WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

In an attempt to protect patients with epilepsy from harm, clinicians and relatives sometimes take an overcautious view and advise them to avoid sports and exercise. A recent consensus paper from the International League Against Epilepsy (ILAE) Task Force on Sports and Epilepsy provides a more objective evaluation of the benefits and risks of exercise in this patient population, offering suggestions on issuing medical fitness certificates in various sports. The consensus paper divides sports into three categories. In group 1, the paper discusses activities that are not associated with any significant risk; category 2 includes sports that incur significant risk to persons with epilepsy but that do not pose a risk to bystanders, while the third group includes major risk factors for both patients and observers. Among the factors that ILAE takes into account when making its recommendations: the type of sport, the likelihood of a seizure occurring during participation, the type and severity of the seizures, and the "usual timing of seizure occurrence."

Capovilla G, Kaufman KR, Perucca E, Moshé SL, Arida RM. Epilepsy, seizures, physical exercise, and sports: A report from the ILAE Task Force on Sports and Epilepsy. Epilepsia. 2016;57(1):6-12.

In an attempt to protect patients with epilepsy from harm, clinicians and relatives sometimes take an overcautious view and advise them to avoid sports and exercise. A recent consensus paper from the International League Against Epilepsy (ILAE) Task Force on Sports and Epilepsy provides a more objective evaluation of the benefits and risks of exercise in this patient population, offering suggestions on issuing medical fitness certificates in various sports. The consensus paper divides sports into three categories. In group 1, the paper discusses activities that are not associated with any significant risk; category 2 includes sports that incur significant risk to persons with epilepsy but that do not pose a risk to bystanders, while the third group includes major risk factors for both patients and observers. Among the factors that ILAE takes into account when making its recommendations: the type of sport, the likelihood of a seizure occurring during participation, the type and severity of the seizures, and the "usual timing of seizure occurrence."

Capovilla G, Kaufman KR, Perucca E, Moshé SL, Arida RM. Epilepsy, seizures, physical exercise, and sports: A report from the ILAE Task Force on Sports and Epilepsy. Epilepsia. 2016;57(1):6-12.

In an attempt to protect patients with epilepsy from harm, clinicians and relatives sometimes take an overcautious view and advise them to avoid sports and exercise. A recent consensus paper from the International League Against Epilepsy (ILAE) Task Force on Sports and Epilepsy provides a more objective evaluation of the benefits and risks of exercise in this patient population, offering suggestions on issuing medical fitness certificates in various sports. The consensus paper divides sports into three categories. In group 1, the paper discusses activities that are not associated with any significant risk; category 2 includes sports that incur significant risk to persons with epilepsy but that do not pose a risk to bystanders, while the third group includes major risk factors for both patients and observers. Among the factors that ILAE takes into account when making its recommendations: the type of sport, the likelihood of a seizure occurring during participation, the type and severity of the seizures, and the "usual timing of seizure occurrence."

Capovilla G, Kaufman KR, Perucca E, Moshé SL, Arida RM. Epilepsy, seizures, physical exercise, and sports: A report from the ILAE Task Force on Sports and Epilepsy. Epilepsia. 2016;57(1):6-12.

Patients with epilepsy are more likely to have difficulty accessing health care services, according to the National Health Interview Survey during 2010 and 2013. The survey, which included data from more than 27,000 and 34,000 adults in these respective years, revealed that patients with epilepsy had more problems affording medication (relative risk [RR]: 2.40), gaining access to mental health services (RR = 3.23), getting eyeglasses (RR= 2.36), and obtaining dental services (RR = 1.98). Similarly, this patient population was more than five times as likely to report transportation problems as a barrier to obtaining health care services. The survey data suggested that the relative lack of private health insurance may have contributed to these disparities (RR = 0.58).

Thurman DJ, Kobau R, Luo Y-H, Helmers SL, Zack MM. Health-care access among adults with epilepsy: The U.S. National Health Interview Survey, 2010 and 2013. Epilepsy Behav. 2016;55:184-188.

Patients with epilepsy are more likely to have difficulty accessing health care services, according to the National Health Interview Survey during 2010 and 2013. The survey, which included data from more than 27,000 and 34,000 adults in these respective years, revealed that patients with epilepsy had more problems affording medication (relative risk [RR]: 2.40), gaining access to mental health services (RR = 3.23), getting eyeglasses (RR= 2.36), and obtaining dental services (RR = 1.98). Similarly, this patient population was more than five times as likely to report transportation problems as a barrier to obtaining health care services. The survey data suggested that the relative lack of private health insurance may have contributed to these disparities (RR = 0.58).

Thurman DJ, Kobau R, Luo Y-H, Helmers SL, Zack MM. Health-care access among adults with epilepsy: The U.S. National Health Interview Survey, 2010 and 2013. Epilepsy Behav. 2016;55:184-188.

Patients with epilepsy are more likely to have difficulty accessing health care services, according to the National Health Interview Survey during 2010 and 2013. The survey, which included data from more than 27,000 and 34,000 adults in these respective years, revealed that patients with epilepsy had more problems affording medication (relative risk [RR]: 2.40), gaining access to mental health services (RR = 3.23), getting eyeglasses (RR= 2.36), and obtaining dental services (RR = 1.98). Similarly, this patient population was more than five times as likely to report transportation problems as a barrier to obtaining health care services. The survey data suggested that the relative lack of private health insurance may have contributed to these disparities (RR = 0.58).

Thurman DJ, Kobau R, Luo Y-H, Helmers SL, Zack MM. Health-care access among adults with epilepsy: The U.S. National Health Interview Survey, 2010 and 2013. Epilepsy Behav. 2016;55:184-188.

WASHINGTON – Feel free to continue operating under a fee-for-service system, but according to Neil Kirschner, Ph.D., the senior associate for regulatory and insurer affairs at the American College of Physicians, “It’ll slowly be bled. The updates will be less, and will be linked to quality and efficiency.”

But just what is “value-based care” and why is it now, literally, the law of the land?

In this video interview, Dr. Kirschner explains how and why practice is being transformed and what this means in practical terms, and he lists resources for what you can do to ensure your practice is not left behind.

“I think many doctors still are not seeing the change, or not seeing how quickly it’s coming,” says Dr. Kirschner. “Once it comes, it’s going to hit physicians in the face if they’re not prepared.”

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Feel free to continue operating under a fee-for-service system, but according to Neil Kirschner, Ph.D., the senior associate for regulatory and insurer affairs at the American College of Physicians, “It’ll slowly be bled. The updates will be less, and will be linked to quality and efficiency.”

But just what is “value-based care” and why is it now, literally, the law of the land?

