Clinical Review

Calcium pyrophosphate (CPP) crystals may deposit in both articular tissues (predominantly hyaline cartilage and fibrocartilage) and periarticular soft tissues.^1,2 Calcium pyrophosphate deposition disease (CPPD) may be asymptomatic or be associated with a spectrum of clinical syndromes, including both acute and chronic inflammatory arthritis.²

The European League Against Rheumatism (EULAR) recently suggested changes in CPPD terminology.² According to the new EULAR classification, pseudogout, or CPPD, has been reclassified based on new key terms that include several of the previously described disease phenotypes: asymptomatic CPPD; acute CPP crystal arthritis (previously known as pseudogout); osteoarthritis (OA) with CPPD (previously, pseudo-OA); and the chronic CCP crystal inflammatory arthritis (previously, pseudorheumatoid arthritis). In similar fashion, chondrocalcinosis (CC) refers to calcification of the fibrocartilage and/or hyaline cartilage identified by imaging or histologic analysis. Although CC is most commonly seen in CPPD, it is not exclusive to this disease, as it can be seen in other crystal diseases (oxalosis, basic calcium phosphate [BCP]) and can appear as casual finding or coexist with OA.²

Clinical Manifestations

In clinical practice, CPPD may present with several phenotypic forms. In asymptomatic CPPD, CC is a common radiographic finding without clinical symptoms. Acute CPP arthritis always should be suspected in any patient aged > 65 years presenting with acute monoarticular or oligoarticular, migratory or additive, symmetrical, or polyarticular arthritis.³ Acute CCP arthritis is characterized by self-limited acute or subacute attacks of arthritis involving 1 or several extremity joints (knees, wrists, ankles; rarely affects large toe). Typically, the acute attacks last 7 to 10 days. Several unusual sites (eg, the hip joints, trochanteric bursa, and deep spinal joints) also may be affected. However, differences in pattern of joint involvement are insufficient to permit definitive diagnosis without demonstration of the specific crystal type in the inflammatory joint fluid.

Pseudogout attacks closely resemble gouty arthritis; CPPD presents as intermittent flares and often is asymptomatic between flares. Trauma, surgery, or severe medical illness frequently provokes attacks of monosodium urate (MSU) as well as acute CPP arthritis. Systemic findings, such as fever; leukocytosis with a left shift in the differential count; inflammatory markers, such as elevated sedimentation rate (ESR); or C-reactive protein, also can occur, resembling pyogenic arthritis, osteomyelitis, and/or systemic sepsis in the elderly patient.

Diagnosis must be confirmed with aspiration, Gram stain and cultures of the synovial fluid, and evaluation for the presence of CPP crystals under polarized light microscopy.² The diagnosis can be difficult to confirm secondary to the weakly birefringent nature of CPP crystals.⁴ Coexistence of MSU and CPP crystals in a single inflammatory effusion is neither uncommon nor unexplained given increased frequencies of both hyperuricemia/gout and CC among elderly patients.⁵

Chronic CPP crystal inflammatory arthritis may present as a chronic, symmetrical, bilateral, and deforming polyarthritis. It frequently affects the wrists and metacarpophalangeal joints and tendon sheaths. Chronic CPP may resemble rheumatoid arthritis (RA) and produce wrist tenosynovitis, which may manifest as carpal tunnel syndrome and/or cubital tunnel syndrome. Calcium pyrophosphate deposition disease should be on the differential diagnosis in the elderly patient presenting with a clinical picture that resembles “seronegative” RA, with morning stiffness, synovial thickening, localized edema, and restricted motion due to active inflammation or flexion contracture of the hands/wrist. It may present with prominent systemic features, such as leukocytosis, fevers, mental confusion, and inflammatory oligoarthritis or polyarthritis. The diagnosis of CPPD still may be possible even though the rheumatoid factor (RF) is positive, given the increasing likelihood of elevated RF in the older population. In this setting, aspiration of joint fluid and radiography will assist in clarification of the diagnosis. Furthermore, CPPD typically does not cause the type of erosive disease that is often seen in RA.

Calcium pyrophosphate deposition disease also can mimic polymyalgia rheumatica (PMR). A direct comparison of a cohort of patients with pseudo-PMR (PMR/CPPD) with actual PMR patients found that increased age at diagnosis, presence of knee osteoarthritis, tendinous calcifications, and ankle arthritis carried the highest predictive value in patients with CPPD presenting with PMR-like symptoms.⁶ However, the PMR/CPPD variant can be difficult to distinguish, because both conditions can have elevated systemic inflammatory markers, and both are steroid responsive.

Calcium pyrophosphate deposition disease involving a single joint can rarely lead to extensive destruction—as with neuropathic joints in the absence of any neurologic deficits—and is extremely debilitating. This presentation is not well understood and does not have good treatment alternatives. Calcium pyrophosphate crystals often are associated with manifestations of OA.^1,2 Indeed, up to 20% of OA joints have been found to be positive for CPP crystals in various studies. Given the extensive evidence supporting treatment of OA, usually they are treated in a similar fashion with good results. Occasionally, these will have unusual manifestations for typical OA, such as involvement of wrists and metacarpophalangeal joints; however, the presentation is often indolent like OA.

Calcium pyrophosphate crystal deposition involving the spine has been associated with a number of clinical manifestations. Spine stiffness, sometimes associated with bony ankylosis, can resemble ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Such symptoms are seen more commonly in familial CPPD rather than in the elderly. However, crystal deposition in the ligamentum flavum at the cervical spine levels has been associated with a condition called crowned dens syndrome.⁷ Although mostly asymptomatic, it may be present with acute neck pain, fever, and an increased ESR, sometimes mimicking PMR or giant cell arteritis or neurologic symptoms. Similarly, CPP crystal deposition in the posterior longitudinal ligament at the lower levels of the spine may lead to spinal cord compression syndromes or symptoms of either acute nerve compression or chronic spinal stenosis.^8,9 Calcium pyrophosphate crystal deposition also can occur in other soft tissues, such as bursae, ligaments, and tendons and may be sufficient to cause local nerve compression, such as carpal or cubital tunnel syndrome.

Epidemiology

Radiographic surveys of the knees, hands, wrists, and pelvis and epidemiologic studies have demonstrated an age-related increase in the prevalence of CPPD: 15% prevalence in patients aged 65 to 74 years, 36% prevalence in patients aged 75 to 84 years, and 50% prevalence in patients aged > 84 years.¹⁰ In a recent radiographic study, 40% of patients with CPPD did not present with CC of the knee, and the study’s authors recommended additional radiographs of pelvis, wrists, or hands for accurate diagnosis of radiographic CC.¹¹

Diagnosis

Accurate diagnosis should be achieved on the basis of the clinical picture and demonstration of CPP crystals in synovial fluid or tissue by compensated polarized light microscopy (Figures 1A and 1B).² The sensitivity and specificity for CPP crystal detection has been shown to be 95.9% and 86.5%, respectively.¹² However, the CPP crystal is more readily identified by a rheumatologist rather than in a standard hospital laboratory, which misses 30% of CPP crystals.¹³

Findings of CC on radiograph strengthens a CPPD diagnosis, but its absence does not rule it out (Figure 2A).² More recently, the use of new imaging modalities, such as musculoskeletal ultrasound, provides the capacity to visualize crystal deposits within the joint structures, the hyaline cartilage, and/or fibrocartilage (Figure 2B and 2C).¹⁴ The presence of hyperechoic bands within the intermediate layer hyaline cartilage and hyperechoic spots in fibrocartilage are consistent with CPP crystal deposits.^2,14 The use of computed tomography is the gold standard imaging modality for the identification of CPPD of the spine.¹⁵ There is not enough evidence to support the use of magnetic resonance imaging in CPPD, but it may play a role in rare complications.²

Treatment

The EULAR recently defined new guidelines for the management of CPPD.¹⁶ Asymptomatic CPPD needs no treatment.In other CPPD phenotypes, the goals are to attempt prompt resolution of the acute synovitis, reduction in chronic damage, and management of associated conditions.In acute attacks, treatment modalities used in gout are often required; however, data for CPPD treatment are limited (Table). Treatment relies on the use of colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs), but toxicity and comorbidities in the elderly limit the usage of these drugs.

Given increased renal impairment, the loading dose of colchicine is not recommended.¹⁶ Colchicine has recently been shown to completely block crystal-induced maturation of IL-1β in vitro, indicating that the drug acts upstream of inflammasome activation.¹⁷ This is in addition to the well-known role of colchicine in inhibition of micro-tubule formation, which likely leads to prevention of cell migration, phagocytosis, and activation of inflammasome.^18-20

Intra-articular injection of corticosteroid is an efficient and well-tolerated treatment alternative for monoarticular CPP flares. Oral or parenteral corticosteroids are frequently used for polyarticular flares in particular for those patients in which NSAIDs and colchicine are contraindicated.¹⁶ Parenteral adrenocorticotropic hormone has been used in patients with congestive heart failure, renal insufficiency, gastrointestinal bleeding, or resistance to NSAIDs.²¹ For prophylaxis of acute CPP crystal arthritis, a low dose of oral NSAIDs, oral colchicine, or prednisone may be used with good results.¹⁶ In chronic CPP arthritis, continuous use of colchicine, NSAIDs, or low-dose prednisone is often appropriate. If these interventions are ineffective or contraindicated, using hydroxychloroquine (HCQ) and methotrexate (MTX) have been successfully used to control chronic CPP crystal inflammation.^22,23 Recent trials have raised questions about MTX, and further trials on HCQ usage are underway.²⁴ Biologic agents targeting IL-1 are not currently approved for the treatment of CPPD, but there are suggestions that it may be effective in refractory cases and induce rapid stable remissions after 3 days of therapy.²⁵

In contrast to gout, there is no specific target therapy for lowering CPP crystal load in the elderly. Crucial in the management of CPPD in the elderly is the search for associated diseases, such as hyperparathyroidism, hemochromatosis, hypomagnesemia, and hypophosphatemia, as well as avoidance of tacrolimus, which facilitates or causes CC.¹⁶ Correction of the underlying metabolic disorder, especially when undertaken early, may reduce the severity of CPPD. However, there is little evidence to suggest that treatment of associated disease results in resolution of CPPD—most famously, although therapeutic phlebotomy does not help in hemochromatosis for prevention of crystal disease, chelating agents do seem to be moderately effective.²⁶ Only oral administration of magnesium has shown a reduction in meniscal CC in a patient with CPPD arthropathy.²⁷ In addition, this was in the setting of familial hypomagnesemia associated CPPD. However, unlike uricosuric agents for gout, no pharmacologic treatments can prevent CPPD crystal formation and deposition in tissues.

Therapeutic Agents

Magnesium

Magnesium is a cofactor for the activity of pyrophosphatases that converts inorganic pyrophosphates (PPis) into orthophosphates. In addition, magnesium can increase the solubility of CPP crystals. Early detection and management of hypomagnesemia are recommended, because it occurs in patients who have well-defined conditions and situations: Gitelman syndrome, thiazide and loop diuretics use, tacrolimus use, familial forms of renal magnesium wasting or use of proton pump inhibitors, short bowel syndrome, and intestinal failure in patients receiving home parenteral nutrition. Long-term administration of magnesium in some patients with chronic hypomagnesemia decreased meniscal calcification.^27-29

Dietary Calcium

Epidemiologic studies showed a lower incidence of CC in Chinese subjects. The authors of the study speculate that this lower prevalence of CPPD could result from high levels of calcium found in the drinking water in Beijing, which may affect parathyroid hormone secretion.³⁰ Further studies are needed to confirm this hypothesis, as it could be a cheaper approach to pseudogout prevention.

Probenecid

Probenecid is an in vitro inhibitor of the transmembrane PPi transporter thought to possibly prevent extracellular PPi elaboration. However, this observation has not been confirmed by either case reports or clinical trials.³¹

Phosphocitrate

Phosphocitrate acts directly on preventing crystal deposition in tissues in CPPD as well as BCP based on in vitro evidence and mouse models.^32,33

Hyaluronan

An amelioration of pain and increased range of motion were observed in radiographic CC with OA.³⁴ However, it is associated with increased acute CPP arthritis.³⁵

Radiosynovectomy

In a double-blind study of 15 patients with symmetrical CPPD arthropathy, the knee that underwent intra-articular injection of yttrium-90 (5 mCi) plus steroid had less pain, stiffness, joint line tenderness, and effusion compared with the contralateral control knee injected with saline and steroids.³⁶

Precipitators of Acute Pseudogout

Diuretics are known to exacerbate gout, but they also can exacerbate pseudogout. A recent case-control study nested within a United Kingdom general practice database found that loop diuretics rather than hydrochlorothiazide was associated with increased risk of CPPD mediated primarily by magnesium reabsorption in the loop of Henle.²⁸ Chronic kidney disease associated with secondary and tertiary hyperparathyroidism increases calcium or PPi concentration, which leads to CPP-crystal deposition.

In addition, multiple case reports have described acute pseudogout caused by bisphosphonate administration for osteoporosis or Paget disease—more likely in the elderly population. Intravenous pamidronate, oral etidronate, and alendronate therapy have all been described in the elderly.³⁷ The overall mechanism behind this link is not completely understood, but bisphosphonates are structurally similar to PPi. Pseudogout attacks also have been described in neutropenic patients undergoing treatment with granulocyte-colony stimulating factor.³⁸ In addition to pharmaceutical exacerbation of pseudogout, surgical procedures and trauma can precipitate attacks. Joint lavage has been described to increase the incidence of pseudogout.³⁹ It was hypothesized that joint lavage with fluid induced “crystal shedding” from CPPD crystals imbedded in the joint tissue. Patients who underwent meniscectomy of the knee 20 years ago had a 20% incidence of CC in the knee that was operated compared with 4% CC in the contralateral nonoperated knee.⁴⁰ Overall, the surgery most linked with a pseudogout attack, however, is parathyroidectomy.⁴¹

Basic Calcium Phosphate Crystals

Basic calcium phosphate crystals are common but rarely diagnosed due to the cumbersome and expensive methods required to identify these crystals.⁴²

Basic calcium phosphate and CPPD crystals may coexist in synovial fluid. Similar to CPPD, BCP crystal disease is often concurrent with OA and can cause calcification of articular cartilage. Basic calcium phosphate is more common than CPP crystals with occurrence of 30% to 50% in OA synovial fluid.⁴² Additionally, BCP crystal disease has been linked to increased severity of OA. Basic calcium phosphate crystals in knee joints were found to have radiographically more severe arthritis with larger effusions.^44,45 Similarly, BCP crystals in OA synovial fluid correlated with higher Kellgreen-Lawrence grade scores by radiography.^42,46

It is currently believed that BCP crystals are continuously formed in the extracellular matrix, and their deposition is actively prevented by PPi present in the matrix.⁴⁷ Elevated PPi levels, on the other hand, favor the formation of CPP crystals.⁴⁸ The clinical upshot seems to be that although CPP crystals are almost universally intra-articular and released by chondrocytes, BCD crystals and deposits are more frequently present in soft tissues.

Acute Calcific Tendinitis

Typically, this type of tendinitis involves the shoulder joint and is extra-articular. Common treatments help, including NSAIDs, intra-articular steroids, ice, and rest. In addition, high-energy extracorporeal shock wave therapy has been shown to be effective when used with conscious sedation.^49,50 Needling or barbotage in association with lavage and steroid injections also is effective and has occasionally been shown to reduce the size of the calcium deposit as well, often in combination with IV drugs like ethylenediaminetetraacetic acid.^51-53

Acute calcific periarthritis of the hand presents similar to gout or pseudogout, affecting the wrist, usually in postmenopausal women.⁵⁴ Basic calcium phosphate crystals are aspirated from the joint, and periarticular crystals may be subtle. Local steroid injections are beneficial.Milwaukee shoulder syndrome is an arthropathy associated with BCP crystals in the joint fluid and results in extensive destruction of shoulder articular cartilage and surrounding tissues. It is commonly bilateral and occurs in elderly women more often than it does in men.⁵⁵ Aspiration of the shoulder joint typically reveals a serosanginous fluid. Fluid samples can be assessed for hydroxyapatite crystals by staining with alizarin red dye, which produces a characteristic “halo” or orange-red stain by light microscopy.⁴³ Surgical treatment of Milwaukee shoulder syndrome is difficult due to increased age of the population affected and the severity of the shoulder destruction. Usually a conservative approach of analgesics, recurrent shoulder aspirations, and steroid injections is the best treatment option.

Conclusions

Calcium-containing crystal-associated arthropathies are a complex array of entities that target the veteran elderly population with increasing frequency. Challenges still remain in the diagnosis, crystal identification, and treatment due to coexisting comorbid conditions and polypharmacy commonly seen in veterans. Overall morbidity associated with calcium-containing crystal-associated arthropathies and the coexisting osteoarthritis is great, and focused identification of the disease process with tailored treatment can achieve the goal of decreasing symptoms and improving quality of life.

