessible treatment options due to our fragmented health care system,” Dr. Charles S. Abrams, president of ASH, said in the statement. Sickle cell disease affects approximately 100,000 Americans and remains a growing global health concern, according to the statement.

Courtesy Wikimedia Commons/Osaro Erhabor/Creative Commons License

The coalition’s goals include development of evidence-based treatment guidelines to improve quality of care, education of clinicians to increase the number of health care providers available to treat sickle cell disease, investment in research and clinical trials to improve existing treatments and develop new ones, and expansion of early intervention programs to help ease the global burden of sickle cell disease.

For more information regarding the coalition, click here.

To improve the lives of individuals with sickle cell disease, the American Society of Hematology has launched the Sickle Cell Disease Coalition (SCDC). Creation of the coalition with 20 other organizations coincides with the release of “State of Sickle Cell Disease: 2016” – a report detailing the status of access to care for patients with sickle cell disease, gaps in the training and education of health care professionals, areas of interest for research and clinical trials, and the global state of the disease. All four of these areas need improvement, ASH officials said in a statement.

“Not only are individuals with [sickle cell disease] burdened by the pain and disability that comes with a chronic condition, but they also have very few accessible treatment options due to our fragmented health care system,” Dr. Charles S. Abrams, president of ASH, said in the statement. Sickle cell disease affects approximately 100,000 Americans and remains a growing global health concern, according to the statement.

Courtesy Wikimedia Commons/Osaro Erhabor/Creative Commons License

The coalition’s goals include development of evidence-based treatment guidelines to improve quality of care, education of clinicians to increase the number of health care providers available to treat sickle cell disease, investment in research and clinical trials to improve existing treatments and develop new ones, and expansion of early intervention programs to help ease the global burden of sickle cell disease.

For more information regarding the coalition, click here.

To improve the lives of individuals with sickle cell disease, the American Society of Hematology has launched the Sickle Cell Disease Coalition (SCDC). Creation of the coalition with 20 other organizations coincides with the release of “State of Sickle Cell Disease: 2016” – a report detailing the status of access to care for patients with sickle cell disease, gaps in the training and education of health care professionals, areas of interest for research and clinical trials, and the global state of the disease. All four of these areas need improvement, ASH officials said in a statement.

“Not only are individuals with [sickle cell disease] burdened by the pain and disability that comes with a chronic condition, but they also have very few accessible treatment options due to our fragmented health care system,” Dr. Charles S. Abrams, president of ASH, said in the statement. Sickle cell disease affects approximately 100,000 Americans and remains a growing global health concern, according to the statement.

Courtesy Wikimedia Commons/Osaro Erhabor/Creative Commons License

The coalition’s goals include development of evidence-based treatment guidelines to improve quality of care, education of clinicians to increase the number of health care providers available to treat sickle cell disease, investment in research and clinical trials to improve existing treatments and develop new ones, and expansion of early intervention programs to help ease the global burden of sickle cell disease.

For more information regarding the coalition, click here.

HSCT preparation

Photo by Chad McNeeley

New research suggests hematopoietic stem cell transplant (HSCT) may increase the molecular age of peripheral blood T cells.

The study showed an increase in peripheral blood T-cell senescence in patients with hematologic malignancies who were treated with autologous (auto-) or allogeneic (allo-) HSCT.

The patients had elevated levels of p16INK4a, a known marker of cellular senescence.

Auto-HSCT in particular had a strong effect on p16INK4a, increasing the expression of this marker to a degree comparable to 30 years of chronological aging.

Researchers reported these findings in EBioMedicine.

“We know that transplant is life-prolonging, and, in many cases, it’s life-saving for many patients with blood cancers and other disorders,” said study author William Wood, MD, of the University of North Carolina School of Medicine in Chapel Hill.