In this video interview, Dr. Kirschner explains how and why practice is being transformed and what this means in practical terms, and he lists resources for what you can do to ensure your practice is not left behind.

“I think many doctors still are not seeing the change, or not seeing how quickly it’s coming,” says Dr. Kirschner. “Once it comes, it’s going to hit physicians in the face if they’re not prepared.”

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Feel free to continue operating under a fee-for-service system, but according to Neil Kirschner, Ph.D., the senior associate for regulatory and insurer affairs at the American College of Physicians, “It’ll slowly be bled. The updates will be less, and will be linked to quality and efficiency.”

But just what is “value-based care” and why is it now, literally, the law of the land?

In this video interview, Dr. Kirschner explains how and why practice is being transformed and what this means in practical terms, and he lists resources for what you can do to ensure your practice is not left behind.

“I think many doctors still are not seeing the change, or not seeing how quickly it’s coming,” says Dr. Kirschner. “Once it comes, it’s going to hit physicians in the face if they’re not prepared.”

[email protected]

On Twitter @whitneymcknight

Among 207 patients with epilepsy, 43% reported clinically significant insomnia, while 51% had at least mild insomnia according to investigators from the University of Virginia. Their results, derived from an Insomnia Severity Index survey, also found that younger patients, those with a shorter duration of epilepsy, and patients taking sedatives or hypnotics, reported more severe insomnia. Similarly, patients with delayed sleep timing and depression were more likely to experience more severe insomnia. However, even after researchers factored out these covariates, they found that more severe insomnia was significantly associated with seizures and poorer quality of life.

Quigg M, Gharai S, Ruland J, et al. Insomnia in epilepsy is associated with continuing seizures and worse quality of life. Epilepsy Res. 2016;122:91-96.

Among 207 patients with epilepsy, 43% reported clinically significant insomnia, while 51% had at least mild insomnia according to investigators from the University of Virginia. Their results, derived from an Insomnia Severity Index survey, also found that younger patients, those with a shorter duration of epilepsy, and patients taking sedatives or hypnotics, reported more severe insomnia. Similarly, patients with delayed sleep timing and depression were more likely to experience more severe insomnia. However, even after researchers factored out these covariates, they found that more severe insomnia was significantly associated with seizures and poorer quality of life.

Quigg M, Gharai S, Ruland J, et al. Insomnia in epilepsy is associated with continuing seizures and worse quality of life. Epilepsy Res. 2016;122:91-96.

Among 207 patients with epilepsy, 43% reported clinically significant insomnia, while 51% had at least mild insomnia according to investigators from the University of Virginia. Their results, derived from an Insomnia Severity Index survey, also found that younger patients, those with a shorter duration of epilepsy, and patients taking sedatives or hypnotics, reported more severe insomnia. Similarly, patients with delayed sleep timing and depression were more likely to experience more severe insomnia. However, even after researchers factored out these covariates, they found that more severe insomnia was significantly associated with seizures and poorer quality of life.

Quigg M, Gharai S, Ruland J, et al. Insomnia in epilepsy is associated with continuing seizures and worse quality of life. Epilepsy Res. 2016;122:91-96.

YES: Immediate and safe patient access

Pharmacist-prescribed contraception laws are an opportunity to safely and easily improve access to contraception for women. While over-the-counter access remains an important goal, there are many practical considerations that must be addressed prior to implementation.

For example, in order to change the status of a medication to OTC, each product’s manufacturer needs to apply to the Food and Drug Administration for the change. This application includes studies that demonstrate their product can be safely used by the general public, without guidance from a health professional. The American College of Obstetricians and Gynecologists has already weighed in on the overall safety of oral contraceptives, and some studies have been done that show women can accurately complete a health questionnaire related to their OC eligibility. While these are good steps toward demonstrating safe use, they do not satisfy FDA requirements for OTC status. These initial studies never went to the next step of having women interpret the questions in an “actual use study,” an FDA requirement.

On the other hand, there have been studies demonstrating that pharmacists can safely provide hormonal contraception (J Am Pharm Assoc. 2008 Mar-Apr;48[2]:212-21). State laws can’t overrule the FDA and make hormonal contraception OTC, but they can change the scope of what pharmacists are permitted to do. In Oregon and California, specific laws allowing pharmacists to prescribe hormonal contraception have already been implemented. Speaking from our experience in Oregon, this change has solved many concerns that have been raised about hormonal contraception going OTC.

Maintaining insurance coverage

Since pharmacists are able to write prescriptions, they can bill insurance plans for the product in the same way as for any other prescription. The majority of OTC medications are not covered by insurance and if a future law required insurance to cover contraception obtained OTC, pharmacists would still be involved in billing.

Patients will continue to get counseling

Pharmacists need to undergo training/certification in order to prescribe hormonal contraception. In Oregon, the certification was developed by pharmacists and physicians with input from the Oregon Health Authority and the Oregon Board of Pharmacy. Having a trained health care professional involved in counseling means that accurate and important information is still conveyed, including ensuring women are aware that hormonal contraception is not going to protect against sexually transmitted infections, and teaching women about the importance of adherence, but also how to deal with missed pills and problems. The importance of accessing other preventive health services can also be stressed.

Patients will be appropriately screened for their eligibility

Women who are unable to safely use hormonal contraceptives will be referred for more appropriate methods.

We have the opportunity to act now to prevent unintended pregnancy through pharmacist-prescribed hormonal contraceptives. In addition, allowing pharmacists to directly prescribe hormonal contraceptives provides the opportunity to evaluate the safety, efficacy, and acceptability of the practice. This evidence can then be used to look at the feasibility and possible mechanisms that could be undertaken to safely move hormonal contraceptives to OTC, which helps the OTC movement rather than distracting from it.

Dr. Anderson is an instructor at the Oregon State University College of Pharmacy in Corvallis. Dr. Rodriguez is an assistant professor of ob.gyn. at Oregon Health & Science University in Portland. Dr. Edelman is a professor of ob.gyn. and director of the Oregon Family Planning Fellowship at OHSU. They reported having no relevant financial disclosures.

NO: Exchanging one barrier for another

Birth control is an essential part of women’s health care and the value of contraception has been proven time and again. Not only do oral contraceptives provide women with the ability to choose if, and when, they want to become pregnant, they allow women to have more control over their lives by timing pregnancy around education, careers, and other life goals. Nearly 90% of women in the United States between the ages of 15 and 44 will use a highly effective, reversible method of contraception, such as oral contraceptives, injected contraceptives, cervical rings, contraceptive implants, or intrauterine devices.