Acknowledgements
This work was supported by grant P20GM104937 (A.M.R.).

Calcium pyrophosphate (CPP) crystals may deposit in both articular tissues (predominantly hyaline cartilage and fibrocartilage) and periarticular soft tissues.^1,2 Calcium pyrophosphate deposition disease (CPPD) may be asymptomatic or be associated with a spectrum of clinical syndromes, including both acute and chronic inflammatory arthritis.²

The European League Against Rheumatism (EULAR) recently suggested changes in CPPD terminology.² According to the new EULAR classification, pseudogout, or CPPD, has been reclassified based on new key terms that include several of the previously described disease phenotypes: asymptomatic CPPD; acute CPP crystal arthritis (previously known as pseudogout); osteoarthritis (OA) with CPPD (previously, pseudo-OA); and the chronic CCP crystal inflammatory arthritis (previously, pseudorheumatoid arthritis). In similar fashion, chondrocalcinosis (CC) refers to calcification of the fibrocartilage and/or hyaline cartilage identified by imaging or histologic analysis. Although CC is most commonly seen in CPPD, it is not exclusive to this disease, as it can be seen in other crystal diseases (oxalosis, basic calcium phosphate [BCP]) and can appear as casual finding or coexist with OA.²

Clinical Manifestations

In clinical practice, CPPD may present with several phenotypic forms. In asymptomatic CPPD, CC is a common radiographic finding without clinical symptoms. Acute CPP arthritis always should be suspected in any patient aged > 65 years presenting with acute monoarticular or oligoarticular, migratory or additive, symmetrical, or polyarticular arthritis.³ Acute CCP arthritis is characterized by self-limited acute or subacute attacks of arthritis involving 1 or several extremity joints (knees, wrists, ankles; rarely affects large toe). Typically, the acute attacks last 7 to 10 days. Several unusual sites (eg, the hip joints, trochanteric bursa, and deep spinal joints) also may be affected. However, differences in pattern of joint involvement are insufficient to permit definitive diagnosis without demonstration of the specific crystal type in the inflammatory joint fluid.

Pseudogout attacks closely resemble gouty arthritis; CPPD presents as intermittent flares and often is asymptomatic between flares. Trauma, surgery, or severe medical illness frequently provokes attacks of monosodium urate (MSU) as well as acute CPP arthritis. Systemic findings, such as fever; leukocytosis with a left shift in the differential count; inflammatory markers, such as elevated sedimentation rate (ESR); or C-reactive protein, also can occur, resembling pyogenic arthritis, osteomyelitis, and/or systemic sepsis in the elderly patient.

Diagnosis must be confirmed with aspiration, Gram stain and cultures of the synovial fluid, and evaluation for the presence of CPP crystals under polarized light microscopy.² The diagnosis can be difficult to confirm secondary to the weakly birefringent nature of CPP crystals.⁴ Coexistence of MSU and CPP crystals in a single inflammatory effusion is neither uncommon nor unexplained given increased frequencies of both hyperuricemia/gout and CC among elderly patients.⁵

Chronic CPP crystal inflammatory arthritis may present as a chronic, symmetrical, bilateral, and deforming polyarthritis. It frequently affects the wrists and metacarpophalangeal joints and tendon sheaths. Chronic CPP may resemble rheumatoid arthritis (RA) and produce wrist tenosynovitis, which may manifest as carpal tunnel syndrome and/or cubital tunnel syndrome. Calcium pyrophosphate deposition disease should be on the differential diagnosis in the elderly patient presenting with a clinical picture that resembles “seronegative” RA, with morning stiffness, synovial thickening, localized edema, and restricted motion due to active inflammation or flexion contracture of the hands/wrist. It may present with prominent systemic features, such as leukocytosis, fevers, mental confusion, and inflammatory oligoarthritis or polyarthritis. The diagnosis of CPPD still may be possible even though the rheumatoid factor (RF) is positive, given the increasing likelihood of elevated RF in the older population. In this setting, aspiration of joint fluid and radiography will assist in clarification of the diagnosis. Furthermore, CPPD typically does not cause the type of erosive disease that is often seen in RA.

Calcium pyrophosphate deposition disease also can mimic polymyalgia rheumatica (PMR). A direct comparison of a cohort of patients with pseudo-PMR (PMR/CPPD) with actual PMR patients found that increased age at diagnosis, presence of knee osteoarthritis, tendinous calcifications, and ankle arthritis carried the highest predictive value in patients with CPPD presenting with PMR-like symptoms.⁶ However, the PMR/CPPD variant can be difficult to distinguish, because both conditions can have elevated systemic inflammatory markers, and both are steroid responsive.

Calcium pyrophosphate deposition disease involving a single joint can rarely lead to extensive destruction—as with neuropathic joints in the absence of any neurologic deficits—and is extremely debilitating. This presentation is not well understood and does not have good treatment alternatives. Calcium pyrophosphate crystals often are associated with manifestations of OA.^1,2 Indeed, up to 20% of OA joints have been found to be positive for CPP crystals in various studies. Given the extensive evidence supporting treatment of OA, usually they are treated in a similar fashion with good results. Occasionally, these will have unusual manifestations for typical OA, such as involvement of wrists and metacarpophalangeal joints; however, the presentation is often indolent like OA.

Calcium pyrophosphate crystal deposition involving the spine has been associated with a number of clinical manifestations. Spine stiffness, sometimes associated with bony ankylosis, can resemble ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Such symptoms are seen more commonly in familial CPPD rather than in the elderly. However, crystal deposition in the ligamentum flavum at the cervical spine levels has been associated with a condition called crowned dens syndrome.⁷ Although mostly asymptomatic, it may be present with acute neck pain, fever, and an increased ESR, sometimes mimicking PMR or giant cell arteritis or neurologic symptoms. Similarly, CPP crystal deposition in the posterior longitudinal ligament at the lower levels of the spine may lead to spinal cord compression syndromes or symptoms of either acute nerve compression or chronic spinal stenosis.^8,9 Calcium pyrophosphate crystal deposition also can occur in other soft tissues, such as bursae, ligaments, and tendons and may be sufficient to cause local nerve compression, such as carpal or cubital tunnel syndrome.

Epidemiology

Radiographic surveys of the knees, hands, wrists, and pelvis and epidemiologic studies have demonstrated an age-related increase in the prevalence of CPPD: 15% prevalence in patients aged 65 to 74 years, 36% prevalence in patients aged 75 to 84 years, and 50% prevalence in patients aged > 84 years.¹⁰ In a recent radiographic study, 40% of patients with CPPD did not present with CC of the knee, and the study’s authors recommended additional radiographs of pelvis, wrists, or hands for accurate diagnosis of radiographic CC.¹¹

Diagnosis

Accurate diagnosis should be achieved on the basis of the clinical picture and demonstration of CPP crystals in synovial fluid or tissue by compensated polarized light microscopy (Figures 1A and 1B).² The sensitivity and specificity for CPP crystal detection has been shown to be 95.9% and 86.5%, respectively.¹² However, the CPP crystal is more readily identified by a rheumatologist rather than in a standard hospital laboratory, which misses 30% of CPP crystals.¹³

Findings of CC on radiograph strengthens a CPPD diagnosis, but its absence does not rule it out (Figure 2A).² More recently, the use of new imaging modalities, such as musculoskeletal ultrasound, provides the capacity to visualize crystal deposits within the joint structures, the hyaline cartilage, and/or fibrocartilage (Figure 2B and 2C).¹⁴ The presence of hyperechoic bands within the intermediate layer hyaline cartilage and hyperechoic spots in fibrocartilage are consistent with CPP crystal deposits.^2,14 The use of computed tomography is the gold standard imaging modality for the identification of CPPD of the spine.¹⁵ There is not enough evidence to support the use of magnetic resonance imaging in CPPD, but it may play a role in rare complications.²

Treatment

The EULAR recently defined new guidelines for the management of CPPD.¹⁶ Asymptomatic CPPD needs no treatment.In other CPPD phenotypes, the goals are to attempt prompt resolution of the acute synovitis, reduction in chronic damage, and management of associated conditions.In acute attacks, treatment modalities used in gout are often required; however, data for CPPD treatment are limited (Table). Treatment relies on the use of colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs), but toxicity and comorbidities in the elderly limit the usage of these drugs.

Given increased renal impairment, the loading dose of colchicine is not recommended.¹⁶ Colchicine has recently been shown to completely block crystal-induced maturation of IL-1β in vitro, indicating that the drug acts upstream of inflammasome activation.¹⁷ This is in addition to the well-known role of colchicine in inhibition of micro-tubule formation, which likely leads to prevention of cell migration, phagocytosis, and activation of inflammasome.^18-20

Intra-articular injection of corticosteroid is an efficient and well-tolerated treatment alternative for monoarticular CPP flares. Oral or parenteral corticosteroids are frequently used for polyarticular flares in particular for those patients in which NSAIDs and colchicine are contraindicated.¹⁶ Parenteral adrenocorticotropic hormone has been used in patients with congestive heart failure, renal insufficiency, gastrointestinal bleeding, or resistance to NSAIDs.²¹ For prophylaxis of acute CPP crystal arthritis, a low dose of oral NSAIDs, oral colchicine, or prednisone may be used with good results.¹⁶ In chronic CPP arthritis, continuous use of colchicine, NSAIDs, or low-dose prednisone is often appropriate. If these interventions are ineffective or contraindicated, using hydroxychloroquine (HCQ) and methotrexate (MTX) have been successfully used to control chronic CPP crystal inflammation.^22,23 Recent trials have raised questions about MTX, and further trials on HCQ usage are underway.²⁴ Biologic agents targeting IL-1 are not currently approved for the treatment of CPPD, but there are suggestions that it may be effective in refractory cases and induce rapid stable remissions after 3 days of therapy.²⁵

In contrast to gout, there is no specific target therapy for lowering CPP crystal load in the elderly. Crucial in the management of CPPD in the elderly is the search for associated diseases, such as hyperparathyroidism, hemochromatosis, hypomagnesemia, and hypophosphatemia, as well as avoidance of tacrolimus, which facilitates or causes CC.¹⁶ Correction of the underlying metabolic disorder, especially when undertaken early, may reduce the severity of CPPD. However, there is little evidence to suggest that treatment of associated disease results in resolution of CPPD—most famously, although therapeutic phlebotomy does not help in hemochromatosis for prevention of crystal disease, chelating agents do seem to be moderately effective.²⁶ Only oral administration of magnesium has shown a reduction in meniscal CC in a patient with CPPD arthropathy.²⁷ In addition, this was in the setting of familial hypomagnesemia associated CPPD. However, unlike uricosuric agents for gout, no pharmacologic treatments can prevent CPPD crystal formation and deposition in tissues.

Therapeutic Agents

Magnesium

Magnesium is a cofactor for the activity of pyrophosphatases that converts inorganic pyrophosphates (PPis) into orthophosphates. In addition, magnesium can increase the solubility of CPP crystals. Early detection and management of hypomagnesemia are recommended, because it occurs in patients who have well-defined conditions and situations: Gitelman syndrome, thiazide and loop diuretics use, tacrolimus use, familial forms of renal magnesium wasting or use of proton pump inhibitors, short bowel syndrome, and intestinal failure in patients receiving home parenteral nutrition. Long-term administration of magnesium in some patients with chronic hypomagnesemia decreased meniscal calcification.^27-29

Dietary Calcium

Epidemiologic studies showed a lower incidence of CC in Chinese subjects. The authors of the study speculate that this lower prevalence of CPPD could result from high levels of calcium found in the drinking water in Beijing, which may affect parathyroid hormone secretion.³⁰ Further studies are needed to confirm this hypothesis, as it could be a cheaper approach to pseudogout prevention.

Probenecid

Probenecid is an in vitro inhibitor of the transmembrane PPi transporter thought to possibly prevent extracellular PPi elaboration. However, this observation has not been confirmed by either case reports or clinical trials.³¹

Phosphocitrate

Phosphocitrate acts directly on preventing crystal deposition in tissues in CPPD as well as BCP based on in vitro evidence and mouse models.^32,33

Hyaluronan

An amelioration of pain and increased range of motion were observed in radiographic CC with OA.³⁴ However, it is associated with increased acute CPP arthritis.³⁵

Radiosynovectomy

In a double-blind study of 15 patients with symmetrical CPPD arthropathy, the knee that underwent intra-articular injection of yttrium-90 (5 mCi) plus steroid had less pain, stiffness, joint line tenderness, and effusion compared with the contralateral control knee injected with saline and steroids.³⁶

Precipitators of Acute Pseudogout

Diuretics are known to exacerbate gout, but they also can exacerbate pseudogout. A recent case-control study nested within a United Kingdom general practice database found that loop diuretics rather than hydrochlorothiazide was associated with increased risk of CPPD mediated primarily by magnesium reabsorption in the loop of Henle.²⁸ Chronic kidney disease associated with secondary and tertiary hyperparathyroidism increases calcium or PPi concentration, which leads to CPP-crystal deposition.

In addition, multiple case reports have described acute pseudogout caused by bisphosphonate administration for osteoporosis or Paget disease—more likely in the elderly population. Intravenous pamidronate, oral etidronate, and alendronate therapy have all been described in the elderly.³⁷ The overall mechanism behind this link is not completely understood, but bisphosphonates are structurally similar to PPi. Pseudogout attacks also have been described in neutropenic patients undergoing treatment with granulocyte-colony stimulating factor.³⁸ In addition to pharmaceutical exacerbation of pseudogout, surgical procedures and trauma can precipitate attacks. Joint lavage has been described to increase the incidence of pseudogout.³⁹ It was hypothesized that joint lavage with fluid induced “crystal shedding” from CPPD crystals imbedded in the joint tissue. Patients who underwent meniscectomy of the knee 20 years ago had a 20% incidence of CC in the knee that was operated compared with 4% CC in the contralateral nonoperated knee.⁴⁰ Overall, the surgery most linked with a pseudogout attack, however, is parathyroidectomy.⁴¹

Basic Calcium Phosphate Crystals

Basic calcium phosphate crystals are common but rarely diagnosed due to the cumbersome and expensive methods required to identify these crystals.⁴²

Basic calcium phosphate and CPPD crystals may coexist in synovial fluid. Similar to CPPD, BCP crystal disease is often concurrent with OA and can cause calcification of articular cartilage. Basic calcium phosphate is more common than CPP crystals with occurrence of 30% to 50% in OA synovial fluid.⁴² Additionally, BCP crystal disease has been linked to increased severity of OA. Basic calcium phosphate crystals in knee joints were found to have radiographically more severe arthritis with larger effusions.^44,45 Similarly, BCP crystals in OA synovial fluid correlated with higher Kellgreen-Lawrence grade scores by radiography.^42,46

It is currently believed that BCP crystals are continuously formed in the extracellular matrix, and their deposition is actively prevented by PPi present in the matrix.⁴⁷ Elevated PPi levels, on the other hand, favor the formation of CPP crystals.⁴⁸ The clinical upshot seems to be that although CPP crystals are almost universally intra-articular and released by chondrocytes, BCD crystals and deposits are more frequently present in soft tissues.

Acute Calcific Tendinitis

Typically, this type of tendinitis involves the shoulder joint and is extra-articular. Common treatments help, including NSAIDs, intra-articular steroids, ice, and rest. In addition, high-energy extracorporeal shock wave therapy has been shown to be effective when used with conscious sedation.^49,50 Needling or barbotage in association with lavage and steroid injections also is effective and has occasionally been shown to reduce the size of the calcium deposit as well, often in combination with IV drugs like ethylenediaminetetraacetic acid.^51-53

Acute calcific periarthritis of the hand presents similar to gout or pseudogout, affecting the wrist, usually in postmenopausal women.⁵⁴ Basic calcium phosphate crystals are aspirated from the joint, and periarticular crystals may be subtle. Local steroid injections are beneficial.Milwaukee shoulder syndrome is an arthropathy associated with BCP crystals in the joint fluid and results in extensive destruction of shoulder articular cartilage and surrounding tissues. It is commonly bilateral and occurs in elderly women more often than it does in men.⁵⁵ Aspiration of the shoulder joint typically reveals a serosanginous fluid. Fluid samples can be assessed for hydroxyapatite crystals by staining with alizarin red dye, which produces a characteristic “halo” or orange-red stain by light microscopy.⁴³ Surgical treatment of Milwaukee shoulder syndrome is difficult due to increased age of the population affected and the severity of the shoulder destruction. Usually a conservative approach of analgesics, recurrent shoulder aspirations, and steroid injections is the best treatment option.

Conclusions

Calcium-containing crystal-associated arthropathies are a complex array of entities that target the veteran elderly population with increasing frequency. Challenges still remain in the diagnosis, crystal identification, and treatment due to coexisting comorbid conditions and polypharmacy commonly seen in veterans. Overall morbidity associated with calcium-containing crystal-associated arthropathies and the coexisting osteoarthritis is great, and focused identification of the disease process with tailored treatment can achieve the goal of decreasing symptoms and improving quality of life.

