BETHESDA, MD. – A smartphone application helped decrease depressive symptoms and improve confidence in self care for low-income pregnant women in their third trimester, a pilot study has shown.

“There is a difficulty in bringing mental health into the OB setting, particularly for underserved communities, in part because of too much to accomplish during a visit or because some women don’t think it’s the appropriate place to talk about their mental health concerns,” Liisa Hantsoo, PhD, a researcher at the Penn Center for Women’s Behavioral Wellness in Philadelphia, said during the annual National Institute of Mental Health Conference on Mental Health Services Research.

However, in a single academic site pilot study of 64 pregnant women, most of whom were covered under Medicaid, Dr. Hantsoo and her colleagues found that when the women were given access to their obstetrician’s office via a smartphone app integrated into the practice, they were significantly more likely to open up about their mental health concerns, spend more time in conversation with their clinician when symptoms increased, and experience fewer symptoms of depression and anxiety.

“Participants used the app frequently, they reported feeling more positive about their emotions, and they reported feeling more confident about taking care of their own health during their third trimester,” Dr. Hantsoo said.

All women in the study were assessed for depression using the Patient Health Questionnaire depression module (PHQ-9). Women with scores of 5 or higher who were no more than 32 weeks pregnant were included in the study. The women – more than half of whom had a prior history of mental illness – were also assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). And they were asked to rate their satisfaction levels with their OB care at baseline, including whether they believed their care team connected with them as individuals. The study participants were all in their mid-20s and had previously given birth.

Twenty-two women were randomly assigned to use a control app, which only allowed self-initiated communication with the practice through an established patient portal not designed specifically for mental health. Another 23 women were assigned to the same control app plus an app designed by Ginger.io for mental health self-care and symptom tracking. The study app included daily cognitive-behavioral therapy messages, other behavioral health educational messages, and prompts to record self-assessments of mood that were monitored daily by a care coordinator. The remaining 19 women were assigned to both apps and received additional prompts throughout the day to record their thoughts and mood, which were also monitored. If a patient’s depressive symptoms increased, the care coordinator alerted a physician in the practice, who then contacted the patient.

By week 8, the study app users had significantly decreased PHQ-9 scores (P = .001) and significantly decreased GAD-7 scores (P = .003). The combined study cohorts (women using the study app and those with the study app plus prompts to record mood) also self-reported significantly improved mood ratings at week 8 (P = .03). The combined study groups also reported more confidence in their ability to care for themselves, particularly in their third trimester, compared with women using only the control app (P = .002).

The difference is likely because of the ways that the study app was integrated into care, Dr. Hantsoo said. “Apps allow self-monitoring and identify your patterns over time, but they are also limited in that they aren’t often integrated into treatment or care, leaving a person hanging in distress if they enter their data, but then not having it seem to go anywhere. This app allowed patients to interact with their providers.”

Use of any app did not significantly affect how participants rated their overall care, although at least half of all study app users reported feeling more confident in their ability to assess and manage their moods and their overall health, particularly in their third trimester.

As for the physicians who participated in the study, they reported needing more time each week to respond to app-triggered patient needs. “It was a bit of a disruption, but they did report they thought it was worthwhile to do,” Dr. Hantsoo said in an interview.

Support for this study was provided by Ginger.io and by the Penn Medicine Center for Health Care Innovation. Dr. Hantsoo reported having no relevant financial 

BETHESDA, MD. – A smartphone application helped decrease depressive symptoms and improve confidence in self care for low-income pregnant women in their third trimester, a pilot study has shown.

“There is a difficulty in bringing mental health into the OB setting, particularly for underserved communities, in part because of too much to accomplish during a visit or because some women don’t think it’s the appropriate place to talk about their mental health concerns,” Liisa Hantsoo, PhD, a researcher at the Penn Center for Women’s Behavioral Wellness in Philadelphia, said during the annual National Institute of Mental Health Conference on Mental Health Services Research.

However, in a single academic site pilot study of 64 pregnant women, most of whom were covered under Medicaid, Dr. Hantsoo and her colleagues found that when the women were given access to their obstetrician’s office via a smartphone app integrated into the practice, they were significantly more likely to open up about their mental health concerns, spend more time in conversation with their clinician when symptoms increased, and experience fewer symptoms of depression and anxiety.

“Participants used the app frequently, they reported feeling more positive about their emotions, and they reported feeling more confident about taking care of their own health during their third trimester,” Dr. Hantsoo said.

All women in the study were assessed for depression using the Patient Health Questionnaire depression module (PHQ-9). Women with scores of 5 or higher who were no more than 32 weeks pregnant were included in the study. The women – more than half of whom had a prior history of mental illness – were also assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). And they were asked to rate their satisfaction levels with their OB care at baseline, including whether they believed their care team connected with them as individuals. The study participants were all in their mid-20s and had previously given birth.

Twenty-two women were randomly assigned to use a control app, which only allowed self-initiated communication with the practice through an established patient portal not designed specifically for mental health. Another 23 women were assigned to the same control app plus an app designed by Ginger.io for mental health self-care and symptom tracking. The study app included daily cognitive-behavioral therapy messages, other behavioral health educational messages, and prompts to record self-assessments of mood that were monitored daily by a care coordinator. The remaining 19 women were assigned to both apps and received additional prompts throughout the day to record their thoughts and mood, which were also monitored. If a patient’s depressive symptoms increased, the care coordinator alerted a physician in the practice, who then contacted the patient.

By week 8, the study app users had significantly decreased PHQ-9 scores (P = .001) and significantly decreased GAD-7 scores (P = .003). The combined study cohorts (women using the study app and those with the study app plus prompts to record mood) also self-reported significantly improved mood ratings at week 8 (P = .03). The combined study groups also reported more confidence in their ability to care for themselves, particularly in their third trimester, compared with women using only the control app (P = .002).

The difference is likely because of the ways that the study app was integrated into care, Dr. Hantsoo said. “Apps allow self-monitoring and identify your patterns over time, but they are also limited in that they aren’t often integrated into treatment or care, leaving a person hanging in distress if they enter their data, but then not having it seem to go anywhere. This app allowed patients to interact with their providers.”

Use of any app did not significantly affect how participants rated their overall care, although at least half of all study app users reported feeling more confident in their ability to assess and manage their moods and their overall health, particularly in their third trimester.

As for the physicians who participated in the study, they reported needing more time each week to respond to app-triggered patient needs. “It was a bit of a disruption, but they did report they thought it was worthwhile to do,” Dr. Hantsoo said in an interview.

Support for this study was provided by Ginger.io and by the Penn Medicine Center for Health Care Innovation. Dr. Hantsoo reported having no relevant financial 

BETHESDA, MD. – A smartphone application helped decrease depressive symptoms and improve confidence in self care for low-income pregnant women in their third trimester, a pilot study has shown.

“There is a difficulty in bringing mental health into the OB setting, particularly for underserved communities, in part because of too much to accomplish during a visit or because some women don’t think it’s the appropriate place to talk about their mental health concerns,” Liisa Hantsoo, PhD, a researcher at the Penn Center for Women’s Behavioral Wellness in Philadelphia, said during the annual National Institute of Mental Health Conference on Mental Health Services Research.

However, in a single academic site pilot study of 64 pregnant women, most of whom were covered under Medicaid, Dr. Hantsoo and her colleagues found that when the women were given access to their obstetrician’s office via a smartphone app integrated into the practice, they were significantly more likely to open up about their mental health concerns, spend more time in conversation with their clinician when symptoms increased, and experience fewer symptoms of depression and anxiety.

“Participants used the app frequently, they reported feeling more positive about their emotions, and they reported feeling more confident about taking care of their own health during their third trimester,” Dr. Hantsoo said.

All women in the study were assessed for depression using the Patient Health Questionnaire depression module (PHQ-9). Women with scores of 5 or higher who were no more than 32 weeks pregnant were included in the study. The women – more than half of whom had a prior history of mental illness – were also assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). And they were asked to rate their satisfaction levels with their OB care at baseline, including whether they believed their care team connected with them as individuals. The study participants were all in their mid-20s and had previously given birth.