Ob.gyns. know from evidence and experience that oral contraceptives are safe enough for OTC access. In fact, oral contraceptives are safer than many other medications that are already available OTC, such as acetaminophen. Of note, thromboembolism, the most common serious risk associated with oral contraceptives, is not only exceedingly low but is also much lower than the risk for thromboembolism during pregnancy and the postpartum period. After all, no diagnosis is required to prescribe oral contraceptives. Of course, ob.gyns. and other women’s health care providers do screen for easily recognizable risk factors, such as smoking. However, research shows that women are very adept at self-screening for any potential risks.

For these reasons, ACOG has long been a public supporter of OTC access to oral contraceptives, as it already is in many countries around the world. ACOG supports efforts to increase affordable, reliable access for American women to the contraceptives they need, when they need them.

However, the pharmacist-prescribing laws do not go far enough in expanding access to contraception. A pharmacist’s prescription simply exchanges one barrier – a physician’s prescription – for another.

Women still need to arrange a consultation with a pharmacist during pharmacy hours and any potential cost associated with that consultation would add out-of-pocket expenses. This will not allow us to reach women who remain underserved by the current prescribing requirements. For example, this may prevent women who are uninsured or underinsured from accessing contraception. For some, the need to visit a health care provider prevents access to contraception.

ACOG continues to stand by full, no-copay coverage of all FDA-approved methods of birth control, under the Affordable Care Act, as we recognize that OTC access to birth control is not a blanket solution. We also continue to strongly advocate for access to long-acting reversible contraceptive methods, the most effective method of preventing pregnancy.

Pharmacists and ob.gyns. alike share a commitment to quality patient care. However, if our shared goal is increasing access to safe, effective contraception, women should be trusted to control their reproductive lives and should be able to do so without barriers.

Dr. DeFrancesco is an ob.gyn. in Cheshire, Conn., and the president of the American College of Obstetricians and Gynecologists. He reported having no relevant financial disclosures.

YES: Immediate and safe patient access

Pharmacist-prescribed contraception laws are an opportunity to safely and easily improve access to contraception for women. While over-the-counter access remains an important goal, there are many practical considerations that must be addressed prior to implementation.

For example, in order to change the status of a medication to OTC, each product’s manufacturer needs to apply to the Food and Drug Administration for the change. This application includes studies that demonstrate their product can be safely used by the general public, without guidance from a health professional. The American College of Obstetricians and Gynecologists has already weighed in on the overall safety of oral contraceptives, and some studies have been done that show women can accurately complete a health questionnaire related to their OC eligibility. While these are good steps toward demonstrating safe use, they do not satisfy FDA requirements for OTC status. These initial studies never went to the next step of having women interpret the questions in an “actual use study,” an FDA requirement.

On the other hand, there have been studies demonstrating that pharmacists can safely provide hormonal contraception (J Am Pharm Assoc. 2008 Mar-Apr;48[2]:212-21). State laws can’t overrule the FDA and make hormonal contraception OTC, but they can change the scope of what pharmacists are permitted to do. In Oregon and California, specific laws allowing pharmacists to prescribe hormonal contraception have already been implemented. Speaking from our experience in Oregon, this change has solved many concerns that have been raised about hormonal contraception going OTC.

Maintaining insurance coverage

Since pharmacists are able to write prescriptions, they can bill insurance plans for the product in the same way as for any other prescription. The majority of OTC medications are not covered by insurance and if a future law required insurance to cover contraception obtained OTC, pharmacists would still be involved in billing.

Patients will continue to get counseling

Pharmacists need to undergo training/certification in order to prescribe hormonal contraception. In Oregon, the certification was developed by pharmacists and physicians with input from the Oregon Health Authority and the Oregon Board of Pharmacy. Having a trained health care professional involved in counseling means that accurate and important information is still conveyed, including ensuring women are aware that hormonal contraception is not going to protect against sexually transmitted infections, and teaching women about the importance of adherence, but also how to deal with missed pills and problems. The importance of accessing other preventive health services can also be stressed.

Patients will be appropriately screened for their eligibility

Women who are unable to safely use hormonal contraceptives will be referred for more appropriate methods.

We have the opportunity to act now to prevent unintended pregnancy through pharmacist-prescribed hormonal contraceptives. In addition, allowing pharmacists to directly prescribe hormonal contraceptives provides the opportunity to evaluate the safety, efficacy, and acceptability of the practice. This evidence can then be used to look at the feasibility and possible mechanisms that could be undertaken to safely move hormonal contraceptives to OTC, which helps the OTC movement rather than distracting from it.

Dr. Anderson is an instructor at the Oregon State University College of Pharmacy in Corvallis. Dr. Rodriguez is an assistant professor of ob.gyn. at Oregon Health & Science University in Portland. Dr. Edelman is a professor of ob.gyn. and director of the Oregon Family Planning Fellowship at OHSU. They reported having no relevant financial disclosures.

NO: Exchanging one barrier for another

Birth control is an essential part of women’s health care and the value of contraception has been proven time and again. Not only do oral contraceptives provide women with the ability to choose if, and when, they want to become pregnant, they allow women to have more control over their lives by timing pregnancy around education, careers, and other life goals. Nearly 90% of women in the United States between the ages of 15 and 44 will use a highly effective, reversible method of contraception, such as oral contraceptives, injected contraceptives, cervical rings, contraceptive implants, or intrauterine devices.

Ob.gyns. know from evidence and experience that oral contraceptives are safe enough for OTC access. In fact, oral contraceptives are safer than many other medications that are already available OTC, such as acetaminophen. Of note, thromboembolism, the most common serious risk associated with oral contraceptives, is not only exceedingly low but is also much lower than the risk for thromboembolism during pregnancy and the postpartum period. After all, no diagnosis is required to prescribe oral contraceptives. Of course, ob.gyns. and other women’s health care providers do screen for easily recognizable risk factors, such as smoking. However, research shows that women are very adept at self-screening for any potential risks.

For these reasons, ACOG has long been a public supporter of OTC access to oral contraceptives, as it already is in many countries around the world. ACOG supports efforts to increase affordable, reliable access for American women to the contraceptives they need, when they need them.

However, the pharmacist-prescribing laws do not go far enough in expanding access to contraception. A pharmacist’s prescription simply exchanges one barrier – a physician’s prescription – for another.

Women still need to arrange a consultation with a pharmacist during pharmacy hours and any potential cost associated with that consultation would add out-of-pocket expenses. This will not allow us to reach women who remain underserved by the current prescribing requirements. For example, this may prevent women who are uninsured or underinsured from accessing contraception. For some, the need to visit a health care provider prevents access to contraception.