Acknowledgements
This work was supported by grant P20GM104937 (A.M.R.).

Calcium pyrophosphate (CPP) crystals may deposit in both articular tissues (predominantly hyaline cartilage and fibrocartilage) and periarticular soft tissues.^1,2 Calcium pyrophosphate deposition disease (CPPD) may be asymptomatic or be associated with a spectrum of clinical syndromes, including both acute and chronic inflammatory arthritis.²

The European League Against Rheumatism (EULAR) recently suggested changes in CPPD terminology.² According to the new EULAR classification, pseudogout, or CPPD, has been reclassified based on new key terms that include several of the previously described disease phenotypes: asymptomatic CPPD; acute CPP crystal arthritis (previously known as pseudogout); osteoarthritis (OA) with CPPD (previously, pseudo-OA); and the chronic CCP crystal inflammatory arthritis (previously, pseudorheumatoid arthritis). In similar fashion, chondrocalcinosis (CC) refers to calcification of the fibrocartilage and/or hyaline cartilage identified by imaging or histologic analysis. Although CC is most commonly seen in CPPD, it is not exclusive to this disease, as it can be seen in other crystal diseases (oxalosis, basic calcium phosphate [BCP]) and can appear as casual finding or coexist with OA.²

Clinical Manifestations

In clinical practice, CPPD may present with several phenotypic forms. In asymptomatic CPPD, CC is a common radiographic finding without clinical symptoms. Acute CPP arthritis always should be suspected in any patient aged > 65 years presenting with acute monoarticular or oligoarticular, migratory or additive, symmetrical, or polyarticular arthritis.³ Acute CCP arthritis is characterized by self-limited acute or subacute attacks of arthritis involving 1 or several extremity joints (knees, wrists, ankles; rarely affects large toe). Typically, the acute attacks last 7 to 10 days. Several unusual sites (eg, the hip joints, trochanteric bursa, and deep spinal joints) also may be affected. However, differences in pattern of joint involvement are insufficient to permit definitive diagnosis without demonstration of the specific crystal type in the inflammatory joint fluid.

Pseudogout attacks closely resemble gouty arthritis; CPPD presents as intermittent flares and often is asymptomatic between flares. Trauma, surgery, or severe medical illness frequently provokes attacks of monosodium urate (MSU) as well as acute CPP arthritis. Systemic findings, such as fever; leukocytosis with a left shift in the differential count; inflammatory markers, such as elevated sedimentation rate (ESR); or C-reactive protein, also can occur, resembling pyogenic arthritis, osteomyelitis, and/or systemic sepsis in the elderly patient.

Diagnosis must be confirmed with aspiration, Gram stain and cultures of the synovial fluid, and evaluation for the presence of CPP crystals under polarized light microscopy.² The diagnosis can be difficult to confirm secondary to the weakly birefringent nature of CPP crystals.⁴ Coexistence of MSU and CPP crystals in a single inflammatory effusion is neither uncommon nor unexplained given increased frequencies of both hyperuricemia/gout and CC among elderly patients.⁵

Chronic CPP crystal inflammatory arthritis may present as a chronic, symmetrical, bilateral, and deforming polyarthritis. It frequently affects the wrists and metacarpophalangeal joints and tendon sheaths. Chronic CPP may resemble rheumatoid arthritis (RA) and produce wrist tenosynovitis, which may manifest as carpal tunnel syndrome and/or cubital tunnel syndrome. Calcium pyrophosphate deposition disease should be on the differential diagnosis in the elderly patient presenting with a clinical picture that resembles “seronegative” RA, with morning stiffness, synovial thickening, localized edema, and restricted motion due to active inflammation or flexion contracture of the hands/wrist. It may present with prominent systemic features, such as leukocytosis, fevers, mental confusion, and inflammatory oligoarthritis or polyarthritis. The diagnosis of CPPD still may be possible even though the rheumatoid factor (RF) is positive, given the increasing likelihood of elevated RF in the older population. In this setting, aspiration of joint fluid and radiography will assist in clarification of the diagnosis. Furthermore, CPPD typically does not cause the type of erosive disease that is often seen in RA.

Calcium pyrophosphate deposition disease also can mimic polymyalgia rheumatica (PMR). A direct comparison of a cohort of patients with pseudo-PMR (PMR/CPPD) with actual PMR patients found that increased age at diagnosis, presence of knee osteoarthritis, tendinous calcifications, and ankle arthritis carried the highest predictive value in patients with CPPD presenting with PMR-like symptoms.⁶ However, the PMR/CPPD variant can be difficult to distinguish, because both conditions can have elevated systemic inflammatory markers, and both are steroid responsive.

Calcium pyrophosphate deposition disease involving a single joint can rarely lead to extensive destruction—as with neuropathic joints in the absence of any neurologic deficits—and is extremely debilitating. This presentation is not well understood and does not have good treatment alternatives. Calcium pyrophosphate crystals often are associated with manifestations of OA.^1,2 Indeed, up to 20% of OA joints have been found to be positive for CPP crystals in various studies. Given the extensive evidence supporting treatment of OA, usually they are treated in a similar fashion with good results. Occasionally, these will have unusual manifestations for typical OA, such as involvement of wrists and metacarpophalangeal joints; however, the presentation is often indolent like OA.

Calcium pyrophosphate crystal deposition involving the spine has been associated with a number of clinical manifestations. Spine stiffness, sometimes associated with bony ankylosis, can resemble ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Such symptoms are seen more commonly in familial CPPD rather than in the elderly. However, crystal deposition in the ligamentum flavum at the cervical spine levels has been associated with a condition called crowned dens syndrome.⁷ Although mostly asymptomatic, it may be present with acute neck pain, fever, and an increased ESR, sometimes mimicking PMR or giant cell arteritis or neurologic symptoms. Similarly, CPP crystal deposition in the posterior longitudinal ligament at the lower levels of the spine may lead to spinal cord compression syndromes or symptoms of either acute nerve compression or chronic spinal stenosis.^8,9 Calcium pyrophosphate crystal deposition also can occur in other soft tissues, such as bursae, ligaments, and tendons and may be sufficient to cause local nerve compression, such as carpal or cubital tunnel syndrome.

Epidemiology

Radiographic surveys of the knees, hands, wrists, and pelvis and epidemiologic studies have demonstrated an age-related increase in the prevalence of CPPD: 15% prevalence in patients aged 65 to 74 years, 36% prevalence in patients aged 75 to 84 years, and 50% prevalence in patients aged > 84 years.¹⁰ In a recent radiographic study, 40% of patients with CPPD did not present with CC of the knee, and the study’s authors recommended additional radiographs of pelvis, wrists, or hands for accurate diagnosis of radiographic CC.¹¹

Diagnosis

Accurate diagnosis should be achieved on the basis of the clinical picture and demonstration of CPP crystals in synovial fluid or tissue by compensated polarized light microscopy (Figures 1A and 1B).² The sensitivity and specificity for CPP crystal detection has been shown to be 95.9% and 86.5%, respectively.¹² However, the CPP crystal is more readily identified by a rheumatologist rather than in a standard hospital laboratory, which misses 30% of CPP crystals.¹³

Findings of CC on radiograph strengthens a CPPD diagnosis, but its absence does not rule it out (Figure 2A).² More recently, the use of new imaging modalities, such as musculoskeletal ultrasound, provides the capacity to visualize crystal deposits within the joint structures, the hyaline cartilage, and/or fibrocartilage (Figure 2B and 2C).¹⁴ The presence of hyperechoic bands within the intermediate layer hyaline cartilage and hyperechoic spots in fibrocartilage are consistent with CPP crystal deposits.^2,14 The use of computed tomography is the gold standard imaging modality for the identification of CPPD of the spine.¹⁵ There is not enough evidence to support the use of magnetic resonance imaging in CPPD, but it may play a role in rare complications.²

Treatment

The EULAR recently defined new guidelines for the management of CPPD.¹⁶ Asymptomatic CPPD needs no treatment.In other CPPD phenotypes, the goals are to attempt prompt resolution of the acute synovitis, reduction in chronic damage, and management of associated conditions.In acute attacks, treatment modalities used in gout are often required; however, data for CPPD treatment are limited (Table). Treatment relies on the use of colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs), but toxicity and comorbidities in the elderly limit the usage of these drugs.

Given increased renal impairment, the loading dose of colchicine is not recommended.¹⁶ Colchicine has recently been shown to completely block crystal-induced maturation of IL-1β in vitro, indicating that the drug acts upstream of inflammasome activation.¹⁷ This is in addition to the well-known role of colchicine in inhibition of micro-tubule formation, which likely leads to prevention of cell migration, phagocytosis, and activation of inflammasome.^18-20

Intra-articular injection of corticosteroid is an efficient and well-tolerated treatment alternative for monoarticular CPP flares. Oral or parenteral corticosteroids are frequently used for polyarticular flares in particular for those patients in which NSAIDs and colchicine are contraindicated.¹⁶ Parenteral adrenocorticotropic hormone has been used in patients with congestive heart failure, renal insufficiency, gastrointestinal bleeding, or resistance to NSAIDs.²¹ For prophylaxis of acute CPP crystal arthritis, a low dose of oral NSAIDs, oral colchicine, or prednisone may be used with good results.¹⁶ In chronic CPP arthritis, continuous use of colchicine, NSAIDs, or low-dose prednisone is often appropriate. If these interventions are ineffective or contraindicated, using hydroxychloroquine (HCQ) and methotrexate (MTX) have been successfully used to control chronic CPP crystal inflammation.^22,23 Recent trials have raised questions about MTX, and further trials on HCQ usage are underway.²⁴ Biologic agents targeting IL-1 are not currently approved for the treatment of CPPD, but there are suggestions that it may be effective in refractory cases and induce rapid stable remissions after 3 days of therapy.²⁵

In contrast to gout, there is no specific target therapy for lowering CPP crystal load in the elderly. Crucial in the management of CPPD in the elderly is the search for associated diseases, such as hyperparathyroidism, hemochromatosis, hypomagnesemia, and hypophosphatemia, as well as avoidance of tacrolimus, which facilitates or causes CC.¹⁶ Correction of the underlying metabolic disorder, especially when undertaken early, may reduce the severity of CPPD. However, there is little evidence to suggest that treatment of associated disease results in resolution of CPPD—most famously, although therapeutic phlebotomy does not help in hemochromatosis for prevention of crystal disease, chelating agents do seem to be moderately effective.²⁶ Only oral administration of magnesium has shown a reduction in meniscal CC in a patient with CPPD arthropathy.²⁷ In addition, this was in the setting of familial hypomagnesemia associated CPPD. However, unlike uricosuric agents for gout, no pharmacologic treatments can prevent CPPD crystal formation and deposition in tissues.

Therapeutic Agents

Magnesium

Magnesium is a cofactor for the activity of pyrophosphatases that converts inorganic pyrophosphates (PPis) into orthophosphates. In addition, magnesium can increase the solubility of CPP crystals. Early detection and management of hypomagnesemia are recommended, because it occurs in patients who have well-defined conditions and situations: Gitelman syndrome, thiazide and loop diuretics use, tacrolimus use, familial forms of renal magnesium wasting or use of proton pump inhibitors, short bowel syndrome, and intestinal failure in patients receiving home parenteral nutrition. Long-term administration of magnesium in some patients with chronic hypomagnesemia decreased meniscal calcification.^27-29

Dietary Calcium

Epidemiologic studies showed a lower incidence of CC in Chinese subjects. The authors of the study speculate that this lower prevalence of CPPD could result from high levels of calcium found in the drinking water in Beijing, which may affect parathyroid hormone secretion.³⁰ Further studies are needed to confirm this hypothesis, as it could be a cheaper approach to pseudogout prevention.

Probenecid

Probenecid is an in vitro inhibitor of the transmembrane PPi transporter thought to possibly prevent extracellular PPi elaboration. However, this observation has not been confirmed by either case reports or clinical trials.³¹

Phosphocitrate

Phosphocitrate acts directly on preventing crystal deposition in tissues in CPPD as well as BCP based on in vitro evidence and mouse models.^32,33

Hyaluronan

An amelioration of pain and increased range of motion were observed in radiographic CC with OA.³⁴ However, it is associated with increased acute CPP arthritis.³⁵

Radiosynovectomy

In a double-blind study of 15 patients with symmetrical CPPD arthropathy, the knee that underwent intra-articular injection of yttrium-90 (5 mCi) plus steroid had less pain, stiffness, joint line tenderness, and effusion compared with the contralateral control knee injected with saline and steroids.³⁶

Precipitators of Acute Pseudogout

Diuretics are known to exacerbate gout, but they also can exacerbate pseudogout. A recent case-control study nested within a United Kingdom general practice database found that loop diuretics rather than hydrochlorothiazide was associated with increased risk of CPPD mediated primarily by magnesium reabsorption in the loop of Henle.²⁸ Chronic kidney disease associated with secondary and tertiary hyperparathyroidism increases calcium or PPi concentration, which leads to CPP-crystal deposition.

In addition, multiple case reports have described acute pseudogout caused by bisphosphonate administration for osteoporosis or Paget disease—more likely in the elderly population. Intravenous pamidronate, oral etidronate, and alendronate therapy have all been described in the elderly.³⁷ The overall mechanism behind this link is not completely understood, but bisphosphonates are structurally similar to PPi. Pseudogout attacks also have been described in neutropenic patients undergoing treatment with granulocyte-colony stimulating factor.³⁸ In addition to pharmaceutical exacerbation of pseudogout, surgical procedures and trauma can precipitate attacks. Joint lavage has been described to increase the incidence of pseudogout.³⁹ It was hypothesized that joint lavage with fluid induced “crystal shedding” from CPPD crystals imbedded in the joint tissue. Patients who underwent meniscectomy of the knee 20 years ago had a 20% incidence of CC in the knee that was operated compared with 4% CC in the contralateral nonoperated knee.⁴⁰ Overall, the surgery most linked with a pseudogout attack, however, is parathyroidectomy.⁴¹

Basic Calcium Phosphate Crystals

Basic calcium phosphate crystals are common but rarely diagnosed due to the cumbersome and expensive methods required to identify these crystals.⁴²

Basic calcium phosphate and CPPD crystals may coexist in synovial fluid. Similar to CPPD, BCP crystal disease is often concurrent with OA and can cause calcification of articular cartilage. Basic calcium phosphate is more common than CPP crystals with occurrence of 30% to 50% in OA synovial fluid.⁴² Additionally, BCP crystal disease has been linked to increased severity of OA. Basic calcium phosphate crystals in knee joints were found to have radiographically more severe arthritis with larger effusions.^44,45 Similarly, BCP crystals in OA synovial fluid correlated with higher Kellgreen-Lawrence grade scores by radiography.^42,46

It is currently believed that BCP crystals are continuously formed in the extracellular matrix, and their deposition is actively prevented by PPi present in the matrix.⁴⁷ Elevated PPi levels, on the other hand, favor the formation of CPP crystals.⁴⁸ The clinical upshot seems to be that although CPP crystals are almost universally intra-articular and released by chondrocytes, BCD crystals and deposits are more frequently present in soft tissues.

Acute Calcific Tendinitis

Typically, this type of tendinitis involves the shoulder joint and is extra-articular. Common treatments help, including NSAIDs, intra-articular steroids, ice, and rest. In addition, high-energy extracorporeal shock wave therapy has been shown to be effective when used with conscious sedation.^49,50 Needling or barbotage in association with lavage and steroid injections also is effective and has occasionally been shown to reduce the size of the calcium deposit as well, often in combination with IV drugs like ethylenediaminetetraacetic acid.^51-53

Acute calcific periarthritis of the hand presents similar to gout or pseudogout, affecting the wrist, usually in postmenopausal women.⁵⁴ Basic calcium phosphate crystals are aspirated from the joint, and periarticular crystals may be subtle. Local steroid injections are beneficial.Milwaukee shoulder syndrome is an arthropathy associated with BCP crystals in the joint fluid and results in extensive destruction of shoulder articular cartilage and surrounding tissues. It is commonly bilateral and occurs in elderly women more often than it does in men.⁵⁵ Aspiration of the shoulder joint typically reveals a serosanginous fluid. Fluid samples can be assessed for hydroxyapatite crystals by staining with alizarin red dye, which produces a characteristic “halo” or orange-red stain by light microscopy.⁴³ Surgical treatment of Milwaukee shoulder syndrome is difficult due to increased age of the population affected and the severity of the shoulder destruction. Usually a conservative approach of analgesics, recurrent shoulder aspirations, and steroid injections is the best treatment option.