Twenty-two women were randomly assigned to use a control app, which only allowed self-initiated communication with the practice through an established patient portal not designed specifically for mental health. Another 23 women were assigned to the same control app plus an app designed by Ginger.io for mental health self-care and symptom tracking. The study app included daily cognitive-behavioral therapy messages, other behavioral health educational messages, and prompts to record self-assessments of mood that were monitored daily by a care coordinator. The remaining 19 women were assigned to both apps and received additional prompts throughout the day to record their thoughts and mood, which were also monitored. If a patient’s depressive symptoms increased, the care coordinator alerted a physician in the practice, who then contacted the patient.

By week 8, the study app users had significantly decreased PHQ-9 scores (P = .001) and significantly decreased GAD-7 scores (P = .003). The combined study cohorts (women using the study app and those with the study app plus prompts to record mood) also self-reported significantly improved mood ratings at week 8 (P = .03). The combined study groups also reported more confidence in their ability to care for themselves, particularly in their third trimester, compared with women using only the control app (P = .002).

The difference is likely because of the ways that the study app was integrated into care, Dr. Hantsoo said. “Apps allow self-monitoring and identify your patterns over time, but they are also limited in that they aren’t often integrated into treatment or care, leaving a person hanging in distress if they enter their data, but then not having it seem to go anywhere. This app allowed patients to interact with their providers.”

Use of any app did not significantly affect how participants rated their overall care, although at least half of all study app users reported feeling more confident in their ability to assess and manage their moods and their overall health, particularly in their third trimester.

As for the physicians who participated in the study, they reported needing more time each week to respond to app-triggered patient needs. “It was a bit of a disruption, but they did report they thought it was worthwhile to do,” Dr. Hantsoo said in an interview.

Support for this study was provided by Ginger.io and by the Penn Medicine Center for Health Care Innovation. Dr. Hantsoo reported having no relevant financial 

BETHESDA, MD. – A smartphone application helped decrease depressive symptoms and improve confidence in self care for low-income pregnant women in their third trimester, a pilot study has shown.

“There is a difficulty in bringing mental health into the OB setting, particularly for underserved communities, in part because of too much to accomplish during a visit or because some women don’t think it’s the appropriate place to talk about their mental health concerns,” Liisa Hantsoo, PhD, a researcher at the Penn Center for Women’s Behavioral Wellness in Philadelphia, said during the annual National Institute of Mental Health Conference on Mental Health Services Research.

However, in a single academic site pilot study of 64 pregnant women, most of whom were covered under Medicaid, Dr. Hantsoo and her colleagues found that when the women were given access to their obstetrician’s office via a smartphone app integrated into the practice, they were significantly more likely to open up about their mental health concerns, spend more time in conversation with their clinician when symptoms increased, and experience fewer symptoms of depression and anxiety.

“Participants used the app frequently, they reported feeling more positive about their emotions, and they reported feeling more confident about taking care of their own health during their third trimester,” Dr. Hantsoo said.

All women in the study were assessed for depression using the Patient Health Questionnaire depression module (PHQ-9). Women with scores of 5 or higher who were no more than 32 weeks pregnant were included in the study. The women – more than half of whom had a prior history of mental illness – were also assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). And they were asked to rate their satisfaction levels with their OB care at baseline, including whether they believed their care team connected with them as individuals. The study participants were all in their mid-20s and had previously given birth.

Twenty-two women were randomly assigned to use a control app, which only allowed self-initiated communication with the practice through an established patient portal not designed specifically for mental health. Another 23 women were assigned to the same control app plus an app designed by Ginger.io for mental health self-care and symptom tracking. The study app included daily cognitive-behavioral therapy messages, other behavioral health educational messages, and prompts to record self-assessments of mood that were monitored daily by a care coordinator. The remaining 19 women were assigned to both apps and received additional prompts throughout the day to record their thoughts and mood, which were also monitored. If a patient’s depressive symptoms increased, the care coordinator alerted a physician in the practice, who then contacted the patient.

By week 8, the study app users had significantly decreased PHQ-9 scores (P = .001) and significantly decreased GAD-7 scores (P = .003). The combined study cohorts (women using the study app and those with the study app plus prompts to record mood) also self-reported significantly improved mood ratings at week 8 (P = .03). The combined study groups also reported more confidence in their ability to care for themselves, particularly in their third trimester, compared with women using only the control app (P = .002).

The difference is likely because of the ways that the study app was integrated into care, Dr. Hantsoo said. “Apps allow self-monitoring and identify your patterns over time, but they are also limited in that they aren’t often integrated into treatment or care, leaving a person hanging in distress if they enter their data, but then not having it seem to go anywhere. This app allowed patients to interact with their providers.”

Use of any app did not significantly affect how participants rated their overall care, although at least half of all study app users reported feeling more confident in their ability to assess and manage their moods and their overall health, particularly in their third trimester.

As for the physicians who participated in the study, they reported needing more time each week to respond to app-triggered patient needs. “It was a bit of a disruption, but they did report they thought it was worthwhile to do,” Dr. Hantsoo said in an interview.

Support for this study was provided by Ginger.io and by the Penn Medicine Center for Health Care Innovation. Dr. Hantsoo reported having no relevant financial

[email protected]

On Twitter @whitneymcknight

BETHESDA, MD. – A smartphone application helped decrease depressive symptoms and improve confidence in self care for low-income pregnant women in their third trimester, a pilot study has shown.

“There is a difficulty in bringing mental health into the OB setting, particularly for underserved communities, in part because of too much to accomplish during a visit or because some women don’t think it’s the appropriate place to talk about their mental health concerns,” Liisa Hantsoo, PhD, a researcher at the Penn Center for Women’s Behavioral Wellness in Philadelphia, said during the annual National Institute of Mental Health Conference on Mental Health Services Research.

However, in a single academic site pilot study of 64 pregnant women, most of whom were covered under Medicaid, Dr. Hantsoo and her colleagues found that when the women were given access to their obstetrician’s office via a smartphone app integrated into the practice, they were significantly more likely to open up about their mental health concerns, spend more time in conversation with their clinician when symptoms increased, and experience fewer symptoms of depression and anxiety.

“Participants used the app frequently, they reported feeling more positive about their emotions, and they reported feeling more confident about taking care of their own health during their third trimester,” Dr. Hantsoo said.

All women in the study were assessed for depression using the Patient Health Questionnaire depression module (PHQ-9). Women with scores of 5 or higher who were no more than 32 weeks pregnant were included in the study. The women – more than half of whom had a prior history of mental illness – were also assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). And they were asked to rate their satisfaction levels with their OB care at baseline, including whether they believed their care team connected with them as individuals. The study participants were all in their mid-20s and had previously given birth.

Twenty-two women were randomly assigned to use a control app, which only allowed self-initiated communication with the practice through an established patient portal not designed specifically for mental health. Another 23 women were assigned to the same control app plus an app designed by Ginger.io for mental health self-care and symptom tracking. The study app included daily cognitive-behavioral therapy messages, other behavioral health educational messages, and prompts to record self-assessments of mood that were monitored daily by a care coordinator. The remaining 19 women were assigned to both apps and received additional prompts throughout the day to record their thoughts and mood, which were also monitored. If a patient’s depressive symptoms increased, the care coordinator alerted a physician in the practice, who then contacted the patient.

By week 8, the study app users had significantly decreased PHQ-9 scores (P = .001) and significantly decreased GAD-7 scores (P = .003). The combined study cohorts (women using the study app and those with the study app plus prompts to record mood) also self-reported significantly improved mood ratings at week 8 (P = .03). The combined study groups also reported more confidence in their ability to care for themselves, particularly in their third trimester, compared with women using only the control app (P = .002).

The difference is likely because of the ways that the study app was integrated into care, Dr. Hantsoo said. “Apps allow self-monitoring and identify your patterns over time, but they are also limited in that they aren’t often integrated into treatment or care, leaving a person hanging in distress if they enter their data, but then not having it seem to go anywhere. This app allowed patients to interact with their providers.”

Use of any app did not significantly affect how participants rated their overall care, although at least half of all study app users reported feeling more confident in their ability to assess and manage their moods and their overall health, particularly in their third trimester.