ACOG continues to stand by full, no-copay coverage of all FDA-approved methods of birth control, under the Affordable Care Act, as we recognize that OTC access to birth control is not a blanket solution. We also continue to strongly advocate for access to long-acting reversible contraceptive methods, the most effective method of preventing pregnancy.

Pharmacists and ob.gyns. alike share a commitment to quality patient care. However, if our shared goal is increasing access to safe, effective contraception, women should be trusted to control their reproductive lives and should be able to do so without barriers.

Dr. DeFrancesco is an ob.gyn. in Cheshire, Conn., and the president of the American College of Obstetricians and Gynecologists. He reported having no relevant financial disclosures.

YES: Immediate and safe patient access

Pharmacist-prescribed contraception laws are an opportunity to safely and easily improve access to contraception for women. While over-the-counter access remains an important goal, there are many practical considerations that must be addressed prior to implementation.

For example, in order to change the status of a medication to OTC, each product’s manufacturer needs to apply to the Food and Drug Administration for the change. This application includes studies that demonstrate their product can be safely used by the general public, without guidance from a health professional. The American College of Obstetricians and Gynecologists has already weighed in on the overall safety of oral contraceptives, and some studies have been done that show women can accurately complete a health questionnaire related to their OC eligibility. While these are good steps toward demonstrating safe use, they do not satisfy FDA requirements for OTC status. These initial studies never went to the next step of having women interpret the questions in an “actual use study,” an FDA requirement.

On the other hand, there have been studies demonstrating that pharmacists can safely provide hormonal contraception (J Am Pharm Assoc. 2008 Mar-Apr;48[2]:212-21). State laws can’t overrule the FDA and make hormonal contraception OTC, but they can change the scope of what pharmacists are permitted to do. In Oregon and California, specific laws allowing pharmacists to prescribe hormonal contraception have already been implemented. Speaking from our experience in Oregon, this change has solved many concerns that have been raised about hormonal contraception going OTC.

Maintaining insurance coverage

Since pharmacists are able to write prescriptions, they can bill insurance plans for the product in the same way as for any other prescription. The majority of OTC medications are not covered by insurance and if a future law required insurance to cover contraception obtained OTC, pharmacists would still be involved in billing.

Patients will continue to get counseling

Pharmacists need to undergo training/certification in order to prescribe hormonal contraception. In Oregon, the certification was developed by pharmacists and physicians with input from the Oregon Health Authority and the Oregon Board of Pharmacy. Having a trained health care professional involved in counseling means that accurate and important information is still conveyed, including ensuring women are aware that hormonal contraception is not going to protect against sexually transmitted infections, and teaching women about the importance of adherence, but also how to deal with missed pills and problems. The importance of accessing other preventive health services can also be stressed.

Patients will be appropriately screened for their eligibility

Women who are unable to safely use hormonal contraceptives will be referred for more appropriate methods.

We have the opportunity to act now to prevent unintended pregnancy through pharmacist-prescribed hormonal contraceptives. In addition, allowing pharmacists to directly prescribe hormonal contraceptives provides the opportunity to evaluate the safety, efficacy, and acceptability of the practice. This evidence can then be used to look at the feasibility and possible mechanisms that could be undertaken to safely move hormonal contraceptives to OTC, which helps the OTC movement rather than distracting from it.

Dr. Anderson is an instructor at the Oregon State University College of Pharmacy in Corvallis. Dr. Rodriguez is an assistant professor of ob.gyn. at Oregon Health & Science University in Portland. Dr. Edelman is a professor of ob.gyn. and director of the Oregon Family Planning Fellowship at OHSU. They reported having no relevant financial disclosures.

NO: Exchanging one barrier for another

Birth control is an essential part of women’s health care and the value of contraception has been proven time and again. Not only do oral contraceptives provide women with the ability to choose if, and when, they want to become pregnant, they allow women to have more control over their lives by timing pregnancy around education, careers, and other life goals. Nearly 90% of women in the United States between the ages of 15 and 44 will use a highly effective, reversible method of contraception, such as oral contraceptives, injected contraceptives, cervical rings, contraceptive implants, or intrauterine devices.

Ob.gyns. know from evidence and experience that oral contraceptives are safe enough for OTC access. In fact, oral contraceptives are safer than many other medications that are already available OTC, such as acetaminophen. Of note, thromboembolism, the most common serious risk associated with oral contraceptives, is not only exceedingly low but is also much lower than the risk for thromboembolism during pregnancy and the postpartum period. After all, no diagnosis is required to prescribe oral contraceptives. Of course, ob.gyns. and other women’s health care providers do screen for easily recognizable risk factors, such as smoking. However, research shows that women are very adept at self-screening for any potential risks.

For these reasons, ACOG has long been a public supporter of OTC access to oral contraceptives, as it already is in many countries around the world. ACOG supports efforts to increase affordable, reliable access for American women to the contraceptives they need, when they need them.

However, the pharmacist-prescribing laws do not go far enough in expanding access to contraception. A pharmacist’s prescription simply exchanges one barrier – a physician’s prescription – for another.

Women still need to arrange a consultation with a pharmacist during pharmacy hours and any potential cost associated with that consultation would add out-of-pocket expenses. This will not allow us to reach women who remain underserved by the current prescribing requirements. For example, this may prevent women who are uninsured or underinsured from accessing contraception. For some, the need to visit a health care provider prevents access to contraception.

ACOG continues to stand by full, no-copay coverage of all FDA-approved methods of birth control, under the Affordable Care Act, as we recognize that OTC access to birth control is not a blanket solution. We also continue to strongly advocate for access to long-acting reversible contraceptive methods, the most effective method of preventing pregnancy.

Pharmacists and ob.gyns. alike share a commitment to quality patient care. However, if our shared goal is increasing access to safe, effective contraception, women should be trusted to control their reproductive lives and should be able to do so without barriers.

Dr. DeFrancesco is an ob.gyn. in Cheshire, Conn., and the president of the American College of Obstetricians and Gynecologists. He reported having no relevant financial disclosures.

The percentage of emergency department (ED) visits due to anaphylaxis more than doubled from 2011 to 2015 at one Canadian children’s hospital, according to a Research Letter to the Editor published in the Journal of Allergy and Clinical Immunology.

“Our results are limited to one pediatric center, but they suggest a worrisome increase in anaphylaxis rate that is consistent with the worldwide reported increase,” said Dr. Elana Hochstadter of the Hospital for Sick Children, University of Toronto, and her associates. The investigators analyzed longitudinal data in a national registry of anaphylaxis cases to track time trends for the disorder at their hospital. They identified 965 cases presenting to their ED during a 4-year period. The percentage of all ED visits accounted for by anaphylaxis rose from 0.20% to 0.41%. The overall volume of ED visits and the volume of specific ED diagnoses did not change during this interval.