Conclusions

Calcium-containing crystal-associated arthropathies are a complex array of entities that target the veteran elderly population with increasing frequency. Challenges still remain in the diagnosis, crystal identification, and treatment due to coexisting comorbid conditions and polypharmacy commonly seen in veterans. Overall morbidity associated with calcium-containing crystal-associated arthropathies and the coexisting osteoarthritis is great, and focused identification of the disease process with tailored treatment can achieve the goal of decreasing symptoms and improving quality of life.

Acknowledgements
This work was supported by grant P20GM104937 (A.M.R.).

Navigating the postsecondary educational pathway can be an intimidating process for post-9/11 veterans struggling with mental health concerns that may alter learning styles and negatively impact performance.^1-4 When significant interference with learning ability is anticipated for more than 6 months, these veterans may qualify for formal academic “reasonable” accommodations under federal disability laws that include the Americans with Disabilities Act (ADA) of 1990 as amended in 2008 and Section 504 of the Rehabilitation Act of 1973. These accommodations enable students to compensate for learning disabilities and help support the transition to student life. Student veterans often are not aware of the existence of academic reasonable accommodations, because military separation classes, civilian postdeployment orientation, and popular media do not routinely cover information on this subject.

With an overall objective to ease veteran reintegration into the civilian world and promote emotional stability, health care providers (HCPs) are in a unique position to promote the use of formal academic accommodations for post-9/11 veterans with psychiatric conditions. However, HCPs must have basic information regarding these interventions before initiating discussions with patients. Current peer-reviewed medical literature has scant information regarding specific aspects of academic reasonable accommodations for individuals with psychiatric diagnoses.

The purpose of this 2-part article (part 2 will be published in May 2016) is to promote a greater understanding of academic accommodations for post-9/11 veterans with psychiatric diagnoses. Part 1 provides a brief background regarding issues pertinent to the post-9/11 student veteran role transition and reviews information regarding various aspects of academic reasonable accommodations, including details on the definition, request process, medical documentation requirements, and common accommodation examples.

Although the focus of the article is on the characteristics of post-9/11 veterans who have separated from military service, it also is relevant for providers involved with service members who have not yet separated. The impact of mental health issues, traumatic brain injury (TBI), and psychosocial stressors on learning ability are potentially applicable to many post-9/11 active-duty soldiers and reservists who are pursuing a secondary education. The academic reasonable accommodations discussed are available to any adult who meets the eligibility criteria—regardless of military status.

Influence of Psychiatric Symptoms on Learning

Although each mental health diagnosis is unique, mental health conditions involving mood share the common symptoms of impaired learning ability.^3-8 Problems frequently experienced include decreased concentration, shortened attention span, difficulty in making new memories or storing new information, and the inability to recall information previously learned.^6-8 Other reported conditions include difficulty with prioritization of tasks, losing track of time, difficulty focusing on tasks, and taking longer to complete assignments.^3,4 Increased irritability accompanies many of these issues. Low tolerance to frustration may occur as evidenced by an outburst of anger or resignation to defeat when minor barriers are encountered, especially when authority figures or bureaucratic rules create those perceived barriers.^3,4 Persistent impaired ability to articulate ideas or thoughts and difficulty performing abstract thinking also are often noticed when moderate-to-severe mental health symptoms are present.^4,8

Medications commonly used to control psychiatric symptoms and stabilize underlying mental health also can produce adverse effects (AEs) that impact learning ability.^9,10 Drug AEs vary but often include significant fatigue, impaired memory, and impaired executive function involving insight, judgment, and/or abstract thinking. Depending on the medication, the individual may experience restlessness or insomnia.

Factors Complicating Successful Integration

The transition period from military service to civilian life presents unique complications for student veterans with symptomatic psychiatric concerns.^1,11 Veterans who separate from military service go through a civilian transition period of variable intensity influenced by readjustment difficulties and comorbid conditions.^11,12 During this time, veterans are reintegrating into civilian life and assuming new roles that include partner, parent, employee, and family member. This transition can cause many symptoms to appear that potentially influence learning to varying degrees. A summary of impediments to learning in post-9/11 veterans is found in Table 1.

Common transition symptoms include irritability, decreased ability to store and recall information, decreased concentration, decreased attention, and slowed executive functioning.^13,14 Sleep disturbances such as altered sleep-wake cycles, nonrestful sleep, inadequate sleep, and nightmares also may occur.^13,14 Veterans experiencing these transition period symptoms may face significant difficulties with time management skills, organization, and task execution. If the veteran successfully assimilates into his or her new roles and becomes self-confident within those roles, the symptoms may abate. However, if moderate-to-severe psychiatric symptoms also are present, all transition symptoms likely will have an unpredictable time frame for resolution.^3,13,14

Understanding the role responsibilities of student veterans is important in recognizing the added stressors veterans with psychiatric diagnoses have within the academic setting. In general, demographic data indicate that student veterans lead far more complex lives than those of 18- to 22-year-olds who enter postsecondary education without military experience. Student veterans are older, have a broader life experience, and may feel less connected to nonveteran students.^15,16 Compared with typical younger college students, undergraduate student veterans are more likely to be married but somewhat less likely to be parents.¹⁷ Student veterans who are pursuing graduate degrees are more likely to be married and/or have dependents.¹⁷ Those roles imply that student veterans often are juggling multiple responsibilities that are constantly competing for student veterans’ time and attention.

Age differences, multiple roles, and lack of shared life experiences with traditional college students contribute to student veterans’ perceptions of a paucity of campus social support and often lead to a sense of distinct isolation.^18,19 These added stressors deplete a veteran’s ability to concentrate on academic studies and may exacerbate the effects of underlying mental health diagnoses, transition issues, and medication use.

Symptomatic psychiatric diagnoses can amplify the difficulties normally experienced when changing from a veteran role to a student veteran role.¹ The student veteran’s apprehension about returning to school often is elevated because of the time gap since the veteran was last in a formal, nonmilitary classroom. Acclimated to the structured style of military coursework for many years, student veterans may find adjusting to new teaching styles or different academic expectations awkward.^20,21 They may experience heightened anxiety, because expectations of classroom performance may not be as clearcut as it was in the military. Such heightened anxiety can compound learning difficulties caused by underlying emotional states, transition issues, medication AEs, and life stressors.

Related: The VA/DoD Chronic Effects of Neurotrauma Consortium: An Overview at Year 1

Many student veterans with impaired learning ability related to psychiatric symptoms also have secondary physical diagnoses that can impede learning. For example, tinnitus and hearing loss are common in combat veterans.^22,23 These issues make it hard to participate in a classroom setting because of difficulty in recognizing speech or filtering out background noise. For some, chronic pain may impede concentration, depress mood, worsen irritability, and make prolonged sitting difficult.^24,25 Physical disabilities related to amputation or major joint injury may present challenges to participating in certain types of college settings and/or navigating between classes in a timely fashion.²⁶

Although mild-to-moderate TBI sustained in combat often will spontaneously resolve within 3 months, in some individuals, TBI symptoms may persist after months or years.^27,28 During this time, learning styles may be altered for veterans exposed to TBI. Similar to the effects caused by other factors impeding learning in post-9/11 veterans, common post-TBI symptoms that reduce academic performance include fatigue, decreased memory, slowed abstract thinking, difficulty articulating thoughts, poor tolerance to frustration, sleep difficulties, chronic pain, and increased irritability.^27-29 Veterans with a history of mild TBI often are found to have clinically significant rates of depression, anxiety, or posttraumatic stress disorder (PTSD).^27,28,30,31 These findings mirror those found in the general population.³² Mild TBI and PTSD may further complicate the learning process by exacerbating underlying mental health symptoms that already impair academic performance. The degree to which these individuals with TBI and mental health issues will return to premorbid academic functioning is not predictable based on current literature.³³

Recognizing the stressors that some combat veterans face in an academic setting is vital to anticipating the added support that is needed by student veterans with concurrent moderate-to-severe psychiatric issues.³⁴ Symptoms usually noted in the transition period may be much more pronounced. Automatic behaviors developed as survival responses during deployment can complicate participation in the educational arena.^4,35 Seemingly mundane tasks, such as the daily school commute, can cause significant anxiety and hypervigilance especially when the veterans must navigate crowds and traffic formerly associated with risk of attack in combat-related circumstances.⁴ Minor roadway debris or roadside construction also can abnormally heighten anxiety because of reflex training to avoid potentially hidden explosive devices during convoy movements.⁴ Random assignment of a classroom seat can be stress-provoking, because combat veterans’ training compels them to position themselves with the greatest vantage point, usually nearest to exits and with minimal activity behind them.^4,35 A need to constantly survey the surroundings for potential cover from hostile events can cause hyper alertness that distracts the student veteran’s full concentration on academic tasks.^3,4

Although veterans should be able to adjust learning styles for minor issues or transitory problems, significant psychiatric symptoms have a negative effect on learning and pose a direct threat to academic performance.^33,36-38 Moderate-to-severe psychiatric concerns may further heighten transition symptoms, compound psychosocial adjustment, and complicate TBI recovery. In addition, periods of high stress may further provoke symptoms of the underlying psychiatric diagnosis.

Reasonable Accommodations

In postsecondary education, reasonable accommodations are formal modifications or adjustments in the school environment that enable individuals with physical or psychological issues to successfully learn and function within the academic institution. In general, these academic accommodations for student veterans with mental health diagnoses involve modifying the learning environment to compensate for delays in executive functioning, such as memorization, recall, and complex analysis. Coursework is not altered; rather specific actions are used to assist the student to process and recall the material more easily. The reasonable accommodations also may be structured in a way that avoids exacerbating an underlying mental health diagnosis, such as PTSD or anxiety. The purpose of reasonable accommodations is to effectively remove barriers to a student veteran’s ability to learn and succeed academically.

Federal law states that reasonable accommodations must be implemented by all schools that accept federal monies—including GI bill payments.³⁹ Although schools are not required to implement all preferred accommodations requested by veterans, academic institutions are required to implement reasonable, effective strategies for the individual student veteran with a psychological diagnosis that causes learning impairment. However, these institutions are not required to proactively determine who might qualify for such accommodations. A school will not initiate formal academic accommodations unless a veteran makes a specific request and provides qualifying documentation.

Many veterans qualify for reasonable accommodations in the academic setting to compensate for the negative impact that mental health issues can have on academic performance. Specifically, student veterans with psychiatric diagnoses are classified as having a learning disability and are eligible to receive academic accommodations if the psychiatric condition substantially limits, or is expected to limit, learning for more than 6 months.³⁹ Individuals with psychiatric conditions in remission are still classified as having a disability if the disorder would impede learning when symptomatic. A veteran does not need to establish verification of a psychiatric diagnosis connected to military service in order to receive formal academic accommodations. Student veterans who qualify for formal academic accommodations can be fully functional in all other areas of their lives. Examples of qualifying psychiatric diagnoses include PTSD, depression, anxiety, bipolar disorder, and schizophrenia.

Although accommodations are individually tailored, there are frequently used accommodations for student veterans with psychiatric diagnoses that have been extremely helpful for those who qualify. Additional time for testing helps the student veteran compensate for the difficulty with abstract thinking, concentration, attention, and recall. Low stimulus testing environments, such as a quiet room, enable a veteran to more easily concentrate. Additional time for completion of assignments without academic penalties is beneficial for a veteran experiencing difficulty with attention, focus, concentration, and organization. Assistance with note-taking or advanced access to lecture notes helps the veteran compensate for decreased focus, attention, and short-term memory impairment. Permitting short breaks without repercussions during a lecture allows the veteran to regain focus and composure if he or she is having difficulties with concentration, attention, restlessness, anxiety, body pain, or emotional flares. Tutoring can help the veteran overcome slowed executive functioning. Faculty-approved notes on an index card may help the veteran compensate for extreme difficulty with memory recall. To prevent visual distraction while reading, use of a blank note card or blank sheet of paper during testing may make it easier for the veteran to focus on each sentence or test question.

On a case-by-case basis, other creative strategies may be used to enable the student veteran to participate more fully in the academic setting. Preferential class scheduling can be arranged to compensate for severely altered sleep patterns. Such changes to the schedule mean a veteran would not have to attend classes during a time frame when his or her body is accustomed to sleeping. Flexibility with class attendance decreases external stressors for the veteran who is having intermittent difficulty with severe sleep disturbances or anxiety in group settings. “Unstacking” midterms or finals allows the student veteran to avoid back-to-back exams and enables him or her to study more effectively for each exam. Virtual classes with self-pacing options may provide more flexibility to complete course requirements while the veteran is dealing with fluctuating emotional symptoms.

Legal Process

Barring undue hardship to provide accommodations, the ADA of 1990 as amended in 2008 and Section 504 of the Rehabilitation Act of 1973 enable equal rights and access to benefits and services for all individuals with disabilities to the same degree as persons without such disabilities in multiple environments including the academic setting. Although the U.S. military system narrowly interprets the term disability, individuals classified as having disabilities under these federal laws fall under a much broader definition. Specifically, any person with “a physical or mental impairment that constitutes or results in substantial impediment” of one of life’s major activities is considered to have a disability.³⁹ As per the ADA of 1990, learning is defined as one of the major life activities.³⁹ This law recognizes that the individual with a learning disability may be fully functional in all other areas of his or her life.

Related: Using Life Stories to Connect Veterans and Providers

Because students must officially request and receive approval for these accommodations within the academic institution, the veteran should speak with the school’s disability resource center counselor regarding the process. If the school does not have a disability resource center, then the student veteran should speak to an admissions counselor at the academic facility. The discussion with the facility’s counselor should include which types of accommodations may be possible to compensate for the veteran’s learning impediments. The counselor will inform the veteran of the required medical documentation that enables the school to grant the needed academic accommodations. In general, veterans can qualify for academic accommodations by receiving a letter with medical documentation of the psychiatric disorder, its anticipated effect on learning, and if known, the suggested reasonable accommodations to compensate for the learning deficit. The veteran can receive a qualifying letter from a psychologist, psychiatrist, PCP, social worker, or licensed counselor with the expertise to diagnose and document the disorder. Student veterans can take this letter to the school’s disability resource center to enable the institution to approve and adopt the accommodations for the student veteran. To ensure compliance with privacy regulations and any facility privacy policies, most providers require a signed release of information form before providing the medical documentation letter.

Such letters need to contain only the basic information required by the disability resource center at each school. Common information required for such a letter includes a clear statement that the disorder and diagnosis are present, the symptoms experienced by the student veteran as a result of the diagnosis, and the impact of those symptoms on the veteran’s learning abilities. If possible, the letter also should specify recommended accommodations that can help the student veteran compensate for the disability. Additional details that some schools may request include associated psychological or medical diagnoses and a listing of medications prescribed to the veteran with AEs experienced. Depending on the institution’s individual policy, the letters may require yearly updates. Federal law forbids schools from requiring onerous amounts of documentation to support the need for academic accommodations.

How many of the preapproved accommodations are used is up to the student veteran. Depending on their baseline functional status and mental health issues, eligible veterans may not need to use all the accommodations each semester or for every class. However, formal accommodations are much easier to implement when needed if the student veteran already has the school preapprove them.

Conclusion

Acquired learning disabilities can prevent successful transition to the student veteran role. Implementation of academic reasonable accommodations is an important avenue by which qualifying post-9/11 student veterans with psychiatric diagnoses can compensate for the negative impact mental health symptoms have on learning styles and academic performance. Because academic stressors and emotional stability are closely intertwined, it is crucial that eligible post-9/11 veterans understand and accept the benefits that formal academic accommodations provide in postsecondary education. Academic accommodations should be offered to empower veterans with mental health concerns. A summary of academic reasonable accommodations is provided in Table 2.

The way clinicians approach this topic will greatly influence veterans’ perspective on academic accommodations. Because there can be a stigma associated with the term learning disability in addition to a general lack of understanding about formal academic accommodations, post-9/11 veterans may not readily pursue the accommodations. Therefore, HCPs should be aware of the best methods for addressing student veterans’ concerns regarding identification of learning disabilities and use of academic accommodations. Unfortunately, information regarding these topics is not readily available in peer-reviewed literature or popular media. Therefore, in part 2, practical interventions for holding crucial conversations with post-9/11 veterans are discussed using a theoretical framework.

Navigating the postsecondary educational pathway can be an intimidating process for post-9/11 veterans struggling with mental health concerns that may alter learning styles and negatively impact performance.^1-4 When significant interference with learning ability is anticipated for more than 6 months, these veterans may qualify for formal academic “reasonable” accommodations under federal disability laws that include the Americans with Disabilities Act (ADA) of 1990 as amended in 2008 and Section 504 of the Rehabilitation Act of 1973. These accommodations enable students to compensate for learning disabilities and help support the transition to student life. Student veterans often are not aware of the existence of academic reasonable accommodations, because military separation classes, civilian postdeployment orientation, and popular media do not routinely cover information on this subject.