As for the physicians who participated in the study, they reported needing more time each week to respond to app-triggered patient needs. “It was a bit of a disruption, but they did report they thought it was worthwhile to do,” Dr. Hantsoo said in an interview.

Support for this study was provided by Ginger.io and by the Penn Medicine Center for Health Care Innovation. Dr. Hantsoo reported having no relevant financial

[email protected]

On Twitter @whitneymcknight

BETHESDA, MD. – A smartphone application helped decrease depressive symptoms and improve confidence in self care for low-income pregnant women in their third trimester, a pilot study has shown.

“There is a difficulty in bringing mental health into the OB setting, particularly for underserved communities, in part because of too much to accomplish during a visit or because some women don’t think it’s the appropriate place to talk about their mental health concerns,” Liisa Hantsoo, PhD, a researcher at the Penn Center for Women’s Behavioral Wellness in Philadelphia, said during the annual National Institute of Mental Health Conference on Mental Health Services Research.

However, in a single academic site pilot study of 64 pregnant women, most of whom were covered under Medicaid, Dr. Hantsoo and her colleagues found that when the women were given access to their obstetrician’s office via a smartphone app integrated into the practice, they were significantly more likely to open up about their mental health concerns, spend more time in conversation with their clinician when symptoms increased, and experience fewer symptoms of depression and anxiety.

“Participants used the app frequently, they reported feeling more positive about their emotions, and they reported feeling more confident about taking care of their own health during their third trimester,” Dr. Hantsoo said.

All women in the study were assessed for depression using the Patient Health Questionnaire depression module (PHQ-9). Women with scores of 5 or higher who were no more than 32 weeks pregnant were included in the study. The women – more than half of whom had a prior history of mental illness – were also assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). And they were asked to rate their satisfaction levels with their OB care at baseline, including whether they believed their care team connected with them as individuals. The study participants were all in their mid-20s and had previously given birth.

Twenty-two women were randomly assigned to use a control app, which only allowed self-initiated communication with the practice through an established patient portal not designed specifically for mental health. Another 23 women were assigned to the same control app plus an app designed by Ginger.io for mental health self-care and symptom tracking. The study app included daily cognitive-behavioral therapy messages, other behavioral health educational messages, and prompts to record self-assessments of mood that were monitored daily by a care coordinator. The remaining 19 women were assigned to both apps and received additional prompts throughout the day to record their thoughts and mood, which were also monitored. If a patient’s depressive symptoms increased, the care coordinator alerted a physician in the practice, who then contacted the patient.

By week 8, the study app users had significantly decreased PHQ-9 scores (P = .001) and significantly decreased GAD-7 scores (P = .003). The combined study cohorts (women using the study app and those with the study app plus prompts to record mood) also self-reported significantly improved mood ratings at week 8 (P = .03). The combined study groups also reported more confidence in their ability to care for themselves, particularly in their third trimester, compared with women using only the control app (P = .002).

The difference is likely because of the ways that the study app was integrated into care, Dr. Hantsoo said. “Apps allow self-monitoring and identify your patterns over time, but they are also limited in that they aren’t often integrated into treatment or care, leaving a person hanging in distress if they enter their data, but then not having it seem to go anywhere. This app allowed patients to interact with their providers.”

Use of any app did not significantly affect how participants rated their overall care, although at least half of all study app users reported feeling more confident in their ability to assess and manage their moods and their overall health, particularly in their third trimester.

As for the physicians who participated in the study, they reported needing more time each week to respond to app-triggered patient needs. “It was a bit of a disruption, but they did report they thought it was worthwhile to do,” Dr. Hantsoo said in an interview.

Support for this study was provided by Ginger.io and by the Penn Medicine Center for Health Care Innovation. Dr. Hantsoo reported having no relevant financial

[email protected]

On Twitter @whitneymcknight

In 2015, researchers in China announced they had found for the first time a bacterial gene conferring resistance to colistin. The gene was present in samples from agricultural animals and in 1% of tested patients.1 Colistin, an antibiotic from the 1950s, is rarely prescribed; it is often considered an antibiotic of last resort.

In May 2016, the U.S. Department of Defense announced this gene, called mcr-1, had been found in E. coli isolated from the urine of a patient in Pennsylvania presenting with symptoms of a urinary tract infection.2 Subsequent surveillance also found mcr-1 E. coli in a pig.

The news has been met with grave concern by public health officials, scientists, infectious disease specialists, and countless physicians around the U.S. It has also served as a reminder that good antibiotic stewardship is a national, if not international, imperative.

“The recent discovery of a plasmid-borne colistin resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” the authors of the recent U.S. study, from the Walter Reed National Military Medical Center, wrote in their opening sentence.

In November 2015, the Society of Hospital Medicine (SHM) launched an antibiotic stewardship campaign, “Fight the Resistance,” in partnership with the Centers for Disease Control and Prevention (CDC). Hospitalists around the country have taken the lead on confronting the issue head on.

When the CDC and the White House called for action last year, “SHM jumped in with both feet,” says Eric Howell, MD, MHM, SHM’s senior physician advisor, chief of the Division of Hospital Medicine at Johns Hopkins Bayview, and professor of medicine at Johns Hopkins University in Baltimore. The “Fight the Resistance” campaign calls for the nation’s 44,000 hospitalists to commit to responsible antibiotic-prescribing practices.

“While it’s extremely alarming, leading up to this, we knew there was a crisis of antibiotic resistance,” says Megan Mack, MD, a hospitalist and clinical instructor in the University of Michigan Health System in Ann Arbor. “We know more antibiotic use is not the answer, stronger is not the answer. We need to be peeling back antibiotic use, honing when we need them, narrowing how we use them as much as possible, and keeping the duration as short as possible.”

Dr. Mack is first author of a new study in the Journal of Hospital Medicine that examines hospitalist-driven antibiotic stewardship efforts in five hospitals around the country.3

The Institute for Healthcare Improvement, with the CDC, recruited Dr. Mack and her study coauthors, hospitalists Jeff Rohde, MD, and Scott Flanders, MD, MHM, to participate.

“We were interested in the opportunity to put into place interventions in five different hospitals and to be able to share our successes and our barriers, which we did twice monthly,” Dr. Mack says.

Each hospital in the collaborative, which included teaching and non-teaching community hospitals and academic medical centers, focused on its own data and tailored its stewardship interventions to three strategies shown to be quality indicators of successful stewardship programs.

These strategies included:

• Enhanced documentation with regard to antimicrobial prescribing and use
• Improved quality and accessibility of guidelines for common infections
• Adoption of a 72-hour antibiotic timeout to reassess a patient’s antibiotic treatment plan once culture results were available

Each hospital used its own particular antibiotic stewardship practice data to educate and inform its physicians, which Dr. Mack says was important to the success of interventions because it was “concrete and realistic.”

The study found that in two hospitals, complete antibiotic documentation in patient records increased to 51% from 4% and to 65% from 8%. It also recorded 726 antibiotic timeouts, resulting in 218 antibiotic treatment adjustments or discontinuations. It also found several barriers to improved antibiotic stewardship.

“[Hospitalists] are stretched for time. We’re constantly being pulled in multiple directions,” Dr. Mack says. “We are bombarded daily with quality improvement initiatives and with constantly meeting metrics deemed to be priorities, so we tried interventions that were easily incorporated into daily workflow.”

The team learned that workflow integration was a requirement for success. For instance, Dr. Mack suggests building antibiotic prescribing into hospitalists’ electronic health records, with automatic stop dates that must be overridden by a physician. “It’s too easy to overlook it, and 10 days later, your patient is still on vancomycin.”

The experience, she says, made her fellow physicians in the collaborative realize that, despite some skepticism, good antimicrobial stewardship can be achieved without significant disruption.

“If we don’t change our practice patterns, there are not enough antibiotics in the pipeline to mitigate the effects,” of resistance, says Dr. Howell, who was not involved in the study. “We can’t stop resistance, but we can change our practice patterns so we slow the rate of resistance and give ourselves time to develop new therapies to treat infections.”

This includes behavioral changes hospitalists can easily incorporate, Dr. Howell says, which align with the strategies assessed in Dr. Mack’s study. These include rethinking the treatment time course, antibiotic timeouts, and adhering to prescribing guidelines.