EPG_europhotographics/ThinkStock

As in other studies of anaphylaxis around the world, food was the most common trigger in this series, responsible for 82% of cases. Peanut was the most common food allergen, accounting for 22% of cases. Most reactions were of moderate severity, and the percentages of mild, moderate, and severe reactions remained relatively stable throughout the study period. The presence of asthma was associated with increased severity of anaphylaxis (odds ratio, 2.3), as was the presence of eczema (OR, 2.1). Only half of the patients who had an epinephrine autoinjector used it before presenting to the ED, Dr. Hochstadter and her associates said (J Allergy Clin Immunol. 2016 doi: 10.1016/j.jaci.2016.02.016). The median age of the patients was 6 years.

The reason for this rapid increase is unknown, but it parallels that reported in studies of anaphylaxis throughout North America and Europe. “An important observation in our study is that administration of epinephrine before arrival in the ED is independently associated with a decreased likelihood of requiring multiple doses of epinephrine in the ED, suggesting that prompt epinephrine administration is beneficial,” they noted.

The Allergy, Genes, and Environment Network Centres of Excellence, Health Canada, and Sanofi funded the study. Dr. Hochstadter and her associates reported having no relevant disclosures.

[email protected]

The percentage of emergency department (ED) visits due to anaphylaxis more than doubled from 2011 to 2015 at one Canadian children’s hospital, according to a Research Letter to the Editor published in the Journal of Allergy and Clinical Immunology.

“Our results are limited to one pediatric center, but they suggest a worrisome increase in anaphylaxis rate that is consistent with the worldwide reported increase,” said Dr. Elana Hochstadter of the Hospital for Sick Children, University of Toronto, and her associates. The investigators analyzed longitudinal data in a national registry of anaphylaxis cases to track time trends for the disorder at their hospital. They identified 965 cases presenting to their ED during a 4-year period. The percentage of all ED visits accounted for by anaphylaxis rose from 0.20% to 0.41%. The overall volume of ED visits and the volume of specific ED diagnoses did not change during this interval.

EPG_europhotographics/ThinkStock

As in other studies of anaphylaxis around the world, food was the most common trigger in this series, responsible for 82% of cases. Peanut was the most common food allergen, accounting for 22% of cases. Most reactions were of moderate severity, and the percentages of mild, moderate, and severe reactions remained relatively stable throughout the study period. The presence of asthma was associated with increased severity of anaphylaxis (odds ratio, 2.3), as was the presence of eczema (OR, 2.1). Only half of the patients who had an epinephrine autoinjector used it before presenting to the ED, Dr. Hochstadter and her associates said (J Allergy Clin Immunol. 2016 doi: 10.1016/j.jaci.2016.02.016). The median age of the patients was 6 years.

The reason for this rapid increase is unknown, but it parallels that reported in studies of anaphylaxis throughout North America and Europe. “An important observation in our study is that administration of epinephrine before arrival in the ED is independently associated with a decreased likelihood of requiring multiple doses of epinephrine in the ED, suggesting that prompt epinephrine administration is beneficial,” they noted.

The Allergy, Genes, and Environment Network Centres of Excellence, Health Canada, and Sanofi funded the study. Dr. Hochstadter and her associates reported having no relevant disclosures.

[email protected]

The percentage of emergency department (ED) visits due to anaphylaxis more than doubled from 2011 to 2015 at one Canadian children’s hospital, according to a Research Letter to the Editor published in the Journal of Allergy and Clinical Immunology.

“Our results are limited to one pediatric center, but they suggest a worrisome increase in anaphylaxis rate that is consistent with the worldwide reported increase,” said Dr. Elana Hochstadter of the Hospital for Sick Children, University of Toronto, and her associates. The investigators analyzed longitudinal data in a national registry of anaphylaxis cases to track time trends for the disorder at their hospital. They identified 965 cases presenting to their ED during a 4-year period. The percentage of all ED visits accounted for by anaphylaxis rose from 0.20% to 0.41%. The overall volume of ED visits and the volume of specific ED diagnoses did not change during this interval.

EPG_europhotographics/ThinkStock

As in other studies of anaphylaxis around the world, food was the most common trigger in this series, responsible for 82% of cases. Peanut was the most common food allergen, accounting for 22% of cases. Most reactions were of moderate severity, and the percentages of mild, moderate, and severe reactions remained relatively stable throughout the study period. The presence of asthma was associated with increased severity of anaphylaxis (odds ratio, 2.3), as was the presence of eczema (OR, 2.1). Only half of the patients who had an epinephrine autoinjector used it before presenting to the ED, Dr. Hochstadter and her associates said (J Allergy Clin Immunol. 2016 doi: 10.1016/j.jaci.2016.02.016). The median age of the patients was 6 years.

The reason for this rapid increase is unknown, but it parallels that reported in studies of anaphylaxis throughout North America and Europe. “An important observation in our study is that administration of epinephrine before arrival in the ED is independently associated with a decreased likelihood of requiring multiple doses of epinephrine in the ED, suggesting that prompt epinephrine administration is beneficial,” they noted.

The Allergy, Genes, and Environment Network Centres of Excellence, Health Canada, and Sanofi funded the study. Dr. Hochstadter and her associates reported having no relevant disclosures.

[email protected]

Voice recognition software has come a long way. I tried it 15 years ago, but gave up in frustration. Recently, I took another look and found that technology has advanced a lot. Although I can now dictate fast and see the words pour out with impressive accuracy, there are still plenty of errors – some of them quite … interesting. Below is a case summary made up of examples from my growing collection of things the computer seems to have thought I said.

The moral: If you dictate with voice recognition software, proofread!

Chief Complaint

This 43-year-old woman presents with chief complaints of “facial and skin issues.”

Past Medical History

She reports that he has been engaged in a prolonged bottle with acne. It has lasted 18 months, urinary half. A previous physician prescribed an oral antibiotic, either doxycycline or minor cycling. She reports recurrent tachycardia on the forehead and cheeks. Although her outbreaks are not always hormonal, she sometimes gets worse around her. I said around her.! Her menstrual.!! Oh, never mind. It’s good that her name isn’t Cohen, because the computer hears that as :

She has scalp itch and here loss, and is convinced she has pediculosis capitis because of head Lausten chief found. There is a remote history of localized baldness, but not of alopecia universe Alice.

Though free of eczema in recent years, she recalls ataxic childhood.

She was recently exposed to chicken pox but did not contract Maricella. Her history of viral illnesses includes Molested contagiosum.