“At the same time, we’re increasingly recognizing that survivors of transplant are at risk for long-term health problems, and so there is interest in determining what markers may exist to help predict risk for long-term health problems or even in helping choose which patients are best candidates for transplantation.”

With this in mind, Dr Wood and his colleagues looked at levels of p16INK4a in 63 patients who underwent auto- or allo-HSCT to treat myeloma, lymphoma, or leukemia. The researchers assessed p16INK4a expression in T cells before HSCT and 6 months after.

Among auto-HSCT recipients, there were no baseline characteristics associated with pre-transplant p16INK4a expression.

However, allo-HSCT recipients had significantly higher pre-transplant p16INK4a levels the more cycles of chemotherapy they received before transplant (P=0.003), if they had previously undergone auto-HSCT (P=0.01), and if they had been exposed to alkylating agents (P=0.01).

After transplant, allo-HSCT recipients had a 1.93-fold increase in p16INK4a expression (P=0.0004), and auto-HSCT recipients had a 3.05-fold increase (P=0.002).

The researchers said the measured change in p16INK4a from pre- to post-HSCT in allogeneic recipients likely underestimates the age-promoting effects of HSCT, given that the pre-HSCT levels were elevated in the recipients from prior therapeutic exposure.

The researchers also pointed out that this study does not show a clear connection between changes in p16INK4a levels and the actual function of peripheral blood T cells, but they did say that p16INK4a is “arguably one of the best in vivo markers of cellular senescence and is directly associated with age-related deterioration.”

So the results of this research suggest the forced bone marrow repopulation associated with HSCT accelerates the molecular aging of peripheral blood T cells.

“Many oncologists would not be surprised by the finding that stem cell transplant accelerates aspects of aging,” said study author Norman Sharpless, MD, of the University of North Carolina School of Medicine.

“We know that, years after a curative transplant, stem cell transplant survivors are at increased risk for blood problems that can occur with aging, such as reduced immunity, increased risk for bone marrow failure, and increased risk of blood cancers. What is important about this work, however, is that it allows us to quantify the effect of stem cell transplant on molecular age.”

HSCT preparation

Photo by Chad McNeeley

New research suggests hematopoietic stem cell transplant (HSCT) may increase the molecular age of peripheral blood T cells.

The study showed an increase in peripheral blood T-cell senescence in patients with hematologic malignancies who were treated with autologous (auto-) or allogeneic (allo-) HSCT.

The patients had elevated levels of p16INK4a, a known marker of cellular senescence.

Auto-HSCT in particular had a strong effect on p16INK4a, increasing the expression of this marker to a degree comparable to 30 years of chronological aging.

Researchers reported these findings in EBioMedicine.

“We know that transplant is life-prolonging, and, in many cases, it’s life-saving for many patients with blood cancers and other disorders,” said study author William Wood, MD, of the University of North Carolina School of Medicine in Chapel Hill.

“At the same time, we’re increasingly recognizing that survivors of transplant are at risk for long-term health problems, and so there is interest in determining what markers may exist to help predict risk for long-term health problems or even in helping choose which patients are best candidates for transplantation.”

With this in mind, Dr Wood and his colleagues looked at levels of p16INK4a in 63 patients who underwent auto- or allo-HSCT to treat myeloma, lymphoma, or leukemia. The researchers assessed p16INK4a expression in T cells before HSCT and 6 months after.

Among auto-HSCT recipients, there were no baseline characteristics associated with pre-transplant p16INK4a expression.

However, allo-HSCT recipients had significantly higher pre-transplant p16INK4a levels the more cycles of chemotherapy they received before transplant (P=0.003), if they had previously undergone auto-HSCT (P=0.01), and if they had been exposed to alkylating agents (P=0.01).

After transplant, allo-HSCT recipients had a 1.93-fold increase in p16INK4a expression (P=0.0004), and auto-HSCT recipients had a 3.05-fold increase (P=0.002).