Hospitalists, he says, are well-positioned to lead antibiotic stewardship efforts.

“We’re quality improvement experts … and there are not enough infectious disease physicians in the country to roll out antibiotic stewardship programs, so there is space for hospitalists,” Dr. Howell explains. “In every hospital, we are prescribing these medications, so we own the problem.” TH

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Liu YY, Wang Y, Walsh TR, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis. 2016;16(2):161-168. doi:10.1016/S1473-3099(15)00424-7.
2. McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: First report of mcr-1 in the USA. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
3. Mack MR, Rohde JM, Jacobsen D, et al. Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative [published online ahead of print on April 30, 2016]. J Hosp Med. doi:10.1002/jhm.2599.

In 2015, researchers in China announced they had found for the first time a bacterial gene conferring resistance to colistin. The gene was present in samples from agricultural animals and in 1% of tested patients.1 Colistin, an antibiotic from the 1950s, is rarely prescribed; it is often considered an antibiotic of last resort.

In May 2016, the U.S. Department of Defense announced this gene, called mcr-1, had been found in E. coli isolated from the urine of a patient in Pennsylvania presenting with symptoms of a urinary tract infection.2 Subsequent surveillance also found mcr-1 E. coli in a pig.

The news has been met with grave concern by public health officials, scientists, infectious disease specialists, and countless physicians around the U.S. It has also served as a reminder that good antibiotic stewardship is a national, if not international, imperative.

“The recent discovery of a plasmid-borne colistin resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” the authors of the recent U.S. study, from the Walter Reed National Military Medical Center, wrote in their opening sentence.

In November 2015, the Society of Hospital Medicine (SHM) launched an antibiotic stewardship campaign, “Fight the Resistance,” in partnership with the Centers for Disease Control and Prevention (CDC). Hospitalists around the country have taken the lead on confronting the issue head on.

When the CDC and the White House called for action last year, “SHM jumped in with both feet,” says Eric Howell, MD, MHM, SHM’s senior physician advisor, chief of the Division of Hospital Medicine at Johns Hopkins Bayview, and professor of medicine at Johns Hopkins University in Baltimore. The “Fight the Resistance” campaign calls for the nation’s 44,000 hospitalists to commit to responsible antibiotic-prescribing practices.

“While it’s extremely alarming, leading up to this, we knew there was a crisis of antibiotic resistance,” says Megan Mack, MD, a hospitalist and clinical instructor in the University of Michigan Health System in Ann Arbor. “We know more antibiotic use is not the answer, stronger is not the answer. We need to be peeling back antibiotic use, honing when we need them, narrowing how we use them as much as possible, and keeping the duration as short as possible.”

Dr. Mack is first author of a new study in the Journal of Hospital Medicine that examines hospitalist-driven antibiotic stewardship efforts in five hospitals around the country.3

The Institute for Healthcare Improvement, with the CDC, recruited Dr. Mack and her study coauthors, hospitalists Jeff Rohde, MD, and Scott Flanders, MD, MHM, to participate.

“We were interested in the opportunity to put into place interventions in five different hospitals and to be able to share our successes and our barriers, which we did twice monthly,” Dr. Mack says.

Each hospital in the collaborative, which included teaching and non-teaching community hospitals and academic medical centers, focused on its own data and tailored its stewardship interventions to three strategies shown to be quality indicators of successful stewardship programs.

These strategies included:

• Enhanced documentation with regard to antimicrobial prescribing and use
• Improved quality and accessibility of guidelines for common infections
• Adoption of a 72-hour antibiotic timeout to reassess a patient’s antibiotic treatment plan once culture results were available

Each hospital used its own particular antibiotic stewardship practice data to educate and inform its physicians, which Dr. Mack says was important to the success of interventions because it was “concrete and realistic.”

The study found that in two hospitals, complete antibiotic documentation in patient records increased to 51% from 4% and to 65% from 8%. It also recorded 726 antibiotic timeouts, resulting in 218 antibiotic treatment adjustments or discontinuations. It also found several barriers to improved antibiotic stewardship.

“[Hospitalists] are stretched for time. We’re constantly being pulled in multiple directions,” Dr. Mack says. “We are bombarded daily with quality improvement initiatives and with constantly meeting metrics deemed to be priorities, so we tried interventions that were easily incorporated into daily workflow.”

The team learned that workflow integration was a requirement for success. For instance, Dr. Mack suggests building antibiotic prescribing into hospitalists’ electronic health records, with automatic stop dates that must be overridden by a physician. “It’s too easy to overlook it, and 10 days later, your patient is still on vancomycin.”

The experience, she says, made her fellow physicians in the collaborative realize that, despite some skepticism, good antimicrobial stewardship can be achieved without significant disruption.

“If we don’t change our practice patterns, there are not enough antibiotics in the pipeline to mitigate the effects,” of resistance, says Dr. Howell, who was not involved in the study. “We can’t stop resistance, but we can change our practice patterns so we slow the rate of resistance and give ourselves time to develop new therapies to treat infections.”

This includes behavioral changes hospitalists can easily incorporate, Dr. Howell says, which align with the strategies assessed in Dr. Mack’s study. These include rethinking the treatment time course, antibiotic timeouts, and adhering to prescribing guidelines.

Hospitalists, he says, are well-positioned to lead antibiotic stewardship efforts.

“We’re quality improvement experts … and there are not enough infectious disease physicians in the country to roll out antibiotic stewardship programs, so there is space for hospitalists,” Dr. Howell explains. “In every hospital, we are prescribing these medications, so we own the problem.” TH

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Liu YY, Wang Y, Walsh TR, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis. 2016;16(2):161-168. doi:10.1016/S1473-3099(15)00424-7.
2. McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: First report of mcr-1 in the USA. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
3. Mack MR, Rohde JM, Jacobsen D, et al. Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative [published online ahead of print on April 30, 2016]. J Hosp Med. doi:10.1002/jhm.2599.

In 2015, researchers in China announced they had found for the first time a bacterial gene conferring resistance to colistin. The gene was present in samples from agricultural animals and in 1% of tested patients.1 Colistin, an antibiotic from the 1950s, is rarely prescribed; it is often considered an antibiotic of last resort.

In May 2016, the U.S. Department of Defense announced this gene, called mcr-1, had been found in E. coli isolated from the urine of a patient in Pennsylvania presenting with symptoms of a urinary tract infection.2 Subsequent surveillance also found mcr-1 E. coli in a pig.

The news has been met with grave concern by public health officials, scientists, infectious disease specialists, and countless physicians around the U.S. It has also served as a reminder that good antibiotic stewardship is a national, if not international, imperative.

“The recent discovery of a plasmid-borne colistin resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” the authors of the recent U.S. study, from the Walter Reed National Military Medical Center, wrote in their opening sentence.

In November 2015, the Society of Hospital Medicine (SHM) launched an antibiotic stewardship campaign, “Fight the Resistance,” in partnership with the Centers for Disease Control and Prevention (CDC). Hospitalists around the country have taken the lead on confronting the issue head on.

When the CDC and the White House called for action last year, “SHM jumped in with both feet,” says Eric Howell, MD, MHM, SHM’s senior physician advisor, chief of the Division of Hospital Medicine at Johns Hopkins Bayview, and professor of medicine at Johns Hopkins University in Baltimore. The “Fight the Resistance” campaign calls for the nation’s 44,000 hospitalists to commit to responsible antibiotic-prescribing practices.

“While it’s extremely alarming, leading up to this, we knew there was a crisis of antibiotic resistance,” says Megan Mack, MD, a hospitalist and clinical instructor in the University of Michigan Health System in Ann Arbor. “We know more antibiotic use is not the answer, stronger is not the answer. We need to be peeling back antibiotic use, honing when we need them, narrowing how we use them as much as possible, and keeping the duration as short as possible.”

Dr. Mack is first author of a new study in the Journal of Hospital Medicine that examines hospitalist-driven antibiotic stewardship efforts in five hospitals around the country.3

The Institute for Healthcare Improvement, with the CDC, recruited Dr. Mack and her study coauthors, hospitalists Jeff Rohde, MD, and Scott Flanders, MD, MHM, to participate.