With an overall objective to ease veteran reintegration into the civilian world and promote emotional stability, health care providers (HCPs) are in a unique position to promote the use of formal academic accommodations for post-9/11 veterans with psychiatric conditions. However, HCPs must have basic information regarding these interventions before initiating discussions with patients. Current peer-reviewed medical literature has scant information regarding specific aspects of academic reasonable accommodations for individuals with psychiatric diagnoses.

The purpose of this 2-part article (part 2 will be published in May 2016) is to promote a greater understanding of academic accommodations for post-9/11 veterans with psychiatric diagnoses. Part 1 provides a brief background regarding issues pertinent to the post-9/11 student veteran role transition and reviews information regarding various aspects of academic reasonable accommodations, including details on the definition, request process, medical documentation requirements, and common accommodation examples.

Although the focus of the article is on the characteristics of post-9/11 veterans who have separated from military service, it also is relevant for providers involved with service members who have not yet separated. The impact of mental health issues, traumatic brain injury (TBI), and psychosocial stressors on learning ability are potentially applicable to many post-9/11 active-duty soldiers and reservists who are pursuing a secondary education. The academic reasonable accommodations discussed are available to any adult who meets the eligibility criteria—regardless of military status.

Influence of Psychiatric Symptoms on Learning

Although each mental health diagnosis is unique, mental health conditions involving mood share the common symptoms of impaired learning ability.^3-8 Problems frequently experienced include decreased concentration, shortened attention span, difficulty in making new memories or storing new information, and the inability to recall information previously learned.^6-8 Other reported conditions include difficulty with prioritization of tasks, losing track of time, difficulty focusing on tasks, and taking longer to complete assignments.^3,4 Increased irritability accompanies many of these issues. Low tolerance to frustration may occur as evidenced by an outburst of anger or resignation to defeat when minor barriers are encountered, especially when authority figures or bureaucratic rules create those perceived barriers.^3,4 Persistent impaired ability to articulate ideas or thoughts and difficulty performing abstract thinking also are often noticed when moderate-to-severe mental health symptoms are present.^4,8

Medications commonly used to control psychiatric symptoms and stabilize underlying mental health also can produce adverse effects (AEs) that impact learning ability.^9,10 Drug AEs vary but often include significant fatigue, impaired memory, and impaired executive function involving insight, judgment, and/or abstract thinking. Depending on the medication, the individual may experience restlessness or insomnia.

Factors Complicating Successful Integration

The transition period from military service to civilian life presents unique complications for student veterans with symptomatic psychiatric concerns.^1,11 Veterans who separate from military service go through a civilian transition period of variable intensity influenced by readjustment difficulties and comorbid conditions.^11,12 During this time, veterans are reintegrating into civilian life and assuming new roles that include partner, parent, employee, and family member. This transition can cause many symptoms to appear that potentially influence learning to varying degrees. A summary of impediments to learning in post-9/11 veterans is found in Table 1.

Common transition symptoms include irritability, decreased ability to store and recall information, decreased concentration, decreased attention, and slowed executive functioning.^13,14 Sleep disturbances such as altered sleep-wake cycles, nonrestful sleep, inadequate sleep, and nightmares also may occur.^13,14 Veterans experiencing these transition period symptoms may face significant difficulties with time management skills, organization, and task execution. If the veteran successfully assimilates into his or her new roles and becomes self-confident within those roles, the symptoms may abate. However, if moderate-to-severe psychiatric symptoms also are present, all transition symptoms likely will have an unpredictable time frame for resolution.^3,13,14

Understanding the role responsibilities of student veterans is important in recognizing the added stressors veterans with psychiatric diagnoses have within the academic setting. In general, demographic data indicate that student veterans lead far more complex lives than those of 18- to 22-year-olds who enter postsecondary education without military experience. Student veterans are older, have a broader life experience, and may feel less connected to nonveteran students.^15,16 Compared with typical younger college students, undergraduate student veterans are more likely to be married but somewhat less likely to be parents.¹⁷ Student veterans who are pursuing graduate degrees are more likely to be married and/or have dependents.¹⁷ Those roles imply that student veterans often are juggling multiple responsibilities that are constantly competing for student veterans’ time and attention.

Age differences, multiple roles, and lack of shared life experiences with traditional college students contribute to student veterans’ perceptions of a paucity of campus social support and often lead to a sense of distinct isolation.^18,19 These added stressors deplete a veteran’s ability to concentrate on academic studies and may exacerbate the effects of underlying mental health diagnoses, transition issues, and medication use.

Symptomatic psychiatric diagnoses can amplify the difficulties normally experienced when changing from a veteran role to a student veteran role.¹ The student veteran’s apprehension about returning to school often is elevated because of the time gap since the veteran was last in a formal, nonmilitary classroom. Acclimated to the structured style of military coursework for many years, student veterans may find adjusting to new teaching styles or different academic expectations awkward.^20,21 They may experience heightened anxiety, because expectations of classroom performance may not be as clearcut as it was in the military. Such heightened anxiety can compound learning difficulties caused by underlying emotional states, transition issues, medication AEs, and life stressors.

Related: The VA/DoD Chronic Effects of Neurotrauma Consortium: An Overview at Year 1

Many student veterans with impaired learning ability related to psychiatric symptoms also have secondary physical diagnoses that can impede learning. For example, tinnitus and hearing loss are common in combat veterans.^22,23 These issues make it hard to participate in a classroom setting because of difficulty in recognizing speech or filtering out background noise. For some, chronic pain may impede concentration, depress mood, worsen irritability, and make prolonged sitting difficult.^24,25 Physical disabilities related to amputation or major joint injury may present challenges to participating in certain types of college settings and/or navigating between classes in a timely fashion.²⁶

Although mild-to-moderate TBI sustained in combat often will spontaneously resolve within 3 months, in some individuals, TBI symptoms may persist after months or years.^27,28 During this time, learning styles may be altered for veterans exposed to TBI. Similar to the effects caused by other factors impeding learning in post-9/11 veterans, common post-TBI symptoms that reduce academic performance include fatigue, decreased memory, slowed abstract thinking, difficulty articulating thoughts, poor tolerance to frustration, sleep difficulties, chronic pain, and increased irritability.^27-29 Veterans with a history of mild TBI often are found to have clinically significant rates of depression, anxiety, or posttraumatic stress disorder (PTSD).^27,28,30,31 These findings mirror those found in the general population.³² Mild TBI and PTSD may further complicate the learning process by exacerbating underlying mental health symptoms that already impair academic performance. The degree to which these individuals with TBI and mental health issues will return to premorbid academic functioning is not predictable based on current literature.³³

Recognizing the stressors that some combat veterans face in an academic setting is vital to anticipating the added support that is needed by student veterans with concurrent moderate-to-severe psychiatric issues.³⁴ Symptoms usually noted in the transition period may be much more pronounced. Automatic behaviors developed as survival responses during deployment can complicate participation in the educational arena.^4,35 Seemingly mundane tasks, such as the daily school commute, can cause significant anxiety and hypervigilance especially when the veterans must navigate crowds and traffic formerly associated with risk of attack in combat-related circumstances.⁴ Minor roadway debris or roadside construction also can abnormally heighten anxiety because of reflex training to avoid potentially hidden explosive devices during convoy movements.⁴ Random assignment of a classroom seat can be stress-provoking, because combat veterans’ training compels them to position themselves with the greatest vantage point, usually nearest to exits and with minimal activity behind them.^4,35 A need to constantly survey the surroundings for potential cover from hostile events can cause hyper alertness that distracts the student veteran’s full concentration on academic tasks.^3,4

Although veterans should be able to adjust learning styles for minor issues or transitory problems, significant psychiatric symptoms have a negative effect on learning and pose a direct threat to academic performance.^33,36-38 Moderate-to-severe psychiatric concerns may further heighten transition symptoms, compound psychosocial adjustment, and complicate TBI recovery. In addition, periods of high stress may further provoke symptoms of the underlying psychiatric diagnosis.

Reasonable Accommodations

In postsecondary education, reasonable accommodations are formal modifications or adjustments in the school environment that enable individuals with physical or psychological issues to successfully learn and function within the academic institution. In general, these academic accommodations for student veterans with mental health diagnoses involve modifying the learning environment to compensate for delays in executive functioning, such as memorization, recall, and complex analysis. Coursework is not altered; rather specific actions are used to assist the student to process and recall the material more easily. The reasonable accommodations also may be structured in a way that avoids exacerbating an underlying mental health diagnosis, such as PTSD or anxiety. The purpose of reasonable accommodations is to effectively remove barriers to a student veteran’s ability to learn and succeed academically.

Federal law states that reasonable accommodations must be implemented by all schools that accept federal monies—including GI bill payments.³⁹ Although schools are not required to implement all preferred accommodations requested by veterans, academic institutions are required to implement reasonable, effective strategies for the individual student veteran with a psychological diagnosis that causes learning impairment. However, these institutions are not required to proactively determine who might qualify for such accommodations. A school will not initiate formal academic accommodations unless a veteran makes a specific request and provides qualifying documentation.

Many veterans qualify for reasonable accommodations in the academic setting to compensate for the negative impact that mental health issues can have on academic performance. Specifically, student veterans with psychiatric diagnoses are classified as having a learning disability and are eligible to receive academic accommodations if the psychiatric condition substantially limits, or is expected to limit, learning for more than 6 months.³⁹ Individuals with psychiatric conditions in remission are still classified as having a disability if the disorder would impede learning when symptomatic. A veteran does not need to establish verification of a psychiatric diagnosis connected to military service in order to receive formal academic accommodations. Student veterans who qualify for formal academic accommodations can be fully functional in all other areas of their lives. Examples of qualifying psychiatric diagnoses include PTSD, depression, anxiety, bipolar disorder, and schizophrenia.

Although accommodations are individually tailored, there are frequently used accommodations for student veterans with psychiatric diagnoses that have been extremely helpful for those who qualify. Additional time for testing helps the student veteran compensate for the difficulty with abstract thinking, concentration, attention, and recall. Low stimulus testing environments, such as a quiet room, enable a veteran to more easily concentrate. Additional time for completion of assignments without academic penalties is beneficial for a veteran experiencing difficulty with attention, focus, concentration, and organization. Assistance with note-taking or advanced access to lecture notes helps the veteran compensate for decreased focus, attention, and short-term memory impairment. Permitting short breaks without repercussions during a lecture allows the veteran to regain focus and composure if he or she is having difficulties with concentration, attention, restlessness, anxiety, body pain, or emotional flares. Tutoring can help the veteran overcome slowed executive functioning. Faculty-approved notes on an index card may help the veteran compensate for extreme difficulty with memory recall. To prevent visual distraction while reading, use of a blank note card or blank sheet of paper during testing may make it easier for the veteran to focus on each sentence or test question.

On a case-by-case basis, other creative strategies may be used to enable the student veteran to participate more fully in the academic setting. Preferential class scheduling can be arranged to compensate for severely altered sleep patterns. Such changes to the schedule mean a veteran would not have to attend classes during a time frame when his or her body is accustomed to sleeping. Flexibility with class attendance decreases external stressors for the veteran who is having intermittent difficulty with severe sleep disturbances or anxiety in group settings. “Unstacking” midterms or finals allows the student veteran to avoid back-to-back exams and enables him or her to study more effectively for each exam. Virtual classes with self-pacing options may provide more flexibility to complete course requirements while the veteran is dealing with fluctuating emotional symptoms.

Legal Process

Barring undue hardship to provide accommodations, the ADA of 1990 as amended in 2008 and Section 504 of the Rehabilitation Act of 1973 enable equal rights and access to benefits and services for all individuals with disabilities to the same degree as persons without such disabilities in multiple environments including the academic setting. Although the U.S. military system narrowly interprets the term disability, individuals classified as having disabilities under these federal laws fall under a much broader definition. Specifically, any person with “a physical or mental impairment that constitutes or results in substantial impediment” of one of life’s major activities is considered to have a disability.³⁹ As per the ADA of 1990, learning is defined as one of the major life activities.³⁹ This law recognizes that the individual with a learning disability may be fully functional in all other areas of his or her life.

Related: Using Life Stories to Connect Veterans and Providers

Because students must officially request and receive approval for these accommodations within the academic institution, the veteran should speak with the school’s disability resource center counselor regarding the process. If the school does not have a disability resource center, then the student veteran should speak to an admissions counselor at the academic facility. The discussion with the facility’s counselor should include which types of accommodations may be possible to compensate for the veteran’s learning impediments. The counselor will inform the veteran of the required medical documentation that enables the school to grant the needed academic accommodations. In general, veterans can qualify for academic accommodations by receiving a letter with medical documentation of the psychiatric disorder, its anticipated effect on learning, and if known, the suggested reasonable accommodations to compensate for the learning deficit. The veteran can receive a qualifying letter from a psychologist, psychiatrist, PCP, social worker, or licensed counselor with the expertise to diagnose and document the disorder. Student veterans can take this letter to the school’s disability resource center to enable the institution to approve and adopt the accommodations for the student veteran. To ensure compliance with privacy regulations and any facility privacy policies, most providers require a signed release of information form before providing the medical documentation letter.

Such letters need to contain only the basic information required by the disability resource center at each school. Common information required for such a letter includes a clear statement that the disorder and diagnosis are present, the symptoms experienced by the student veteran as a result of the diagnosis, and the impact of those symptoms on the veteran’s learning abilities. If possible, the letter also should specify recommended accommodations that can help the student veteran compensate for the disability. Additional details that some schools may request include associated psychological or medical diagnoses and a listing of medications prescribed to the veteran with AEs experienced. Depending on the institution’s individual policy, the letters may require yearly updates. Federal law forbids schools from requiring onerous amounts of documentation to support the need for academic accommodations.

How many of the preapproved accommodations are used is up to the student veteran. Depending on their baseline functional status and mental health issues, eligible veterans may not need to use all the accommodations each semester or for every class. However, formal accommodations are much easier to implement when needed if the student veteran already has the school preapprove them.

Conclusion

Acquired learning disabilities can prevent successful transition to the student veteran role. Implementation of academic reasonable accommodations is an important avenue by which qualifying post-9/11 student veterans with psychiatric diagnoses can compensate for the negative impact mental health symptoms have on learning styles and academic performance. Because academic stressors and emotional stability are closely intertwined, it is crucial that eligible post-9/11 veterans understand and accept the benefits that formal academic accommodations provide in postsecondary education. Academic accommodations should be offered to empower veterans with mental health concerns. A summary of academic reasonable accommodations is provided in Table 2.

The way clinicians approach this topic will greatly influence veterans’ perspective on academic accommodations. Because there can be a stigma associated with the term learning disability in addition to a general lack of understanding about formal academic accommodations, post-9/11 veterans may not readily pursue the accommodations. Therefore, HCPs should be aware of the best methods for addressing student veterans’ concerns regarding identification of learning disabilities and use of academic accommodations. Unfortunately, information regarding these topics is not readily available in peer-reviewed literature or popular media. Therefore, in part 2, practical interventions for holding crucial conversations with post-9/11 veterans are discussed using a theoretical framework.

Navigating the postsecondary educational pathway can be an intimidating process for post-9/11 veterans struggling with mental health concerns that may alter learning styles and negatively impact performance.^1-4 When significant interference with learning ability is anticipated for more than 6 months, these veterans may qualify for formal academic “reasonable” accommodations under federal disability laws that include the Americans with Disabilities Act (ADA) of 1990 as amended in 2008 and Section 504 of the Rehabilitation Act of 1973. These accommodations enable students to compensate for learning disabilities and help support the transition to student life. Student veterans often are not aware of the existence of academic reasonable accommodations, because military separation classes, civilian postdeployment orientation, and popular media do not routinely cover information on this subject.

With an overall objective to ease veteran reintegration into the civilian world and promote emotional stability, health care providers (HCPs) are in a unique position to promote the use of formal academic accommodations for post-9/11 veterans with psychiatric conditions. However, HCPs must have basic information regarding these interventions before initiating discussions with patients. Current peer-reviewed medical literature has scant information regarding specific aspects of academic reasonable accommodations for individuals with psychiatric diagnoses.

The purpose of this 2-part article (part 2 will be published in May 2016) is to promote a greater understanding of academic accommodations for post-9/11 veterans with psychiatric diagnoses. Part 1 provides a brief background regarding issues pertinent to the post-9/11 student veteran role transition and reviews information regarding various aspects of academic reasonable accommodations, including details on the definition, request process, medical documentation requirements, and common accommodation examples.

Although the focus of the article is on the characteristics of post-9/11 veterans who have separated from military service, it also is relevant for providers involved with service members who have not yet separated. The impact of mental health issues, traumatic brain injury (TBI), and psychosocial stressors on learning ability are potentially applicable to many post-9/11 active-duty soldiers and reservists who are pursuing a secondary education. The academic reasonable accommodations discussed are available to any adult who meets the eligibility criteria—regardless of military status.