When she goes in the sun, she is not able to get a 10. She takes no narcotic analgesics, especially Oxyclean.

Occasional scaly rashes have been treated with both antifungal and antibiotic East creams, and sometimes with topical spheroids.

The patient has undergone various medical anesthetic procedures.

Personal and social history

The last 4 digits of her Social Security number are 1/6/09.

She is Director of Marketing for an appetizing agency. Her uncle is a scientist who won the No Bell Prize.

Hobbies: Skiing in Aspirin, Colorado. Competitive barbecue in dialysis, Texas.

Physical Examination

Eyes: There is a cystic lesion on the right I. This is a she’ll lazy on.

Face: Her breakouts are popular. The facial lesions are robbed because of Washington with vigor. Several are just above the nose on the club Ella. There is also sun damage: She has to saltwater keratoses on the 4 head.

Neck: Shotty notes. There is dark thickening typical of a cantholysis Neighbor can’t. There are firm lesions on the occipital scalp consistent with folliculitis Keloid Dallas. The redness on both sides of her neck represents Poikilokderma of survived.

Hands: Xerosis, aggravated by frequent hand washing with puerile. Nails demonstrate the partial separation of cholelithiasis.

Torso: There is a lichenoid rash that sometimes loses. This rash is all over and is very expensive. It is lichenoid and shows a violent color. She has many demented lesions. All are B9.

Upper extremities: There are four systolic keratoses on the vulvar forearm.

Lower extremities: There is a bleeding red lesion of recent onset on the left thigh. It is a high and Janet granuloma.

Groin: Her penile wart is not visible.

Assessment and plan

I will desiccate her high and Janet granuloma.

Will treat her losing rash with Burro solution soaks, followed by topical spheroids.

She was worried that she has precancerous cemented lesions, but I see no indication that she dies.

She will clean her hands less often, otherwise he will have Cirrhosis from Washington. She will moisturize with Aqua 4.

While outdoors, she will protect herself from the son.

For acne, recommended isotretinoin, enrolled patient in iPledge program. She cannot have a fasting blood test today, as she 8 this morning. He will obtain a pregnancy test, and I will confirm patient’s cuddling.

My staph will send a report of today’s visit to the patient’s Coronary Physician.

Dr. Rockoff practices dermatology in Brookline, Mass. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Voice recognition software has come a long way. I tried it 15 years ago, but gave up in frustration. Recently, I took another look and found that technology has advanced a lot. Although I can now dictate fast and see the words pour out with impressive accuracy, there are still plenty of errors – some of them quite … interesting. Below is a case summary made up of examples from my growing collection of things the computer seems to have thought I said.

The moral: If you dictate with voice recognition software, proofread!

Chief Complaint

This 43-year-old woman presents with chief complaints of “facial and skin issues.”

Past Medical History

She reports that he has been engaged in a prolonged bottle with acne. It has lasted 18 months, urinary half. A previous physician prescribed an oral antibiotic, either doxycycline or minor cycling. She reports recurrent tachycardia on the forehead and cheeks. Although her outbreaks are not always hormonal, she sometimes gets worse around her. I said around her.! Her menstrual.!! Oh, never mind. It’s good that her name isn’t Cohen, because the computer hears that as :

She has scalp itch and here loss, and is convinced she has pediculosis capitis because of head Lausten chief found. There is a remote history of localized baldness, but not of alopecia universe Alice.

Though free of eczema in recent years, she recalls ataxic childhood.

She was recently exposed to chicken pox but did not contract Maricella. Her history of viral illnesses includes Molested contagiosum.

When she goes in the sun, she is not able to get a 10. She takes no narcotic analgesics, especially Oxyclean.

Occasional scaly rashes have been treated with both antifungal and antibiotic East creams, and sometimes with topical spheroids.

The patient has undergone various medical anesthetic procedures.

Personal and social history

The last 4 digits of her Social Security number are 1/6/09.

She is Director of Marketing for an appetizing agency. Her uncle is a scientist who won the No Bell Prize.

Hobbies: Skiing in Aspirin, Colorado. Competitive barbecue in dialysis, Texas.

Physical Examination

Eyes: There is a cystic lesion on the right I. This is a she’ll lazy on.

Face: Her breakouts are popular. The facial lesions are robbed because of Washington with vigor. Several are just above the nose on the club Ella. There is also sun damage: She has to saltwater keratoses on the 4 head.

Neck: Shotty notes. There is dark thickening typical of a cantholysis Neighbor can’t. There are firm lesions on the occipital scalp consistent with folliculitis Keloid Dallas. The redness on both sides of her neck represents Poikilokderma of survived.

Hands: Xerosis, aggravated by frequent hand washing with puerile. Nails demonstrate the partial separation of cholelithiasis.

Torso: There is a lichenoid rash that sometimes loses. This rash is all over and is very expensive. It is lichenoid and shows a violent color. She has many demented lesions. All are B9.

Upper extremities: There are four systolic keratoses on the vulvar forearm.

Lower extremities: There is a bleeding red lesion of recent onset on the left thigh. It is a high and Janet granuloma.

Groin: Her penile wart is not visible.

Assessment and plan

I will desiccate her high and Janet granuloma.

Will treat her losing rash with Burro solution soaks, followed by topical spheroids.

She was worried that she has precancerous cemented lesions, but I see no indication that she dies.

She will clean her hands less often, otherwise he will have Cirrhosis from Washington. She will moisturize with Aqua 4.

While outdoors, she will protect herself from the son.

For acne, recommended isotretinoin, enrolled patient in iPledge program. She cannot have a fasting blood test today, as she 8 this morning. He will obtain a pregnancy test, and I will confirm patient’s cuddling.

My staph will send a report of today’s visit to the patient’s Coronary Physician.

Dr. Rockoff practices dermatology in Brookline, Mass. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Voice recognition software has come a long way. I tried it 15 years ago, but gave up in frustration. Recently, I took another look and found that technology has advanced a lot. Although I can now dictate fast and see the words pour out with impressive accuracy, there are still plenty of errors – some of them quite … interesting. Below is a case summary made up of examples from my growing collection of things the computer seems to have thought I said.

The moral: If you dictate with voice recognition software, proofread!

Chief Complaint

This 43-year-old woman presents with chief complaints of “facial and skin issues.”

Past Medical History

She reports that he has been engaged in a prolonged bottle with acne. It has lasted 18 months, urinary half. A previous physician prescribed an oral antibiotic, either doxycycline or minor cycling. She reports recurrent tachycardia on the forehead and cheeks. Although her outbreaks are not always hormonal, she sometimes gets worse around her. I said around her.! Her menstrual.!! Oh, never mind. It’s good that her name isn’t Cohen, because the computer hears that as :

She has scalp itch and here loss, and is convinced she has pediculosis capitis because of head Lausten chief found. There is a remote history of localized baldness, but not of alopecia universe Alice.