“We were interested in the opportunity to put into place interventions in five different hospitals and to be able to share our successes and our barriers, which we did twice monthly,” Dr. Mack says.

Each hospital in the collaborative, which included teaching and non-teaching community hospitals and academic medical centers, focused on its own data and tailored its stewardship interventions to three strategies shown to be quality indicators of successful stewardship programs.

These strategies included:

• Enhanced documentation with regard to antimicrobial prescribing and use
• Improved quality and accessibility of guidelines for common infections
• Adoption of a 72-hour antibiotic timeout to reassess a patient’s antibiotic treatment plan once culture results were available

Each hospital used its own particular antibiotic stewardship practice data to educate and inform its physicians, which Dr. Mack says was important to the success of interventions because it was “concrete and realistic.”

The study found that in two hospitals, complete antibiotic documentation in patient records increased to 51% from 4% and to 65% from 8%. It also recorded 726 antibiotic timeouts, resulting in 218 antibiotic treatment adjustments or discontinuations. It also found several barriers to improved antibiotic stewardship.

“[Hospitalists] are stretched for time. We’re constantly being pulled in multiple directions,” Dr. Mack says. “We are bombarded daily with quality improvement initiatives and with constantly meeting metrics deemed to be priorities, so we tried interventions that were easily incorporated into daily workflow.”

The team learned that workflow integration was a requirement for success. For instance, Dr. Mack suggests building antibiotic prescribing into hospitalists’ electronic health records, with automatic stop dates that must be overridden by a physician. “It’s too easy to overlook it, and 10 days later, your patient is still on vancomycin.”

The experience, she says, made her fellow physicians in the collaborative realize that, despite some skepticism, good antimicrobial stewardship can be achieved without significant disruption.

“If we don’t change our practice patterns, there are not enough antibiotics in the pipeline to mitigate the effects,” of resistance, says Dr. Howell, who was not involved in the study. “We can’t stop resistance, but we can change our practice patterns so we slow the rate of resistance and give ourselves time to develop new therapies to treat infections.”

This includes behavioral changes hospitalists can easily incorporate, Dr. Howell says, which align with the strategies assessed in Dr. Mack’s study. These include rethinking the treatment time course, antibiotic timeouts, and adhering to prescribing guidelines.

Hospitalists, he says, are well-positioned to lead antibiotic stewardship efforts.

“We’re quality improvement experts … and there are not enough infectious disease physicians in the country to roll out antibiotic stewardship programs, so there is space for hospitalists,” Dr. Howell explains. “In every hospital, we are prescribing these medications, so we own the problem.” TH

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Liu YY, Wang Y, Walsh TR, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis. 2016;16(2):161-168. doi:10.1016/S1473-3099(15)00424-7.
2. McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: First report of mcr-1 in the USA. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
3. Mack MR, Rohde JM, Jacobsen D, et al. Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative [published online ahead of print on April 30, 2016]. J Hosp Med. doi:10.1002/jhm.2599.

Rhesus macaque

Photo by Einar Fredriksen

Three types of investigational vaccines can protect monkeys from Zika virus infection, according to research published in Science.

Investigators found that an inactivated virus vaccine, a DNA-based vaccine, and an adenovirus vector-based vaccine induced immune responses and protected against infection in rhesus macaques challenged with the Zika virus.

In addition, there were no adverse events observed with any of the vaccines.

The investigators first tested the inactivated Zika virus vaccine in 16 rhesus macaques. Eight animals received the experimental vaccine, and 8 received a placebo injection.

Within 2 weeks of the initial injection, all vaccinated animals developed neutralizing antibodies as well as antibodies specific to the viral envelope protein, a key vaccine target on the Zika virus. A second dose was given 4 weeks later, which substantially boosted antibody levels.

The monkeys were then challenged with Zika virus. Following exposure, the vaccinated animals had no detectable virus and showed no other evidence of infection, while the group that received the placebo injection developed high levels of virus replication in the blood and other tissues for 6 to 7 days.

In another experiment, the investigators administered 2 doses of a DNA vaccine, 1 dose of an adenovirus vector vaccine, or a placebo injection to 3 groups of 4 monkeys each. The group that received the DNA vaccine received a booster shot 4 weeks after the initial vaccination.

Minimal levels of antibodies were detected after the first injection of the DNA vaccine. However, after the second injection, investigators detected Zika-specific neutralizing antibodies in the animals.

The adenovirus vector-based vaccine induced Zika-specific neutralizing antibodies 2 weeks after the single injection.

The animals were exposed to Zika virus 4 weeks after the final vaccination. Both the DNA vaccine and the adenovirus vector vaccine provided complete protection against infection.

The investigators said these encouraging findings suggest a path forward for clinical development of Zika vaccines in humans.

Rhesus macaque

Photo by Einar Fredriksen

Three types of investigational vaccines can protect monkeys from Zika virus infection, according to research published in Science.

Investigators found that an inactivated virus vaccine, a DNA-based vaccine, and an adenovirus vector-based vaccine induced immune responses and protected against infection in rhesus macaques challenged with the Zika virus.

In addition, there were no adverse events observed with any of the vaccines.

The investigators first tested the inactivated Zika virus vaccine in 16 rhesus macaques. Eight animals received the experimental vaccine, and 8 received a placebo injection.

Within 2 weeks of the initial injection, all vaccinated animals developed neutralizing antibodies as well as antibodies specific to the viral envelope protein, a key vaccine target on the Zika virus. A second dose was given 4 weeks later, which substantially boosted antibody levels.

The monkeys were then challenged with Zika virus. Following exposure, the vaccinated animals had no detectable virus and showed no other evidence of infection, while the group that received the placebo injection developed high levels of virus replication in the blood and other tissues for 6 to 7 days.

In another experiment, the investigators administered 2 doses of a DNA vaccine, 1 dose of an adenovirus vector vaccine, or a placebo injection to 3 groups of 4 monkeys each. The group that received the DNA vaccine received a booster shot 4 weeks after the initial vaccination.

Minimal levels of antibodies were detected after the first injection of the DNA vaccine. However, after the second injection, investigators detected Zika-specific neutralizing antibodies in the animals.

The adenovirus vector-based vaccine induced Zika-specific neutralizing antibodies 2 weeks after the single injection.

The animals were exposed to Zika virus 4 weeks after the final vaccination. Both the DNA vaccine and the adenovirus vector vaccine provided complete protection against infection.

The investigators said these encouraging findings suggest a path forward for clinical development of Zika vaccines in humans.

Rhesus macaque

Photo by Einar Fredriksen

Three types of investigational vaccines can protect monkeys from Zika virus infection, according to research published in Science.

Investigators found that an inactivated virus vaccine, a DNA-based vaccine, and an adenovirus vector-based vaccine induced immune responses and protected against infection in rhesus macaques challenged with the Zika virus.

In addition, there were no adverse events observed with any of the vaccines.

The investigators first tested the inactivated Zika virus vaccine in 16 rhesus macaques. Eight animals received the experimental vaccine, and 8 received a placebo injection.

Within 2 weeks of the initial injection, all vaccinated animals developed neutralizing antibodies as well as antibodies specific to the viral envelope protein, a key vaccine target on the Zika virus. A second dose was given 4 weeks later, which substantially boosted antibody levels.

The monkeys were then challenged with Zika virus. Following exposure, the vaccinated animals had no detectable virus and showed no other evidence of infection, while the group that received the placebo injection developed high levels of virus replication in the blood and other tissues for 6 to 7 days.

In another experiment, the investigators administered 2 doses of a DNA vaccine, 1 dose of an adenovirus vector vaccine, or a placebo injection to 3 groups of 4 monkeys each. The group that received the DNA vaccine received a booster shot 4 weeks after the initial vaccination.

Minimal levels of antibodies were detected after the first injection of the DNA vaccine. However, after the second injection, investigators detected Zika-specific neutralizing antibodies in the animals.

The adenovirus vector-based vaccine induced Zika-specific neutralizing antibodies 2 weeks after the single injection.