Influence of Psychiatric Symptoms on Learning

Although each mental health diagnosis is unique, mental health conditions involving mood share the common symptoms of impaired learning ability.^3-8 Problems frequently experienced include decreased concentration, shortened attention span, difficulty in making new memories or storing new information, and the inability to recall information previously learned.^6-8 Other reported conditions include difficulty with prioritization of tasks, losing track of time, difficulty focusing on tasks, and taking longer to complete assignments.^3,4 Increased irritability accompanies many of these issues. Low tolerance to frustration may occur as evidenced by an outburst of anger or resignation to defeat when minor barriers are encountered, especially when authority figures or bureaucratic rules create those perceived barriers.^3,4 Persistent impaired ability to articulate ideas or thoughts and difficulty performing abstract thinking also are often noticed when moderate-to-severe mental health symptoms are present.^4,8

Medications commonly used to control psychiatric symptoms and stabilize underlying mental health also can produce adverse effects (AEs) that impact learning ability.^9,10 Drug AEs vary but often include significant fatigue, impaired memory, and impaired executive function involving insight, judgment, and/or abstract thinking. Depending on the medication, the individual may experience restlessness or insomnia.

Factors Complicating Successful Integration

The transition period from military service to civilian life presents unique complications for student veterans with symptomatic psychiatric concerns.^1,11 Veterans who separate from military service go through a civilian transition period of variable intensity influenced by readjustment difficulties and comorbid conditions.^11,12 During this time, veterans are reintegrating into civilian life and assuming new roles that include partner, parent, employee, and family member. This transition can cause many symptoms to appear that potentially influence learning to varying degrees. A summary of impediments to learning in post-9/11 veterans is found in Table 1.

Common transition symptoms include irritability, decreased ability to store and recall information, decreased concentration, decreased attention, and slowed executive functioning.^13,14 Sleep disturbances such as altered sleep-wake cycles, nonrestful sleep, inadequate sleep, and nightmares also may occur.^13,14 Veterans experiencing these transition period symptoms may face significant difficulties with time management skills, organization, and task execution. If the veteran successfully assimilates into his or her new roles and becomes self-confident within those roles, the symptoms may abate. However, if moderate-to-severe psychiatric symptoms also are present, all transition symptoms likely will have an unpredictable time frame for resolution.^3,13,14

Understanding the role responsibilities of student veterans is important in recognizing the added stressors veterans with psychiatric diagnoses have within the academic setting. In general, demographic data indicate that student veterans lead far more complex lives than those of 18- to 22-year-olds who enter postsecondary education without military experience. Student veterans are older, have a broader life experience, and may feel less connected to nonveteran students.^15,16 Compared with typical younger college students, undergraduate student veterans are more likely to be married but somewhat less likely to be parents.¹⁷ Student veterans who are pursuing graduate degrees are more likely to be married and/or have dependents.¹⁷ Those roles imply that student veterans often are juggling multiple responsibilities that are constantly competing for student veterans’ time and attention.

Age differences, multiple roles, and lack of shared life experiences with traditional college students contribute to student veterans’ perceptions of a paucity of campus social support and often lead to a sense of distinct isolation.^18,19 These added stressors deplete a veteran’s ability to concentrate on academic studies and may exacerbate the effects of underlying mental health diagnoses, transition issues, and medication use.

Symptomatic psychiatric diagnoses can amplify the difficulties normally experienced when changing from a veteran role to a student veteran role.¹ The student veteran’s apprehension about returning to school often is elevated because of the time gap since the veteran was last in a formal, nonmilitary classroom. Acclimated to the structured style of military coursework for many years, student veterans may find adjusting to new teaching styles or different academic expectations awkward.^20,21 They may experience heightened anxiety, because expectations of classroom performance may not be as clearcut as it was in the military. Such heightened anxiety can compound learning difficulties caused by underlying emotional states, transition issues, medication AEs, and life stressors.

Related: The VA/DoD Chronic Effects of Neurotrauma Consortium: An Overview at Year 1

Many student veterans with impaired learning ability related to psychiatric symptoms also have secondary physical diagnoses that can impede learning. For example, tinnitus and hearing loss are common in combat veterans.^22,23 These issues make it hard to participate in a classroom setting because of difficulty in recognizing speech or filtering out background noise. For some, chronic pain may impede concentration, depress mood, worsen irritability, and make prolonged sitting difficult.^24,25 Physical disabilities related to amputation or major joint injury may present challenges to participating in certain types of college settings and/or navigating between classes in a timely fashion.²⁶

Although mild-to-moderate TBI sustained in combat often will spontaneously resolve within 3 months, in some individuals, TBI symptoms may persist after months or years.^27,28 During this time, learning styles may be altered for veterans exposed to TBI. Similar to the effects caused by other factors impeding learning in post-9/11 veterans, common post-TBI symptoms that reduce academic performance include fatigue, decreased memory, slowed abstract thinking, difficulty articulating thoughts, poor tolerance to frustration, sleep difficulties, chronic pain, and increased irritability.^27-29 Veterans with a history of mild TBI often are found to have clinically significant rates of depression, anxiety, or posttraumatic stress disorder (PTSD).^27,28,30,31 These findings mirror those found in the general population.³² Mild TBI and PTSD may further complicate the learning process by exacerbating underlying mental health symptoms that already impair academic performance. The degree to which these individuals with TBI and mental health issues will return to premorbid academic functioning is not predictable based on current literature.³³

Recognizing the stressors that some combat veterans face in an academic setting is vital to anticipating the added support that is needed by student veterans with concurrent moderate-to-severe psychiatric issues.³⁴ Symptoms usually noted in the transition period may be much more pronounced. Automatic behaviors developed as survival responses during deployment can complicate participation in the educational arena.^4,35 Seemingly mundane tasks, such as the daily school commute, can cause significant anxiety and hypervigilance especially when the veterans must navigate crowds and traffic formerly associated with risk of attack in combat-related circumstances.⁴ Minor roadway debris or roadside construction also can abnormally heighten anxiety because of reflex training to avoid potentially hidden explosive devices during convoy movements.⁴ Random assignment of a classroom seat can be stress-provoking, because combat veterans’ training compels them to position themselves with the greatest vantage point, usually nearest to exits and with minimal activity behind them.^4,35 A need to constantly survey the surroundings for potential cover from hostile events can cause hyper alertness that distracts the student veteran’s full concentration on academic tasks.^3,4

Although veterans should be able to adjust learning styles for minor issues or transitory problems, significant psychiatric symptoms have a negative effect on learning and pose a direct threat to academic performance.^33,36-38 Moderate-to-severe psychiatric concerns may further heighten transition symptoms, compound psychosocial adjustment, and complicate TBI recovery. In addition, periods of high stress may further provoke symptoms of the underlying psychiatric diagnosis.

Reasonable Accommodations

In postsecondary education, reasonable accommodations are formal modifications or adjustments in the school environment that enable individuals with physical or psychological issues to successfully learn and function within the academic institution. In general, these academic accommodations for student veterans with mental health diagnoses involve modifying the learning environment to compensate for delays in executive functioning, such as memorization, recall, and complex analysis. Coursework is not altered; rather specific actions are used to assist the student to process and recall the material more easily. The reasonable accommodations also may be structured in a way that avoids exacerbating an underlying mental health diagnosis, such as PTSD or anxiety. The purpose of reasonable accommodations is to effectively remove barriers to a student veteran’s ability to learn and succeed academically.

Federal law states that reasonable accommodations must be implemented by all schools that accept federal monies—including GI bill payments.³⁹ Although schools are not required to implement all preferred accommodations requested by veterans, academic institutions are required to implement reasonable, effective strategies for the individual student veteran with a psychological diagnosis that causes learning impairment. However, these institutions are not required to proactively determine who might qualify for such accommodations. A school will not initiate formal academic accommodations unless a veteran makes a specific request and provides qualifying documentation.

Many veterans qualify for reasonable accommodations in the academic setting to compensate for the negative impact that mental health issues can have on academic performance. Specifically, student veterans with psychiatric diagnoses are classified as having a learning disability and are eligible to receive academic accommodations if the psychiatric condition substantially limits, or is expected to limit, learning for more than 6 months.³⁹ Individuals with psychiatric conditions in remission are still classified as having a disability if the disorder would impede learning when symptomatic. A veteran does not need to establish verification of a psychiatric diagnosis connected to military service in order to receive formal academic accommodations. Student veterans who qualify for formal academic accommodations can be fully functional in all other areas of their lives. Examples of qualifying psychiatric diagnoses include PTSD, depression, anxiety, bipolar disorder, and schizophrenia.

Although accommodations are individually tailored, there are frequently used accommodations for student veterans with psychiatric diagnoses that have been extremely helpful for those who qualify. Additional time for testing helps the student veteran compensate for the difficulty with abstract thinking, concentration, attention, and recall. Low stimulus testing environments, such as a quiet room, enable a veteran to more easily concentrate. Additional time for completion of assignments without academic penalties is beneficial for a veteran experiencing difficulty with attention, focus, concentration, and organization. Assistance with note-taking or advanced access to lecture notes helps the veteran compensate for decreased focus, attention, and short-term memory impairment. Permitting short breaks without repercussions during a lecture allows the veteran to regain focus and composure if he or she is having difficulties with concentration, attention, restlessness, anxiety, body pain, or emotional flares. Tutoring can help the veteran overcome slowed executive functioning. Faculty-approved notes on an index card may help the veteran compensate for extreme difficulty with memory recall. To prevent visual distraction while reading, use of a blank note card or blank sheet of paper during testing may make it easier for the veteran to focus on each sentence or test question.

On a case-by-case basis, other creative strategies may be used to enable the student veteran to participate more fully in the academic setting. Preferential class scheduling can be arranged to compensate for severely altered sleep patterns. Such changes to the schedule mean a veteran would not have to attend classes during a time frame when his or her body is accustomed to sleeping. Flexibility with class attendance decreases external stressors for the veteran who is having intermittent difficulty with severe sleep disturbances or anxiety in group settings. “Unstacking” midterms or finals allows the student veteran to avoid back-to-back exams and enables him or her to study more effectively for each exam. Virtual classes with self-pacing options may provide more flexibility to complete course requirements while the veteran is dealing with fluctuating emotional symptoms.

Legal Process

Barring undue hardship to provide accommodations, the ADA of 1990 as amended in 2008 and Section 504 of the Rehabilitation Act of 1973 enable equal rights and access to benefits and services for all individuals with disabilities to the same degree as persons without such disabilities in multiple environments including the academic setting. Although the U.S. military system narrowly interprets the term disability, individuals classified as having disabilities under these federal laws fall under a much broader definition. Specifically, any person with “a physical or mental impairment that constitutes or results in substantial impediment” of one of life’s major activities is considered to have a disability.³⁹ As per the ADA of 1990, learning is defined as one of the major life activities.³⁹ This law recognizes that the individual with a learning disability may be fully functional in all other areas of his or her life.

Related: Using Life Stories to Connect Veterans and Providers

Because students must officially request and receive approval for these accommodations within the academic institution, the veteran should speak with the school’s disability resource center counselor regarding the process. If the school does not have a disability resource center, then the student veteran should speak to an admissions counselor at the academic facility. The discussion with the facility’s counselor should include which types of accommodations may be possible to compensate for the veteran’s learning impediments. The counselor will inform the veteran of the required medical documentation that enables the school to grant the needed academic accommodations. In general, veterans can qualify for academic accommodations by receiving a letter with medical documentation of the psychiatric disorder, its anticipated effect on learning, and if known, the suggested reasonable accommodations to compensate for the learning deficit. The veteran can receive a qualifying letter from a psychologist, psychiatrist, PCP, social worker, or licensed counselor with the expertise to diagnose and document the disorder. Student veterans can take this letter to the school’s disability resource center to enable the institution to approve and adopt the accommodations for the student veteran. To ensure compliance with privacy regulations and any facility privacy policies, most providers require a signed release of information form before providing the medical documentation letter.

Such letters need to contain only the basic information required by the disability resource center at each school. Common information required for such a letter includes a clear statement that the disorder and diagnosis are present, the symptoms experienced by the student veteran as a result of the diagnosis, and the impact of those symptoms on the veteran’s learning abilities. If possible, the letter also should specify recommended accommodations that can help the student veteran compensate for the disability. Additional details that some schools may request include associated psychological or medical diagnoses and a listing of medications prescribed to the veteran with AEs experienced. Depending on the institution’s individual policy, the letters may require yearly updates. Federal law forbids schools from requiring onerous amounts of documentation to support the need for academic accommodations.

How many of the preapproved accommodations are used is up to the student veteran. Depending on their baseline functional status and mental health issues, eligible veterans may not need to use all the accommodations each semester or for every class. However, formal accommodations are much easier to implement when needed if the student veteran already has the school preapprove them.

Conclusion

Acquired learning disabilities can prevent successful transition to the student veteran role. Implementation of academic reasonable accommodations is an important avenue by which qualifying post-9/11 student veterans with psychiatric diagnoses can compensate for the negative impact mental health symptoms have on learning styles and academic performance. Because academic stressors and emotional stability are closely intertwined, it is crucial that eligible post-9/11 veterans understand and accept the benefits that formal academic accommodations provide in postsecondary education. Academic accommodations should be offered to empower veterans with mental health concerns. A summary of academic reasonable accommodations is provided in Table 2.

The way clinicians approach this topic will greatly influence veterans’ perspective on academic accommodations. Because there can be a stigma associated with the term learning disability in addition to a general lack of understanding about formal academic accommodations, post-9/11 veterans may not readily pursue the accommodations. Therefore, HCPs should be aware of the best methods for addressing student veterans’ concerns regarding identification of learning disabilities and use of academic accommodations. Unfortunately, information regarding these topics is not readily available in peer-reviewed literature or popular media. Therefore, in part 2, practical interventions for holding crucial conversations with post-9/11 veterans are discussed using a theoretical framework.

Veterans aged > 85 years are the fastest growing cohort; they are living longer with multiple chronic conditions and functional impairments.^1,2 The majority of older veterans (94.6% or about 1.89 million) seeking services in the VA obtain care through primary care providers (PCPs) who are usually not formally trained in geriatrics.^1,3 A 2008 Institute of Medicine report noted that geriatric training was inadequate not only for physicians, but also for all health professions.⁴ For these reasons, new models of care are needed to improve access to geriatric specialists and to improve geriatric care provided by PCPs, especially in rural settings.

In 2010, VA adopted the Patient Aligned Care Team (PACT), based on the patient-centered medical home model, to improve primary care services.⁵ The PACT was designed to deliver patient-centered care and incorporate a team approach to provide comprehensive, coordinated, and personalized care—common themes found in quality geriatric care.^4-6

To provide specialty care support, other programs also were initiated, including the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO). It was implemented in 2011 to increase veteran’s access to specialty care providers and educate PCPs in the treatment of specific diseases. The SCAN-ECHO program is a case-based provider education program conducted via a videoconference that usually occurs monthly and is initiated by a referring PCP for a specific disease or topic.

An interdisciplinary team developed the Geriatric SCAN-ECHO program to help improve veteran access to geriatric specialists and influence care provided to older patients seen by PACTs. The team consisted of a geriatrician, gerontological nurse practitioner (NP), registered nurse (RN), neuropsychologist, social worker (SW), pharmacist, and clinic manager. The geriatric team was located in an urban, academic geriatric specialty clinic in VISN 22 that served 2 ambulatory care centers and 8 satellite community-based outpatient clinics (CBOCs). Veterans using the CBOCs had no direct access to geriatric specialists without traveling to the clinic, which for some could be up to 200 miles away.

This article describes the lessons learned from the implementation of a Geriatric SCAN-ECHO program, preliminary staff survey and chart review results. The program began in January 2013 and ended in February 2014. The article also offers recommendations to increase understanding of geriatric principles for PCP teams.

The Geriatric SCAN-ECHO Program

After obtaining patient consent, primary care clinicians submitted a consult that included the reason for referral (Figure 1). This list of reasons (eg, behavioral management of geriatric syndromes, care management strategies for patients with dementia, caregiver support strategies, and strategies for the patient to continue living in the community safely) assisted the referring clinician in identifying potential cases that might benefit from a geriatric interdisciplinary case review. Patient approval to contact a caregiver or spouse was requested so the Geriatric SCAN-ECHO team could gather additional information.

After the team received the consult, the gerontological NP or geriatrician reviewed the case and identified other relevant members of the team. The electronic medical record (EMR) was reviewed and a phone call made to the patient and/or their caregiver by the appropriate team member to obtain more information, which could include the patient’s current living situation by the social worker, a medication review by the pharmacist, and functional assessment (eg, basic and instrumental activities of daily living) by the nurse. If appropriate, the geriatrician used the Montreal Cognitive Assessment (MoCA)-BLIND to assess the patient’s cognitive abilities.⁷ Finally, the team met to reach a consensus on final recommendations and to identify the didactic lecture topic related to the case being reviewed and presented by members of the Geriatric SCAN-ECHO team.