Though free of eczema in recent years, she recalls ataxic childhood.

She was recently exposed to chicken pox but did not contract Maricella. Her history of viral illnesses includes Molested contagiosum.

When she goes in the sun, she is not able to get a 10. She takes no narcotic analgesics, especially Oxyclean.

Occasional scaly rashes have been treated with both antifungal and antibiotic East creams, and sometimes with topical spheroids.

The patient has undergone various medical anesthetic procedures.

Personal and social history

The last 4 digits of her Social Security number are 1/6/09.

She is Director of Marketing for an appetizing agency. Her uncle is a scientist who won the No Bell Prize.

Hobbies: Skiing in Aspirin, Colorado. Competitive barbecue in dialysis, Texas.

Physical Examination

Eyes: There is a cystic lesion on the right I. This is a she’ll lazy on.

Face: Her breakouts are popular. The facial lesions are robbed because of Washington with vigor. Several are just above the nose on the club Ella. There is also sun damage: She has to saltwater keratoses on the 4 head.

Neck: Shotty notes. There is dark thickening typical of a cantholysis Neighbor can’t. There are firm lesions on the occipital scalp consistent with folliculitis Keloid Dallas. The redness on both sides of her neck represents Poikilokderma of survived.

Hands: Xerosis, aggravated by frequent hand washing with puerile. Nails demonstrate the partial separation of cholelithiasis.

Torso: There is a lichenoid rash that sometimes loses. This rash is all over and is very expensive. It is lichenoid and shows a violent color. She has many demented lesions. All are B9.

Upper extremities: There are four systolic keratoses on the vulvar forearm.

Lower extremities: There is a bleeding red lesion of recent onset on the left thigh. It is a high and Janet granuloma.

Groin: Her penile wart is not visible.

Assessment and plan

I will desiccate her high and Janet granuloma.

Will treat her losing rash with Burro solution soaks, followed by topical spheroids.

She was worried that she has precancerous cemented lesions, but I see no indication that she dies.

She will clean her hands less often, otherwise he will have Cirrhosis from Washington. She will moisturize with Aqua 4.

While outdoors, she will protect herself from the son.

For acne, recommended isotretinoin, enrolled patient in iPledge program. She cannot have a fasting blood test today, as she 8 this morning. He will obtain a pregnancy test, and I will confirm patient’s cuddling.

My staph will send a report of today’s visit to the patient’s Coronary Physician.

Dr. Rockoff practices dermatology in Brookline, Mass. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

The FP diagnosed recurrent orolabial herpes. Orolabial herpes typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Treatment for primary orolabial herpes includes oral acyclovir (200 mg 5 times daily for 5 days), which accelerates healing by one day and can reduce the mean duration of pain by 36%. Alternatively, valacyclovir can be given 2000 mg orally every 12 hours for one day and, like acyclovir, should be started as soon as possible after the onset of symptoms.

Docosanol cream is available without a prescription for oral herpes. One randomized controlled trial (RCT) of 743 patients with herpes labialis showed a faster healing time in patients treated with docosanol 10% cream when compared with placebo cream (4.1 vs 4.8 days), as well as reduced duration of pain symptoms (2.2 vs 2.7 days).¹ More than 90% of patients in both groups healed completely within 10 days.¹ Treatment with docosanol cream, when applied 5 times per day and within 12 hours of episode onset until symptoms are relieved, is safe and somewhat effective.

Suppression for patients with frequent recurrences may be provided with valacyclovir 500 mg daily or acyclovir 400 mg twice daily.

Suppression was not indicated for this patient since she had infrequent episodes. She was told that the best prevention would be to use a high-potency sunscreen on her lips and face when out in the sun and to use protective clothing such as a broad brim hat. To prevent skin cancers and recurrent oral labial herpes, she was told to avoid the midday sun whenever possible.

The FP also explained that it was too late now to start oral antiviral treatment, but that she might want to use topical petrolatum for symptom relief. He also offered her a prescription for an oral antiviral medicine that she could fill at the start of symptoms during a future outbreak. He explained that there is some benefit to the over-the-counter topical medicine, docosanol.

1. Sacks SL, Thisted RA, Jones TM, et al; Docosanol 10% Cream Study Group. Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial. J Am Acad Dermatol. 2001;45:222-230.
 

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Carter K. Herpes simplex. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:735-742.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed recurrent orolabial herpes. Orolabial herpes typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Treatment for primary orolabial herpes includes oral acyclovir (200 mg 5 times daily for 5 days), which accelerates healing by one day and can reduce the mean duration of pain by 36%. Alternatively, valacyclovir can be given 2000 mg orally every 12 hours for one day and, like acyclovir, should be started as soon as possible after the onset of symptoms.

Docosanol cream is available without a prescription for oral herpes. One randomized controlled trial (RCT) of 743 patients with herpes labialis showed a faster healing time in patients treated with docosanol 10% cream when compared with placebo cream (4.1 vs 4.8 days), as well as reduced duration of pain symptoms (2.2 vs 2.7 days).¹ More than 90% of patients in both groups healed completely within 10 days.¹ Treatment with docosanol cream, when applied 5 times per day and within 12 hours of episode onset until symptoms are relieved, is safe and somewhat effective.

Suppression for patients with frequent recurrences may be provided with valacyclovir 500 mg daily or acyclovir 400 mg twice daily.

Suppression was not indicated for this patient since she had infrequent episodes. She was told that the best prevention would be to use a high-potency sunscreen on her lips and face when out in the sun and to use protective clothing such as a broad brim hat. To prevent skin cancers and recurrent oral labial herpes, she was told to avoid the midday sun whenever possible.

The FP also explained that it was too late now to start oral antiviral treatment, but that she might want to use topical petrolatum for symptom relief. He also offered her a prescription for an oral antiviral medicine that she could fill at the start of symptoms during a future outbreak. He explained that there is some benefit to the over-the-counter topical medicine, docosanol.

1. Sacks SL, Thisted RA, Jones TM, et al; Docosanol 10% Cream Study Group. Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial. J Am Acad Dermatol. 2001;45:222-230.
 

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Carter K. Herpes simplex. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:735-742.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed recurrent orolabial herpes. Orolabial herpes typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Treatment for primary orolabial herpes includes oral acyclovir (200 mg 5 times daily for 5 days), which accelerates healing by one day and can reduce the mean duration of pain by 36%. Alternatively, valacyclovir can be given 2000 mg orally every 12 hours for one day and, like acyclovir, should be started as soon as possible after the onset of symptoms.