The animals were exposed to Zika virus 4 weeks after the final vaccination. Both the DNA vaccine and the adenovirus vector vaccine provided complete protection against infection.

The investigators said these encouraging findings suggest a path forward for clinical development of Zika vaccines in humans.

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

The potential feasibility that in vivo human intestine can be developed from pluripotent stem cells offers hope to short-bowel patients chronically dependent on parenteral nutrition. Perhaps greater than this promise is the opportunity that now exists to develop models to test human-specific intestinal diseases that are not well characterized by human in vitro culture systems or current animal models. Translational examples of this include studies to examine normal and diseased conditions involving intestinal development and common human gastrointestinal infectious diseases.

In contrast to using primary cell cultures that require human intestinal samples, Spence et al (Nature. 2011 Feb;470:105-9) described an in vitro approach for generating human intestinal tissue from pluripotent stem cells termed human intestinal organoids (HIOs). Although these in vitro HIOs have some basic intestinal functionality, this model is insufficient for investigating the broad physiologic mechanisms associated with human intestinal diseases. Taking advantage of the fact that HIOs contain both epithelium and supporting mesenchyme required for engraftment that does not exist in enteroids derived from human crypt biopsies, we recently developed an in vivo transplant model (Nature Med. 2014;20:1310-4). Within 6-8 weeks after transplantation, these structures mature and grow 100-fold larger in volume.

Histologic studies show that engrafted tissue resembles native human intestine with crypt-villus architecture, underlying laminated structures, and smooth muscle layers. Further characterization revealed proliferative cells located in the base of crypts that also expressed stem cell markers. The ability to generate in vitro enteroids from these crypts demonstrates the existence of an intestinal stem cell pool. Functionally engrafted HIOs express an active brush border, barrier function, and peptide uptake. HIOs respond to humeral physiologic factors, as we demonstrated that morphometric adaptive changes with HIOs occur following intestinal resection in the host mouse.

To completely develop a functional human intestine it must contain an enteric nervous system (ENS), have an immune component, and be exposed to luminal nutrients and microbiota. Ongoing studies have developed methods to incorporate a functional ENS derived from the same pluripotent stem cell lines used to develop HIOs. Models to transplant HIOs into the mesentery of the murine bowel have allowed the development of surgical models that expose the HIOs to both luminal nutrition and microbiota. New models involving bone marrow transplantation should provide a human immune system.

Finally, the ability to generate induced pluripotent stem cells (iPS cells) from individual patients offers the unique advantage to study patient-specific factors contributing to human intestinal disease. We believe this model will provide an exciting new opportunity to understand many complex human conditions and test new therapies. Ultimately, the ability to grow functional patient-specific intestinal tissue offers the future reality of tissue replacement without immunosuppression for patients with intestinal failure.

Dr. Helmrath is professor of surgery, director of surgical research and the intestinal rehabilitation program, and the Richard Azizkhan Chair in Pediatric Surgery at Cincinnati Children’s Hospital Medical Center. He made these remarks in a Presidential Plenary session at the 2016 Digestive Disease Week.

The potential feasibility that in vivo human intestine can be developed from pluripotent stem cells offers hope to short-bowel patients chronically dependent on parenteral nutrition. Perhaps greater than this promise is the opportunity that now exists to develop models to test human-specific intestinal diseases that are not well characterized by human in vitro culture systems or current animal models. Translational examples of this include studies to examine normal and diseased conditions involving intestinal development and common human gastrointestinal infectious diseases.

In contrast to using primary cell cultures that require human intestinal samples, Spence et al (Nature. 2011 Feb;470:105-9) described an in vitro approach for generating human intestinal tissue from pluripotent stem cells termed human intestinal organoids (HIOs). Although these in vitro HIOs have some basic intestinal functionality, this model is insufficient for investigating the broad physiologic mechanisms associated with human intestinal diseases. Taking advantage of the fact that HIOs contain both epithelium and supporting mesenchyme required for engraftment that does not exist in enteroids derived from human crypt biopsies, we recently developed an in vivo transplant model (Nature Med. 2014;20:1310-4). Within 6-8 weeks after transplantation, these structures mature and grow 100-fold larger in volume.

Histologic studies show that engrafted tissue resembles native human intestine with crypt-villus architecture, underlying laminated structures, and smooth muscle layers. Further characterization revealed proliferative cells located in the base of crypts that also expressed stem cell markers. The ability to generate in vitro enteroids from these crypts demonstrates the existence of an intestinal stem cell pool. Functionally engrafted HIOs express an active brush border, barrier function, and peptide uptake. HIOs respond to humeral physiologic factors, as we demonstrated that morphometric adaptive changes with HIOs occur following intestinal resection in the host mouse.

To completely develop a functional human intestine it must contain an enteric nervous system (ENS), have an immune component, and be exposed to luminal nutrients and microbiota. Ongoing studies have developed methods to incorporate a functional ENS derived from the same pluripotent stem cell lines used to develop HIOs. Models to transplant HIOs into the mesentery of the murine bowel have allowed the development of surgical models that expose the HIOs to both luminal nutrition and microbiota. New models involving bone marrow transplantation should provide a human immune system.

Finally, the ability to generate induced pluripotent stem cells (iPS cells) from individual patients offers the unique advantage to study patient-specific factors contributing to human intestinal disease. We believe this model will provide an exciting new opportunity to understand many complex human conditions and test new therapies. Ultimately, the ability to grow functional patient-specific intestinal tissue offers the future reality of tissue replacement without immunosuppression for patients with intestinal failure.

Dr. Helmrath is professor of surgery, director of surgical research and the intestinal rehabilitation program, and the Richard Azizkhan Chair in Pediatric Surgery at Cincinnati Children’s Hospital Medical Center. He made these remarks in a Presidential Plenary session at the 2016 Digestive Disease Week.

The potential feasibility that in vivo human intestine can be developed from pluripotent stem cells offers hope to short-bowel patients chronically dependent on parenteral nutrition. Perhaps greater than this promise is the opportunity that now exists to develop models to test human-specific intestinal diseases that are not well characterized by human in vitro culture systems or current animal models. Translational examples of this include studies to examine normal and diseased conditions involving intestinal development and common human gastrointestinal infectious diseases.

In contrast to using primary cell cultures that require human intestinal samples, Spence et al (Nature. 2011 Feb;470:105-9) described an in vitro approach for generating human intestinal tissue from pluripotent stem cells termed human intestinal organoids (HIOs). Although these in vitro HIOs have some basic intestinal functionality, this model is insufficient for investigating the broad physiologic mechanisms associated with human intestinal diseases. Taking advantage of the fact that HIOs contain both epithelium and supporting mesenchyme required for engraftment that does not exist in enteroids derived from human crypt biopsies, we recently developed an in vivo transplant model (Nature Med. 2014;20:1310-4). Within 6-8 weeks after transplantation, these structures mature and grow 100-fold larger in volume.

Histologic studies show that engrafted tissue resembles native human intestine with crypt-villus architecture, underlying laminated structures, and smooth muscle layers. Further characterization revealed proliferative cells located in the base of crypts that also expressed stem cell markers. The ability to generate in vitro enteroids from these crypts demonstrates the existence of an intestinal stem cell pool. Functionally engrafted HIOs express an active brush border, barrier function, and peptide uptake. HIOs respond to humeral physiologic factors, as we demonstrated that morphometric adaptive changes with HIOs occur following intestinal resection in the host mouse.

To completely develop a functional human intestine it must contain an enteric nervous system (ENS), have an immune component, and be exposed to luminal nutrients and microbiota. Ongoing studies have developed methods to incorporate a functional ENS derived from the same pluripotent stem cell lines used to develop HIOs. Models to transplant HIOs into the mesentery of the murine bowel have allowed the development of surgical models that expose the HIOs to both luminal nutrition and microbiota. New models involving bone marrow transplantation should provide a human immune system.

Finally, the ability to generate induced pluripotent stem cells (iPS cells) from individual patients offers the unique advantage to study patient-specific factors contributing to human intestinal disease. We believe this model will provide an exciting new opportunity to understand many complex human conditions and test new therapies. Ultimately, the ability to grow functional patient-specific intestinal tissue offers the future reality of tissue replacement without immunosuppression for patients with intestinal failure.