At the start of each SCAN-ECHO session, the geriatrician asked participants 2 to 3 questions on the clinical topic to be covered to elicit interest and motivation to learn. The referring clinician provided a short summary of the case and reason for referral, and the Geriatric SCAN-ECHO team then provided individual findings and recommendations. Due to the complexity of the referrals, the team usually was able to process 1 to 2 cases during the 1-hour session, with 15 minutes allocated for the didactic.

The didactic lectures consisted of evidence-based tools and guidelines that focused on changing provider practice behavior (eg, Assessing Care of Vulnerable Elders criteria) and were posted on the Geriatric SCAN-ECHO SharePoint site after the session for clinicians to download.⁸ The topics covered included fall risk and prevention; the screening, diagnosis, and management of cognitive disorders; psychosocial considerations in older adults; use of anticholinergic drugs; and assessment and management of unsafe geriatric drivers. Participants were then sent a survey to evaluate the usefulness of the session and its impact on the clinician’s practice. At the end of each session, a summary of findings and recommendations by the geriatric team also was documented in the patient’s EMR and forwarded to the referring clinician. Several factors differentiated the Geriatric from other SCAN-ECHO specialty programs. First, nurses and SWs were invited to place consults, because they were often the first clinicians to identify problems. In a typical SCAN-ECHO program, only PCPs place a consult to the specialty clinic. Second, an interdisciplinary team responded to consults. This was done so that members of the PACT could learn about domains covered by the other disciplines and receive discipline-specific guidance (SCAN-ECHO consults are often answered by a specialist). Third, the team supplemented EMR records with telephone-based assessments. Most SCAN-ECHO programs relied mainly on EMR records.

Facilitators

Although the Geriatric SCAN-ECHO program began in January 2013, the VA Greater Los Angeles Healthcare System facility already had several SCAN-ECHO programs. An experienced SCAN-ECHO project director assisted in the implementation of the program. The specialists used existing documents to guide the program, such as a service agreement between SCAN-ECHO and the participating satellite facilities and templates for consults and documentation. Other benefits of the established SCAN-ECHO presence included availability of videoconferencing equipment; local clinical informatics staff who were familiar with the setup of interfacility consults, clinic encounters, and workload credit in the EMR; and PACT clinicians who were familiar with the SCAN-ECHO program and format. Finally, the geriatric interdisciplinary team members had worked together cohesively for years and were supported by the Geriatric Research Education and Clinical Center to implement clinical demonstration projects, such as the SCAN-ECHO program.

Implementation Barriers

Initially the program received few consults. The Geriatric SCAN-ECHO program used a sample case to start the discussion and focused on falls. At times there were also only a small number of facilities and attendees who participated. Most of the attendees were MDs and NPs from Primary Care and Psychiatry. None of the nurses or SWs who were invited by their local leadership participated early on. Informal communication with CBOC staff found that they were feeling overwhelmed with other competing demands. There were multiple SCAN-ECHO programs and no protected time to attend the sessions. In addition, nurses might not have identified the program as a priority because the training topic was too general (geriatrics vs pressure ulcer or pain management).

The Geriatric SCAN-ECHO program adjusted the timing of sessions to convene every other month on a day that most CBOCs had staff meetings, allowing for protected time for staff participation. The CBOC staff was invited again to participate. The gerontological NP contacted the referring clinician to report the date of the case review and followed up afterward to ensure that all questions were answered and recommendations were clear.

The increase in marketing and networking led to more facilities participating; however, the number of staff participants remained low. The program team then changed tactics and focused on facilitating specific clinician behavior changes related to common geriatric syndromes instead of case reviews. The team conducted a session providing an overview of dementia recognition and diagnosis, rationale for objective measures, and a demonstration on the administration of the Mini-Cog Assessment Instrument for Dementia and Montreal Cognitive Assessment (MoCA) tools.⁷ This session had the highest number of total attendees (38), half of whom were nurses.

Feedback after the session resulted in an additional session the following month, which focused on the scoring and documentation of the tools as well as interpretation of the results and how this might be further evaluated by the team. Informal feedback gathered from nurses during this second session included a request for more training, tips on how to administer the tools, and how to document competency in tool administration. A new educational project that would empower PACT nurses to proactively identify and initiate cognitive impairment/dementia evaluations was then started independent of the Geriatric SCAN-ECHO program.

Results

Participants of SCAN-ECHO programs were surveyed on usefulness of information and its influence on their practice (Table 1). A total of 41 respondents (the same person may have attended more than 1 session) completed surveys on 9 Geriatric SCAN-ECHO sessions. Nineteen (46%) were medical doctors, 8 (20%) were NPs, and 14 (34%) were from other disciplines. Overall, the sessions were well received, and participants found the information useful. Because the respondents were from different disciplines and roles, it was not surprising that only 13 respondents (32%) felt that the information would influence their prescribing practices, and only 18 respondents (44%) agreed that the session changed their ordering of diagnostic tests and studies.

Chart Reviews

Six months after completion of the Geriatric SCAN-ECHO session, the gerontological NP reviewed patient charts and identified rates of adherence for geriatric team recommendations. Eight patient cases were reviewed in 6 of the 9 sessions. The other sessions used sample cases from the team’s experience due to lack of submitted consults. Physicians referred 4 cases, and the rest were from NPs; all were from primary care except for a primary mental health NP. Half of the referred cases were forwarded from other departments (eg, neurobehavior and dementia clinics) to avoid travel. Reasons for referral included geriatric syndrome workup and specific medical questions. All patients were men aged 66 to 94 years (mean = 83.25; SD = 8.29).

Table 2 lists the frequency and adherence to recommendations. If the recommendation was discussed but refused by the patient, it was still noted as completed. Several recommendations might have been presented; thus, adherence to recommendations was categorized as “all,” “some,” or “not at all” adherent. Because the referrals involved complex cases, most cases were referred to other clinical programs managed by the geriatric specialty team for further evaluation and management.

Discussion

Although the Geriatric SCAN-ECHO sessions were well received, the impact of the program was limited by the lack of consults and PACT team involvement. Impact was markedly improved once the focus of the sessions changed from case studies to specific clinical tool administration/practice change. Leadership support and coordination to provide protected team learning time was essential. Incentives to participate might include making geriatric quality indicators part of performance measures to improve practice and quality of care. Although the VA monitors several frail elderly measures that are a reflection of quality geriatric care, it is up to each VISN to determine its performance measures (Kenneth Shay, e-mail communication, February 12, 2013).

The most frequently followed recommendation was referral to a program managed by the geriatric specialty team. Full compliance with this recommendation may be due to the ease of placing a single consult and the interaction between the SCAN-ECHO team and the geriatric specialty services staff. The next most commonly followed recommendations were for medication changes/review and referral to a different program or clinic (not inpatient or outpatient geriatric specialty programs). Because completion of medication reconciliation reminders are tied to pay incentives for VA physicians, this may explain why it was fulfilled at a higher rates compared with other recommendations, suggesting that bonus incentives could boost participation.

The least frequently completed recommendations were referrals to non-VA programs or specialty providers. This may be a reflection of poor communication with non-VA providers and/or documentation of such communications and lack of the availability of the programs near the patient’s residence. Developing remote site referral guides might improve this communication.

Another type of recommendation that was partially or not at all followed was for further evaluation, assessment, or diagnostic tests of specific problems identified by the Geriatric SCAN-ECHO team. This may be due to lack of easy access to specific diagnostic tests in outpatient clinics or lack of staff knowledge and skills on doing geriatric-specific evaluations. The chart reviewer also noted that even when the PCP did the evaluations, the quality was below standard; for example, for depression screening, the chart noted that the patient was asked about having depression; however, no specific tool was used to aid in the diagnosis. Further specificity regarding geriatric syndrome evaluations and increasing staff knowledge of common tools to aid in diagnosis and evaluation are needed.

In 2 of the 8 cases reviewed, the Geriatric SCAN-ECHO program recommended that specific family members needed to be involved in the care of the patient. Unfortunately, most often family members only were used as a means of communication or for coordination of care with the PACT teams (eg, scheduling appointments). Changes needed to provide quality care for geriatric veterans are to include family members, use a fully-realized PACT approach, and have nurses “practice to the full extent of their education and training,” as recommended by the Institute of Medicine.⁹

Limitations

This article reported on the experience of a geriatric team that implemented an interdisciplinary telehealth-based consultation program. Facilitators and barriers to program execution may be limited to the local site and VA. The survey following the session was developed by the VA SCAN-ECHO program and was not specific to this local program. Limitations of the chart review include a short follow-up of only 6 months after the program. Many of the behavioral changes or educational recommendations might have been discussed but were not documented. Also services done by non-VA providers might not have been documented and, therefore, would not have been included in this chart review.

Conclusions

The geriatric team decided to discontinue the Geriatric SCAN-ECHO program. The key metric for program success was number of cases reviewed. Only 1 to 2 cases were reviewed every other month. Participation in the program markedly increased when the specific learning needs of PACT teams were addressed; however, most cases were referred to GRECC due to the case complexity and were not appropriate for the SCAN-ECHO format. The chart review, patient and caregiver contact, and presentation preparation required the program staff to invest a significant amount time. It took 3 to 4 hours for the staff to prepare for each case. Furthermore, adherence to recommendations was also poor.

Case-based education and training without follow-up of the recommendations likely is not the best approach to improve care of older veterans in the primary care setting. The authors hope that focusing on specific practice changes and working directly with PACTs and specific team members will be more productive and result in improved outcomes for older veterans. Due to the complexity of geriatric cases involving physical, cognitive, and emotional vulnerabilities, these cases may be better handled by direct multidisciplinary examinations.

Acknowledgments
Funding for this project was supported by the Veterans Health Administration Office of Specialty Care Services T-21 funding initiative.

Veterans aged > 85 years are the fastest growing cohort; they are living longer with multiple chronic conditions and functional impairments.^1,2 The majority of older veterans (94.6% or about 1.89 million) seeking services in the VA obtain care through primary care providers (PCPs) who are usually not formally trained in geriatrics.^1,3 A 2008 Institute of Medicine report noted that geriatric training was inadequate not only for physicians, but also for all health professions.⁴ For these reasons, new models of care are needed to improve access to geriatric specialists and to improve geriatric care provided by PCPs, especially in rural settings.

In 2010, VA adopted the Patient Aligned Care Team (PACT), based on the patient-centered medical home model, to improve primary care services.⁵ The PACT was designed to deliver patient-centered care and incorporate a team approach to provide comprehensive, coordinated, and personalized care—common themes found in quality geriatric care.^4-6

To provide specialty care support, other programs also were initiated, including the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO). It was implemented in 2011 to increase veteran’s access to specialty care providers and educate PCPs in the treatment of specific diseases. The SCAN-ECHO program is a case-based provider education program conducted via a videoconference that usually occurs monthly and is initiated by a referring PCP for a specific disease or topic.

An interdisciplinary team developed the Geriatric SCAN-ECHO program to help improve veteran access to geriatric specialists and influence care provided to older patients seen by PACTs. The team consisted of a geriatrician, gerontological nurse practitioner (NP), registered nurse (RN), neuropsychologist, social worker (SW), pharmacist, and clinic manager. The geriatric team was located in an urban, academic geriatric specialty clinic in VISN 22 that served 2 ambulatory care centers and 8 satellite community-based outpatient clinics (CBOCs). Veterans using the CBOCs had no direct access to geriatric specialists without traveling to the clinic, which for some could be up to 200 miles away.

This article describes the lessons learned from the implementation of a Geriatric SCAN-ECHO program, preliminary staff survey and chart review results. The program began in January 2013 and ended in February 2014. The article also offers recommendations to increase understanding of geriatric principles for PCP teams.

The Geriatric SCAN-ECHO Program

After obtaining patient consent, primary care clinicians submitted a consult that included the reason for referral (Figure 1). This list of reasons (eg, behavioral management of geriatric syndromes, care management strategies for patients with dementia, caregiver support strategies, and strategies for the patient to continue living in the community safely) assisted the referring clinician in identifying potential cases that might benefit from a geriatric interdisciplinary case review. Patient approval to contact a caregiver or spouse was requested so the Geriatric SCAN-ECHO team could gather additional information.

After the team received the consult, the gerontological NP or geriatrician reviewed the case and identified other relevant members of the team. The electronic medical record (EMR) was reviewed and a phone call made to the patient and/or their caregiver by the appropriate team member to obtain more information, which could include the patient’s current living situation by the social worker, a medication review by the pharmacist, and functional assessment (eg, basic and instrumental activities of daily living) by the nurse. If appropriate, the geriatrician used the Montreal Cognitive Assessment (MoCA)-BLIND to assess the patient’s cognitive abilities.⁷ Finally, the team met to reach a consensus on final recommendations and to identify the didactic lecture topic related to the case being reviewed and presented by members of the Geriatric SCAN-ECHO team.

At the start of each SCAN-ECHO session, the geriatrician asked participants 2 to 3 questions on the clinical topic to be covered to elicit interest and motivation to learn. The referring clinician provided a short summary of the case and reason for referral, and the Geriatric SCAN-ECHO team then provided individual findings and recommendations. Due to the complexity of the referrals, the team usually was able to process 1 to 2 cases during the 1-hour session, with 15 minutes allocated for the didactic.

The didactic lectures consisted of evidence-based tools and guidelines that focused on changing provider practice behavior (eg, Assessing Care of Vulnerable Elders criteria) and were posted on the Geriatric SCAN-ECHO SharePoint site after the session for clinicians to download.⁸ The topics covered included fall risk and prevention; the screening, diagnosis, and management of cognitive disorders; psychosocial considerations in older adults; use of anticholinergic drugs; and assessment and management of unsafe geriatric drivers. Participants were then sent a survey to evaluate the usefulness of the session and its impact on the clinician’s practice. At the end of each session, a summary of findings and recommendations by the geriatric team also was documented in the patient’s EMR and forwarded to the referring clinician. Several factors differentiated the Geriatric from other SCAN-ECHO specialty programs. First, nurses and SWs were invited to place consults, because they were often the first clinicians to identify problems. In a typical SCAN-ECHO program, only PCPs place a consult to the specialty clinic. Second, an interdisciplinary team responded to consults. This was done so that members of the PACT could learn about domains covered by the other disciplines and receive discipline-specific guidance (SCAN-ECHO consults are often answered by a specialist). Third, the team supplemented EMR records with telephone-based assessments. Most SCAN-ECHO programs relied mainly on EMR records.

Facilitators

Although the Geriatric SCAN-ECHO program began in January 2013, the VA Greater Los Angeles Healthcare System facility already had several SCAN-ECHO programs. An experienced SCAN-ECHO project director assisted in the implementation of the program. The specialists used existing documents to guide the program, such as a service agreement between SCAN-ECHO and the participating satellite facilities and templates for consults and documentation. Other benefits of the established SCAN-ECHO presence included availability of videoconferencing equipment; local clinical informatics staff who were familiar with the setup of interfacility consults, clinic encounters, and workload credit in the EMR; and PACT clinicians who were familiar with the SCAN-ECHO program and format. Finally, the geriatric interdisciplinary team members had worked together cohesively for years and were supported by the Geriatric Research Education and Clinical Center to implement clinical demonstration projects, such as the SCAN-ECHO program.

Implementation Barriers

Initially the program received few consults. The Geriatric SCAN-ECHO program used a sample case to start the discussion and focused on falls. At times there were also only a small number of facilities and attendees who participated. Most of the attendees were MDs and NPs from Primary Care and Psychiatry. None of the nurses or SWs who were invited by their local leadership participated early on. Informal communication with CBOC staff found that they were feeling overwhelmed with other competing demands. There were multiple SCAN-ECHO programs and no protected time to attend the sessions. In addition, nurses might not have identified the program as a priority because the training topic was too general (geriatrics vs pressure ulcer or pain management).

The Geriatric SCAN-ECHO program adjusted the timing of sessions to convene every other month on a day that most CBOCs had staff meetings, allowing for protected time for staff participation. The CBOC staff was invited again to participate. The gerontological NP contacted the referring clinician to report the date of the case review and followed up afterward to ensure that all questions were answered and recommendations were clear.

The increase in marketing and networking led to more facilities participating; however, the number of staff participants remained low. The program team then changed tactics and focused on facilitating specific clinician behavior changes related to common geriatric syndromes instead of case reviews. The team conducted a session providing an overview of dementia recognition and diagnosis, rationale for objective measures, and a demonstration on the administration of the Mini-Cog Assessment Instrument for Dementia and Montreal Cognitive Assessment (MoCA) tools.⁷ This session had the highest number of total attendees (38), half of whom were nurses.

Feedback after the session resulted in an additional session the following month, which focused on the scoring and documentation of the tools as well as interpretation of the results and how this might be further evaluated by the team. Informal feedback gathered from nurses during this second session included a request for more training, tips on how to administer the tools, and how to document competency in tool administration. A new educational project that would empower PACT nurses to proactively identify and initiate cognitive impairment/dementia evaluations was then started independent of the Geriatric SCAN-ECHO program.