Docosanol cream is available without a prescription for oral herpes. One randomized controlled trial (RCT) of 743 patients with herpes labialis showed a faster healing time in patients treated with docosanol 10% cream when compared with placebo cream (4.1 vs 4.8 days), as well as reduced duration of pain symptoms (2.2 vs 2.7 days).¹ More than 90% of patients in both groups healed completely within 10 days.¹ Treatment with docosanol cream, when applied 5 times per day and within 12 hours of episode onset until symptoms are relieved, is safe and somewhat effective.

Suppression for patients with frequent recurrences may be provided with valacyclovir 500 mg daily or acyclovir 400 mg twice daily.

Suppression was not indicated for this patient since she had infrequent episodes. She was told that the best prevention would be to use a high-potency sunscreen on her lips and face when out in the sun and to use protective clothing such as a broad brim hat. To prevent skin cancers and recurrent oral labial herpes, she was told to avoid the midday sun whenever possible.

The FP also explained that it was too late now to start oral antiviral treatment, but that she might want to use topical petrolatum for symptom relief. He also offered her a prescription for an oral antiviral medicine that she could fill at the start of symptoms during a future outbreak. He explained that there is some benefit to the over-the-counter topical medicine, docosanol.

1. Sacks SL, Thisted RA, Jones TM, et al; Docosanol 10% Cream Study Group. Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial. J Am Acad Dermatol. 2001;45:222-230.
 

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Carter K. Herpes simplex. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:735-742.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The patient’s “slapped-cheek” appearance led to the diagnosis: fifth disease (erythema infectiosum). The name of the diagnosis derives from the fact that it represents the fifth of 6 common childhood viral exanthems. Transmission of the causative parvovirus B19 occurs through respiratory secretions (possibly through fomites), parenterally via vertical transmission from mother to fetus, or by transfusion of blood or blood products.

Fifth disease is very contagious via the respiratory route and occurs more frequently between late winter and early summer. Up to 60% of the population is seropositive for antiparvovirus B19 immunoglobulin G (IgG) by age 20. Thirty to 40% of pregnant women lack measurable IgG to the infecting agent and are therefore presumed to be susceptible to infection. Infection during pregnancy can, in some cases, lead to fetal death.

Fifth disease is usually a biphasic illness, starting with upper respiratory tract symptoms that may include headache, fever, sore throat, pruritus, coryza, abdominal pain, diarrhea, and/or arthralgias. These constitutional symptoms coincide with the onset of viremia and usually resolve (for about a week) before the next stage begins. The second stage is characterized by a classic erythematous malar rash with relative circumoral pallor (the “slapped-cheek” appearance in children). This is followed by a “lace-like” erythematous rash on the trunk and extremities. 

Pregnant women who are exposed to or have symptoms of parvovirus infection should have serologic testing. Fortunately in this case, the mother and the day care providers were not pregnant. The parents were reassured that this would go away on its own. They were told that their son should avoid excessive heat and sunlight, which can cause the rash to flare up. Children who present with the classic skin findings of fifth disease are past the infectious state and can attend school and day care. The child in this case returned to day care the next day with a note from the FP.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Fifth disease. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:728-731.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The patient’s “slapped-cheek” appearance led to the diagnosis: fifth disease (erythema infectiosum). The name of the diagnosis derives from the fact that it represents the fifth of 6 common childhood viral exanthems. Transmission of the causative parvovirus B19 occurs through respiratory secretions (possibly through fomites), parenterally via vertical transmission from mother to fetus, or by transfusion of blood or blood products.

Fifth disease is very contagious via the respiratory route and occurs more frequently between late winter and early summer. Up to 60% of the population is seropositive for antiparvovirus B19 immunoglobulin G (IgG) by age 20. Thirty to 40% of pregnant women lack measurable IgG to the infecting agent and are therefore presumed to be susceptible to infection. Infection during pregnancy can, in some cases, lead to fetal death.

Fifth disease is usually a biphasic illness, starting with upper respiratory tract symptoms that may include headache, fever, sore throat, pruritus, coryza, abdominal pain, diarrhea, and/or arthralgias. These constitutional symptoms coincide with the onset of viremia and usually resolve (for about a week) before the next stage begins. The second stage is characterized by a classic erythematous malar rash with relative circumoral pallor (the “slapped-cheek” appearance in children). This is followed by a “lace-like” erythematous rash on the trunk and extremities. 

Pregnant women who are exposed to or have symptoms of parvovirus infection should have serologic testing. Fortunately in this case, the mother and the day care providers were not pregnant. The parents were reassured that this would go away on its own. They were told that their son should avoid excessive heat and sunlight, which can cause the rash to flare up. Children who present with the classic skin findings of fifth disease are past the infectious state and can attend school and day care. The child in this case returned to day care the next day with a note from the FP.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Fifth disease. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:728-731.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The patient’s “slapped-cheek” appearance led to the diagnosis: fifth disease (erythema infectiosum). The name of the diagnosis derives from the fact that it represents the fifth of 6 common childhood viral exanthems. Transmission of the causative parvovirus B19 occurs through respiratory secretions (possibly through fomites), parenterally via vertical transmission from mother to fetus, or by transfusion of blood or blood products.

Fifth disease is very contagious via the respiratory route and occurs more frequently between late winter and early summer. Up to 60% of the population is seropositive for antiparvovirus B19 immunoglobulin G (IgG) by age 20. Thirty to 40% of pregnant women lack measurable IgG to the infecting agent and are therefore presumed to be susceptible to infection. Infection during pregnancy can, in some cases, lead to fetal death.

Fifth disease is usually a biphasic illness, starting with upper respiratory tract symptoms that may include headache, fever, sore throat, pruritus, coryza, abdominal pain, diarrhea, and/or arthralgias. These constitutional symptoms coincide with the onset of viremia and usually resolve (for about a week) before the next stage begins. The second stage is characterized by a classic erythematous malar rash with relative circumoral pallor (the “slapped-cheek” appearance in children). This is followed by a “lace-like” erythematous rash on the trunk and extremities. 

Pregnant women who are exposed to or have symptoms of parvovirus infection should have serologic testing. Fortunately in this case, the mother and the day care providers were not pregnant. The parents were reassured that this would go away on its own. They were told that their son should avoid excessive heat and sunlight, which can cause the rash to flare up. Children who present with the classic skin findings of fifth disease are past the infectious state and can attend school and day care. The child in this case returned to day care the next day with a note from the FP.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Fifth disease. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:728-731.

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