Dr. Helmrath is professor of surgery, director of surgical research and the intestinal rehabilitation program, and the Richard Azizkhan Chair in Pediatric Surgery at Cincinnati Children’s Hospital Medical Center. He made these remarks in a Presidential Plenary session at the 2016 Digestive Disease Week.

[WpProQuiz 12]

[WpProQuiz 12]

[WpProQuiz 12]

As Oliver Wendell Holmes stated “The great thing in this world is not so much where we stand, as in what direction we are moving.” Where is AGA moving? AGA represents highest values in the field of gastroenterology and hepatology, and a focus on the care of patients. We need to demonstrate value, maintain certification, discover new treatments, and improve patient care.

The era of reimbursement based on value, quality care is here: AGA is the leading GI society helping you provide quality care and demonstrating to payors that you’re doing so. Medicare is in the midst of shifting to a value and quality-driven physician reimbursement system. AGA is here to help you successfully make the transition. You must learn about the new system and start preparations — decisions made this year will impact your payment in the future.

AGA Institute

An important milestone in the transition to the new system was the recent release of proposed rules related to MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which replaces the flawed Sustainable Growth Rate formula. CHIP is the Children’s Health Insurance Program. Under MACRA, physicians will have a choice — to be paid via the Merit-based Incentive Payment System (MIPS) or Alternate Payment Models. Most GIs will participate in MIPS. The most important thing you can do now is report on quality. AGA has quality measures and our Digestive Health Recognition Program is a qualified clinical data registry.

AGA must lead our profession to increase the value of the care we provide. High value, cost conscious care refers to care that aims to assess the benefits, harms, and costs of interventions and, consequently, to provide care that adds value. Guidance to enhance value of care based on cognitive skills and appropriate use of biomarkers and imaging, and Clinical Practice Updates are complementary to AGA Guidelines.

Gastroenterologists must maintain certification in a system we don’t support. Maintenance of certification is a major issue in medicine. AGA is pushing for change, favoring continuous professional development for gastroenterologists who self-categorize their practice expertise, and participate in assessments having a built‐in remediation experience with access to resources during the testing. Having developed consensus principles authored by AGA, AASLD, ACG, ASGE, ANMS, and NASPGHAN, we have achieved a stop to the 10-year high stakes exam. We have developed an alliance with other internal medicine societies to attempt to co-create MOC of the future.

One area that is a constant in medicine is the need for research. AGA is committed to research and supporting young investigators so that the future is bright for our patients. Every year our foundation gives $2.5 million in research grants and we continue to advocate for increased NIH funding.

Patients need us to better understand digestive disease and discover new treatments. We have extensive patient education tools on the AGA website. AGA supports device and drug makers working to bring new treatments to patients, with dedicated centers: Center for GI Technology, Center for Diagnostics and Therapeutics and the Center for the Microbiome, which recently received a prestigious grant from the NIH to support microbiome research.

Patients also want evidence-based care and want to participate in choices. We are developing new patient education materials for use AT THE POINT OF CARE, and for inclusion in EHRs to provide automated qualified clinical data registry (QCDR) reporting by gastroenterologists. At present, there are still challenges of interoperability in the electronic environment.

Obesity is a chronic disease concomitant with many GI diseases and reflects an opportunity for obesity management by gastroenterologists through a forthcoming white paper, entitled Practice Guide on Obesity and Weight Management Education, and Resources.

Finally, we recognized Dr. Martin Brotman for innumerable contributions over almost 3 decades as a leader of the AGA, and Dr. Richard Boland as the Julius Friedenwald Medal awardee.

As Oliver Wendell Holmes stated “The great thing in this world is not so much where we stand, as in what direction we are moving.” Where is AGA moving? AGA represents highest values in the field of gastroenterology and hepatology, and a focus on the care of patients. We need to demonstrate value, maintain certification, discover new treatments, and improve patient care.

The era of reimbursement based on value, quality care is here: AGA is the leading GI society helping you provide quality care and demonstrating to payors that you’re doing so. Medicare is in the midst of shifting to a value and quality-driven physician reimbursement system. AGA is here to help you successfully make the transition. You must learn about the new system and start preparations — decisions made this year will impact your payment in the future.

AGA Institute

An important milestone in the transition to the new system was the recent release of proposed rules related to MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which replaces the flawed Sustainable Growth Rate formula. CHIP is the Children’s Health Insurance Program. Under MACRA, physicians will have a choice — to be paid via the Merit-based Incentive Payment System (MIPS) or Alternate Payment Models. Most GIs will participate in MIPS. The most important thing you can do now is report on quality. AGA has quality measures and our Digestive Health Recognition Program is a qualified clinical data registry.

AGA must lead our profession to increase the value of the care we provide. High value, cost conscious care refers to care that aims to assess the benefits, harms, and costs of interventions and, consequently, to provide care that adds value. Guidance to enhance value of care based on cognitive skills and appropriate use of biomarkers and imaging, and Clinical Practice Updates are complementary to AGA Guidelines.

Gastroenterologists must maintain certification in a system we don’t support. Maintenance of certification is a major issue in medicine. AGA is pushing for change, favoring continuous professional development for gastroenterologists who self-categorize their practice expertise, and participate in assessments having a built‐in remediation experience with access to resources during the testing. Having developed consensus principles authored by AGA, AASLD, ACG, ASGE, ANMS, and NASPGHAN, we have achieved a stop to the 10-year high stakes exam. We have developed an alliance with other internal medicine societies to attempt to co-create MOC of the future.

One area that is a constant in medicine is the need for research. AGA is committed to research and supporting young investigators so that the future is bright for our patients. Every year our foundation gives $2.5 million in research grants and we continue to advocate for increased NIH funding.

Patients need us to better understand digestive disease and discover new treatments. We have extensive patient education tools on the AGA website. AGA supports device and drug makers working to bring new treatments to patients, with dedicated centers: Center for GI Technology, Center for Diagnostics and Therapeutics and the Center for the Microbiome, which recently received a prestigious grant from the NIH to support microbiome research.

Patients also want evidence-based care and want to participate in choices. We are developing new patient education materials for use AT THE POINT OF CARE, and for inclusion in EHRs to provide automated qualified clinical data registry (QCDR) reporting by gastroenterologists. At present, there are still challenges of interoperability in the electronic environment.

Obesity is a chronic disease concomitant with many GI diseases and reflects an opportunity for obesity management by gastroenterologists through a forthcoming white paper, entitled Practice Guide on Obesity and Weight Management Education, and Resources.

Finally, we recognized Dr. Martin Brotman for innumerable contributions over almost 3 decades as a leader of the AGA, and Dr. Richard Boland as the Julius Friedenwald Medal awardee.

As Oliver Wendell Holmes stated “The great thing in this world is not so much where we stand, as in what direction we are moving.” Where is AGA moving? AGA represents highest values in the field of gastroenterology and hepatology, and a focus on the care of patients. We need to demonstrate value, maintain certification, discover new treatments, and improve patient care.

The era of reimbursement based on value, quality care is here: AGA is the leading GI society helping you provide quality care and demonstrating to payors that you’re doing so. Medicare is in the midst of shifting to a value and quality-driven physician reimbursement system. AGA is here to help you successfully make the transition. You must learn about the new system and start preparations — decisions made this year will impact your payment in the future.

AGA Institute

An important milestone in the transition to the new system was the recent release of proposed rules related to MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which replaces the flawed Sustainable Growth Rate formula. CHIP is the Children’s Health Insurance Program. Under MACRA, physicians will have a choice — to be paid via the Merit-based Incentive Payment System (MIPS) or Alternate Payment Models. Most GIs will participate in MIPS. The most important thing you can do now is report on quality. AGA has quality measures and our Digestive Health Recognition Program is a qualified clinical data registry.

AGA must lead our profession to increase the value of the care we provide. High value, cost conscious care refers to care that aims to assess the benefits, harms, and costs of interventions and, consequently, to provide care that adds value. Guidance to enhance value of care based on cognitive skills and appropriate use of biomarkers and imaging, and Clinical Practice Updates are complementary to AGA Guidelines.