The researchers said the measured change in p16INK4a from pre- to post-HSCT in allogeneic recipients likely underestimates the age-promoting effects of HSCT, given that the pre-HSCT levels were elevated in the recipients from prior therapeutic exposure.

The researchers also pointed out that this study does not show a clear connection between changes in p16INK4a levels and the actual function of peripheral blood T cells, but they did say that p16INK4a is “arguably one of the best in vivo markers of cellular senescence and is directly associated with age-related deterioration.”

So the results of this research suggest the forced bone marrow repopulation associated with HSCT accelerates the molecular aging of peripheral blood T cells.

“Many oncologists would not be surprised by the finding that stem cell transplant accelerates aspects of aging,” said study author Norman Sharpless, MD, of the University of North Carolina School of Medicine.

“We know that, years after a curative transplant, stem cell transplant survivors are at increased risk for blood problems that can occur with aging, such as reduced immunity, increased risk for bone marrow failure, and increased risk of blood cancers. What is important about this work, however, is that it allows us to quantify the effect of stem cell transplant on molecular age.”

HSCT preparation

Photo by Chad McNeeley

New research suggests hematopoietic stem cell transplant (HSCT) may increase the molecular age of peripheral blood T cells.

The study showed an increase in peripheral blood T-cell senescence in patients with hematologic malignancies who were treated with autologous (auto-) or allogeneic (allo-) HSCT.

The patients had elevated levels of p16INK4a, a known marker of cellular senescence.

Auto-HSCT in particular had a strong effect on p16INK4a, increasing the expression of this marker to a degree comparable to 30 years of chronological aging.

Researchers reported these findings in EBioMedicine.

“We know that transplant is life-prolonging, and, in many cases, it’s life-saving for many patients with blood cancers and other disorders,” said study author William Wood, MD, of the University of North Carolina School of Medicine in Chapel Hill.

“At the same time, we’re increasingly recognizing that survivors of transplant are at risk for long-term health problems, and so there is interest in determining what markers may exist to help predict risk for long-term health problems or even in helping choose which patients are best candidates for transplantation.”

With this in mind, Dr Wood and his colleagues looked at levels of p16INK4a in 63 patients who underwent auto- or allo-HSCT to treat myeloma, lymphoma, or leukemia. The researchers assessed p16INK4a expression in T cells before HSCT and 6 months after.

Among auto-HSCT recipients, there were no baseline characteristics associated with pre-transplant p16INK4a expression.

However, allo-HSCT recipients had significantly higher pre-transplant p16INK4a levels the more cycles of chemotherapy they received before transplant (P=0.003), if they had previously undergone auto-HSCT (P=0.01), and if they had been exposed to alkylating agents (P=0.01).

After transplant, allo-HSCT recipients had a 1.93-fold increase in p16INK4a expression (P=0.0004), and auto-HSCT recipients had a 3.05-fold increase (P=0.002).

The researchers said the measured change in p16INK4a from pre- to post-HSCT in allogeneic recipients likely underestimates the age-promoting effects of HSCT, given that the pre-HSCT levels were elevated in the recipients from prior therapeutic exposure.

The researchers also pointed out that this study does not show a clear connection between changes in p16INK4a levels and the actual function of peripheral blood T cells, but they did say that p16INK4a is “arguably one of the best in vivo markers of cellular senescence and is directly associated with age-related deterioration.”

So the results of this research suggest the forced bone marrow repopulation associated with HSCT accelerates the molecular aging of peripheral blood T cells.

“Many oncologists would not be surprised by the finding that stem cell transplant accelerates aspects of aging,” said study author Norman Sharpless, MD, of the University of North Carolina School of Medicine.

“We know that, years after a curative transplant, stem cell transplant survivors are at increased risk for blood problems that can occur with aging, such as reduced immunity, increased risk for bone marrow failure, and increased risk of blood cancers. What is important about this work, however, is that it allows us to quantify the effect of stem cell transplant on molecular age.”