Gastroenterologists must maintain certification in a system we don’t support. Maintenance of certification is a major issue in medicine. AGA is pushing for change, favoring continuous professional development for gastroenterologists who self-categorize their practice expertise, and participate in assessments having a built‐in remediation experience with access to resources during the testing. Having developed consensus principles authored by AGA, AASLD, ACG, ASGE, ANMS, and NASPGHAN, we have achieved a stop to the 10-year high stakes exam. We have developed an alliance with other internal medicine societies to attempt to co-create MOC of the future.

One area that is a constant in medicine is the need for research. AGA is committed to research and supporting young investigators so that the future is bright for our patients. Every year our foundation gives $2.5 million in research grants and we continue to advocate for increased NIH funding.

Patients need us to better understand digestive disease and discover new treatments. We have extensive patient education tools on the AGA website. AGA supports device and drug makers working to bring new treatments to patients, with dedicated centers: Center for GI Technology, Center for Diagnostics and Therapeutics and the Center for the Microbiome, which recently received a prestigious grant from the NIH to support microbiome research.

Patients also want evidence-based care and want to participate in choices. We are developing new patient education materials for use AT THE POINT OF CARE, and for inclusion in EHRs to provide automated qualified clinical data registry (QCDR) reporting by gastroenterologists. At present, there are still challenges of interoperability in the electronic environment.

Obesity is a chronic disease concomitant with many GI diseases and reflects an opportunity for obesity management by gastroenterologists through a forthcoming white paper, entitled Practice Guide on Obesity and Weight Management Education, and Resources.

Finally, we recognized Dr. Martin Brotman for innumerable contributions over almost 3 decades as a leader of the AGA, and Dr. Richard Boland as the Julius Friedenwald Medal awardee.

The total number of pregnant women with evidence of Zika virus infection reported in the U.S. territories surpassed that of the 50 states and the District of Columbia during the week ending July 28, 2016, according to the Centers for Disease Control and Prevention.

There were 71 new cases of Zika in pregnant women reported in U.S. territories that week, bringing the total for the year to 493. The states and D.C. reported 46 new cases, for a total of 479 for the year, which puts the United States as a whole at 972 cases of confirmed Zika virus infection in pregnant women for 2016, the CDC reported Aug. 4.

Among the territories, the overwhelming majority of Zika cases are in Puerto Rico, which has reported 5,482 cases so far, compared with 44 in American Samoa and 22 in the U.S. Virgin Islands. In all, there have been 1,825 cases reported in the states and D.C., the CDC reported.

The territories, so far, have mostly avoided Zika-related pregnancy losses and birth defects, with only one case of pregnancy loss and no infants born with birth defects in 2016. Two more cases of infants born with birth defects were reported, however, in the states and D.C. for the week ending July 28, bringing the state/D.C. total to 15 for the year, but no new pregnancy losses with Zika-related birth defects were added to the six reported so far, the CDC announced.

“These outcomes occurred in pregnancies with laboratory evidence of Zika virus infection,” the CDC noted, and it is not known “whether they were caused by Zika virus infection or other factors.”

The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.

Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.

[email protected]

The total number of pregnant women with evidence of Zika virus infection reported in the U.S. territories surpassed that of the 50 states and the District of Columbia during the week ending July 28, 2016, according to the Centers for Disease Control and Prevention.

There were 71 new cases of Zika in pregnant women reported in U.S. territories that week, bringing the total for the year to 493. The states and D.C. reported 46 new cases, for a total of 479 for the year, which puts the United States as a whole at 972 cases of confirmed Zika virus infection in pregnant women for 2016, the CDC reported Aug. 4.

Among the territories, the overwhelming majority of Zika cases are in Puerto Rico, which has reported 5,482 cases so far, compared with 44 in American Samoa and 22 in the U.S. Virgin Islands. In all, there have been 1,825 cases reported in the states and D.C., the CDC reported.

The territories, so far, have mostly avoided Zika-related pregnancy losses and birth defects, with only one case of pregnancy loss and no infants born with birth defects in 2016. Two more cases of infants born with birth defects were reported, however, in the states and D.C. for the week ending July 28, bringing the state/D.C. total to 15 for the year, but no new pregnancy losses with Zika-related birth defects were added to the six reported so far, the CDC announced.

“These outcomes occurred in pregnancies with laboratory evidence of Zika virus infection,” the CDC noted, and it is not known “whether they were caused by Zika virus infection or other factors.”

The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.

Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.

[email protected]

The total number of pregnant women with evidence of Zika virus infection reported in the U.S. territories surpassed that of the 50 states and the District of Columbia during the week ending July 28, 2016, according to the Centers for Disease Control and Prevention.

There were 71 new cases of Zika in pregnant women reported in U.S. territories that week, bringing the total for the year to 493. The states and D.C. reported 46 new cases, for a total of 479 for the year, which puts the United States as a whole at 972 cases of confirmed Zika virus infection in pregnant women for 2016, the CDC reported Aug. 4.

Among the territories, the overwhelming majority of Zika cases are in Puerto Rico, which has reported 5,482 cases so far, compared with 44 in American Samoa and 22 in the U.S. Virgin Islands. In all, there have been 1,825 cases reported in the states and D.C., the CDC reported.

The territories, so far, have mostly avoided Zika-related pregnancy losses and birth defects, with only one case of pregnancy loss and no infants born with birth defects in 2016. Two more cases of infants born with birth defects were reported, however, in the states and D.C. for the week ending July 28, bringing the state/D.C. total to 15 for the year, but no new pregnancy losses with Zika-related birth defects were added to the six reported so far, the CDC announced.

“These outcomes occurred in pregnancies with laboratory evidence of Zika virus infection,” the CDC noted, and it is not known “whether they were caused by Zika virus infection or other factors.”

The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.

Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.

[email protected]

Why is your geriatric patient whose life seemed fulfilling before retirement now talking about not feeling “right”? “Am I depressed, or is this normal,” your patient wants to know. What should be your reply, and what interventions can you take to help this patient in the context of a 15-minute appointment?

In this video, part of the Mental Health Consult series of roundtable discussions, our panel members discuss their recommendations for work-up and next steps for managing a 65-year-old recently retired man with a history of prostate cancer but no psychiatric disorders. He has some mild depressive symptoms, and he brings up suicide during the office visit.

Join our panel of experts from George Washington University, Washington, including Katalin Roth, MD, director of geriatrics and palliative medicine; April Barbour, MD, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to differentiate between the distress often inherent in life passages and mental illness, and how practice models drive treatment decisions and reimbursement.

[email protected]

On Twitter @whitneymcknight

Why is your geriatric patient whose life seemed fulfilling before retirement now talking about not feeling “right”? “Am I depressed, or is this normal,” your patient wants to know. What should be your reply, and what interventions can you take to help this patient in the context of a 15-minute appointment?

In this video, part of the Mental Health Consult series of roundtable discussions, our panel members discuss their recommendations for work-up and next steps for managing a 65-year-old recently retired man with a history of prostate cancer but no psychiatric disorders. He has some mild depressive symptoms, and he brings up suicide during the office visit.

Join our panel of experts from George Washington University, Washington, including Katalin Roth, MD, director of geriatrics and palliative medicine; April Barbour, MD, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to differentiate between the distress often inherent in life passages and mental illness, and how practice models drive treatment decisions and reimbursement.

[email protected]

On Twitter @whitneymcknight

Why is your geriatric patient whose life seemed fulfilling before retirement now talking about not feeling “right”? “Am I depressed, or is this normal,” your patient wants to know. What should be your reply, and what interventions can you take to help this patient in the context of a 15-minute appointment?

In this video, part of the Mental Health Consult series of roundtable discussions, our panel members discuss their recommendations for work-up and next steps for managing a 65-year-old recently retired man with a history of prostate cancer but no psychiatric disorders. He has some mild depressive symptoms, and he brings up suicide during the office visit.

Join our panel of experts from George Washington University, Washington, including Katalin Roth, MD, director of geriatrics and palliative medicine; April Barbour, MD, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to differentiate between the distress often inherent in life passages and mental illness, and how practice models drive treatment decisions and reimbursement.

[email protected]

On Twitter @whitneymcknight