Results

Participants of SCAN-ECHO programs were surveyed on usefulness of information and its influence on their practice (Table 1). A total of 41 respondents (the same person may have attended more than 1 session) completed surveys on 9 Geriatric SCAN-ECHO sessions. Nineteen (46%) were medical doctors, 8 (20%) were NPs, and 14 (34%) were from other disciplines. Overall, the sessions were well received, and participants found the information useful. Because the respondents were from different disciplines and roles, it was not surprising that only 13 respondents (32%) felt that the information would influence their prescribing practices, and only 18 respondents (44%) agreed that the session changed their ordering of diagnostic tests and studies.

Chart Reviews

Six months after completion of the Geriatric SCAN-ECHO session, the gerontological NP reviewed patient charts and identified rates of adherence for geriatric team recommendations. Eight patient cases were reviewed in 6 of the 9 sessions. The other sessions used sample cases from the team’s experience due to lack of submitted consults. Physicians referred 4 cases, and the rest were from NPs; all were from primary care except for a primary mental health NP. Half of the referred cases were forwarded from other departments (eg, neurobehavior and dementia clinics) to avoid travel. Reasons for referral included geriatric syndrome workup and specific medical questions. All patients were men aged 66 to 94 years (mean = 83.25; SD = 8.29).

Table 2 lists the frequency and adherence to recommendations. If the recommendation was discussed but refused by the patient, it was still noted as completed. Several recommendations might have been presented; thus, adherence to recommendations was categorized as “all,” “some,” or “not at all” adherent. Because the referrals involved complex cases, most cases were referred to other clinical programs managed by the geriatric specialty team for further evaluation and management.

Discussion

Although the Geriatric SCAN-ECHO sessions were well received, the impact of the program was limited by the lack of consults and PACT team involvement. Impact was markedly improved once the focus of the sessions changed from case studies to specific clinical tool administration/practice change. Leadership support and coordination to provide protected team learning time was essential. Incentives to participate might include making geriatric quality indicators part of performance measures to improve practice and quality of care. Although the VA monitors several frail elderly measures that are a reflection of quality geriatric care, it is up to each VISN to determine its performance measures (Kenneth Shay, e-mail communication, February 12, 2013).

The most frequently followed recommendation was referral to a program managed by the geriatric specialty team. Full compliance with this recommendation may be due to the ease of placing a single consult and the interaction between the SCAN-ECHO team and the geriatric specialty services staff. The next most commonly followed recommendations were for medication changes/review and referral to a different program or clinic (not inpatient or outpatient geriatric specialty programs). Because completion of medication reconciliation reminders are tied to pay incentives for VA physicians, this may explain why it was fulfilled at a higher rates compared with other recommendations, suggesting that bonus incentives could boost participation.

The least frequently completed recommendations were referrals to non-VA programs or specialty providers. This may be a reflection of poor communication with non-VA providers and/or documentation of such communications and lack of the availability of the programs near the patient’s residence. Developing remote site referral guides might improve this communication.

Another type of recommendation that was partially or not at all followed was for further evaluation, assessment, or diagnostic tests of specific problems identified by the Geriatric SCAN-ECHO team. This may be due to lack of easy access to specific diagnostic tests in outpatient clinics or lack of staff knowledge and skills on doing geriatric-specific evaluations. The chart reviewer also noted that even when the PCP did the evaluations, the quality was below standard; for example, for depression screening, the chart noted that the patient was asked about having depression; however, no specific tool was used to aid in the diagnosis. Further specificity regarding geriatric syndrome evaluations and increasing staff knowledge of common tools to aid in diagnosis and evaluation are needed.

In 2 of the 8 cases reviewed, the Geriatric SCAN-ECHO program recommended that specific family members needed to be involved in the care of the patient. Unfortunately, most often family members only were used as a means of communication or for coordination of care with the PACT teams (eg, scheduling appointments). Changes needed to provide quality care for geriatric veterans are to include family members, use a fully-realized PACT approach, and have nurses “practice to the full extent of their education and training,” as recommended by the Institute of Medicine.⁹

Limitations

This article reported on the experience of a geriatric team that implemented an interdisciplinary telehealth-based consultation program. Facilitators and barriers to program execution may be limited to the local site and VA. The survey following the session was developed by the VA SCAN-ECHO program and was not specific to this local program. Limitations of the chart review include a short follow-up of only 6 months after the program. Many of the behavioral changes or educational recommendations might have been discussed but were not documented. Also services done by non-VA providers might not have been documented and, therefore, would not have been included in this chart review.

Conclusions

The geriatric team decided to discontinue the Geriatric SCAN-ECHO program. The key metric for program success was number of cases reviewed. Only 1 to 2 cases were reviewed every other month. Participation in the program markedly increased when the specific learning needs of PACT teams were addressed; however, most cases were referred to GRECC due to the case complexity and were not appropriate for the SCAN-ECHO format. The chart review, patient and caregiver contact, and presentation preparation required the program staff to invest a significant amount time. It took 3 to 4 hours for the staff to prepare for each case. Furthermore, adherence to recommendations was also poor.

Case-based education and training without follow-up of the recommendations likely is not the best approach to improve care of older veterans in the primary care setting. The authors hope that focusing on specific practice changes and working directly with PACTs and specific team members will be more productive and result in improved outcomes for older veterans. Due to the complexity of geriatric cases involving physical, cognitive, and emotional vulnerabilities, these cases may be better handled by direct multidisciplinary examinations.

Acknowledgments
Funding for this project was supported by the Veterans Health Administration Office of Specialty Care Services T-21 funding initiative.

Veterans aged > 85 years are the fastest growing cohort; they are living longer with multiple chronic conditions and functional impairments.^1,2 The majority of older veterans (94.6% or about 1.89 million) seeking services in the VA obtain care through primary care providers (PCPs) who are usually not formally trained in geriatrics.^1,3 A 2008 Institute of Medicine report noted that geriatric training was inadequate not only for physicians, but also for all health professions.⁴ For these reasons, new models of care are needed to improve access to geriatric specialists and to improve geriatric care provided by PCPs, especially in rural settings.

In 2010, VA adopted the Patient Aligned Care Team (PACT), based on the patient-centered medical home model, to improve primary care services.⁵ The PACT was designed to deliver patient-centered care and incorporate a team approach to provide comprehensive, coordinated, and personalized care—common themes found in quality geriatric care.^4-6

To provide specialty care support, other programs also were initiated, including the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO). It was implemented in 2011 to increase veteran’s access to specialty care providers and educate PCPs in the treatment of specific diseases. The SCAN-ECHO program is a case-based provider education program conducted via a videoconference that usually occurs monthly and is initiated by a referring PCP for a specific disease or topic.

An interdisciplinary team developed the Geriatric SCAN-ECHO program to help improve veteran access to geriatric specialists and influence care provided to older patients seen by PACTs. The team consisted of a geriatrician, gerontological nurse practitioner (NP), registered nurse (RN), neuropsychologist, social worker (SW), pharmacist, and clinic manager. The geriatric team was located in an urban, academic geriatric specialty clinic in VISN 22 that served 2 ambulatory care centers and 8 satellite community-based outpatient clinics (CBOCs). Veterans using the CBOCs had no direct access to geriatric specialists without traveling to the clinic, which for some could be up to 200 miles away.

This article describes the lessons learned from the implementation of a Geriatric SCAN-ECHO program, preliminary staff survey and chart review results. The program began in January 2013 and ended in February 2014. The article also offers recommendations to increase understanding of geriatric principles for PCP teams.

The Geriatric SCAN-ECHO Program

After obtaining patient consent, primary care clinicians submitted a consult that included the reason for referral (Figure 1). This list of reasons (eg, behavioral management of geriatric syndromes, care management strategies for patients with dementia, caregiver support strategies, and strategies for the patient to continue living in the community safely) assisted the referring clinician in identifying potential cases that might benefit from a geriatric interdisciplinary case review. Patient approval to contact a caregiver or spouse was requested so the Geriatric SCAN-ECHO team could gather additional information.

After the team received the consult, the gerontological NP or geriatrician reviewed the case and identified other relevant members of the team. The electronic medical record (EMR) was reviewed and a phone call made to the patient and/or their caregiver by the appropriate team member to obtain more information, which could include the patient’s current living situation by the social worker, a medication review by the pharmacist, and functional assessment (eg, basic and instrumental activities of daily living) by the nurse. If appropriate, the geriatrician used the Montreal Cognitive Assessment (MoCA)-BLIND to assess the patient’s cognitive abilities.⁷ Finally, the team met to reach a consensus on final recommendations and to identify the didactic lecture topic related to the case being reviewed and presented by members of the Geriatric SCAN-ECHO team.

At the start of each SCAN-ECHO session, the geriatrician asked participants 2 to 3 questions on the clinical topic to be covered to elicit interest and motivation to learn. The referring clinician provided a short summary of the case and reason for referral, and the Geriatric SCAN-ECHO team then provided individual findings and recommendations. Due to the complexity of the referrals, the team usually was able to process 1 to 2 cases during the 1-hour session, with 15 minutes allocated for the didactic.

The didactic lectures consisted of evidence-based tools and guidelines that focused on changing provider practice behavior (eg, Assessing Care of Vulnerable Elders criteria) and were posted on the Geriatric SCAN-ECHO SharePoint site after the session for clinicians to download.⁸ The topics covered included fall risk and prevention; the screening, diagnosis, and management of cognitive disorders; psychosocial considerations in older adults; use of anticholinergic drugs; and assessment and management of unsafe geriatric drivers. Participants were then sent a survey to evaluate the usefulness of the session and its impact on the clinician’s practice. At the end of each session, a summary of findings and recommendations by the geriatric team also was documented in the patient’s EMR and forwarded to the referring clinician. Several factors differentiated the Geriatric from other SCAN-ECHO specialty programs. First, nurses and SWs were invited to place consults, because they were often the first clinicians to identify problems. In a typical SCAN-ECHO program, only PCPs place a consult to the specialty clinic. Second, an interdisciplinary team responded to consults. This was done so that members of the PACT could learn about domains covered by the other disciplines and receive discipline-specific guidance (SCAN-ECHO consults are often answered by a specialist). Third, the team supplemented EMR records with telephone-based assessments. Most SCAN-ECHO programs relied mainly on EMR records.

Facilitators

Although the Geriatric SCAN-ECHO program began in January 2013, the VA Greater Los Angeles Healthcare System facility already had several SCAN-ECHO programs. An experienced SCAN-ECHO project director assisted in the implementation of the program. The specialists used existing documents to guide the program, such as a service agreement between SCAN-ECHO and the participating satellite facilities and templates for consults and documentation. Other benefits of the established SCAN-ECHO presence included availability of videoconferencing equipment; local clinical informatics staff who were familiar with the setup of interfacility consults, clinic encounters, and workload credit in the EMR; and PACT clinicians who were familiar with the SCAN-ECHO program and format. Finally, the geriatric interdisciplinary team members had worked together cohesively for years and were supported by the Geriatric Research Education and Clinical Center to implement clinical demonstration projects, such as the SCAN-ECHO program.

Implementation Barriers

Initially the program received few consults. The Geriatric SCAN-ECHO program used a sample case to start the discussion and focused on falls. At times there were also only a small number of facilities and attendees who participated. Most of the attendees were MDs and NPs from Primary Care and Psychiatry. None of the nurses or SWs who were invited by their local leadership participated early on. Informal communication with CBOC staff found that they were feeling overwhelmed with other competing demands. There were multiple SCAN-ECHO programs and no protected time to attend the sessions. In addition, nurses might not have identified the program as a priority because the training topic was too general (geriatrics vs pressure ulcer or pain management).

The Geriatric SCAN-ECHO program adjusted the timing of sessions to convene every other month on a day that most CBOCs had staff meetings, allowing for protected time for staff participation. The CBOC staff was invited again to participate. The gerontological NP contacted the referring clinician to report the date of the case review and followed up afterward to ensure that all questions were answered and recommendations were clear.

The increase in marketing and networking led to more facilities participating; however, the number of staff participants remained low. The program team then changed tactics and focused on facilitating specific clinician behavior changes related to common geriatric syndromes instead of case reviews. The team conducted a session providing an overview of dementia recognition and diagnosis, rationale for objective measures, and a demonstration on the administration of the Mini-Cog Assessment Instrument for Dementia and Montreal Cognitive Assessment (MoCA) tools.⁷ This session had the highest number of total attendees (38), half of whom were nurses.

Feedback after the session resulted in an additional session the following month, which focused on the scoring and documentation of the tools as well as interpretation of the results and how this might be further evaluated by the team. Informal feedback gathered from nurses during this second session included a request for more training, tips on how to administer the tools, and how to document competency in tool administration. A new educational project that would empower PACT nurses to proactively identify and initiate cognitive impairment/dementia evaluations was then started independent of the Geriatric SCAN-ECHO program.

Results

Participants of SCAN-ECHO programs were surveyed on usefulness of information and its influence on their practice (Table 1). A total of 41 respondents (the same person may have attended more than 1 session) completed surveys on 9 Geriatric SCAN-ECHO sessions. Nineteen (46%) were medical doctors, 8 (20%) were NPs, and 14 (34%) were from other disciplines. Overall, the sessions were well received, and participants found the information useful. Because the respondents were from different disciplines and roles, it was not surprising that only 13 respondents (32%) felt that the information would influence their prescribing practices, and only 18 respondents (44%) agreed that the session changed their ordering of diagnostic tests and studies.

Chart Reviews

Six months after completion of the Geriatric SCAN-ECHO session, the gerontological NP reviewed patient charts and identified rates of adherence for geriatric team recommendations. Eight patient cases were reviewed in 6 of the 9 sessions. The other sessions used sample cases from the team’s experience due to lack of submitted consults. Physicians referred 4 cases, and the rest were from NPs; all were from primary care except for a primary mental health NP. Half of the referred cases were forwarded from other departments (eg, neurobehavior and dementia clinics) to avoid travel. Reasons for referral included geriatric syndrome workup and specific medical questions. All patients were men aged 66 to 94 years (mean = 83.25; SD = 8.29).

Table 2 lists the frequency and adherence to recommendations. If the recommendation was discussed but refused by the patient, it was still noted as completed. Several recommendations might have been presented; thus, adherence to recommendations was categorized as “all,” “some,” or “not at all” adherent. Because the referrals involved complex cases, most cases were referred to other clinical programs managed by the geriatric specialty team for further evaluation and management.

Discussion

Although the Geriatric SCAN-ECHO sessions were well received, the impact of the program was limited by the lack of consults and PACT team involvement. Impact was markedly improved once the focus of the sessions changed from case studies to specific clinical tool administration/practice change. Leadership support and coordination to provide protected team learning time was essential. Incentives to participate might include making geriatric quality indicators part of performance measures to improve practice and quality of care. Although the VA monitors several frail elderly measures that are a reflection of quality geriatric care, it is up to each VISN to determine its performance measures (Kenneth Shay, e-mail communication, February 12, 2013).

The most frequently followed recommendation was referral to a program managed by the geriatric specialty team. Full compliance with this recommendation may be due to the ease of placing a single consult and the interaction between the SCAN-ECHO team and the geriatric specialty services staff. The next most commonly followed recommendations were for medication changes/review and referral to a different program or clinic (not inpatient or outpatient geriatric specialty programs). Because completion of medication reconciliation reminders are tied to pay incentives for VA physicians, this may explain why it was fulfilled at a higher rates compared with other recommendations, suggesting that bonus incentives could boost participation.

The least frequently completed recommendations were referrals to non-VA programs or specialty providers. This may be a reflection of poor communication with non-VA providers and/or documentation of such communications and lack of the availability of the programs near the patient’s residence. Developing remote site referral guides might improve this communication.

Another type of recommendation that was partially or not at all followed was for further evaluation, assessment, or diagnostic tests of specific problems identified by the Geriatric SCAN-ECHO team. This may be due to lack of easy access to specific diagnostic tests in outpatient clinics or lack of staff knowledge and skills on doing geriatric-specific evaluations. The chart reviewer also noted that even when the PCP did the evaluations, the quality was below standard; for example, for depression screening, the chart noted that the patient was asked about having depression; however, no specific tool was used to aid in the diagnosis. Further specificity regarding geriatric syndrome evaluations and increasing staff knowledge of common tools to aid in diagnosis and evaluation are needed.

In 2 of the 8 cases reviewed, the Geriatric SCAN-ECHO program recommended that specific family members needed to be involved in the care of the patient. Unfortunately, most often family members only were used as a means of communication or for coordination of care with the PACT teams (eg, scheduling appointments). Changes needed to provide quality care for geriatric veterans are to include family members, use a fully-realized PACT approach, and have nurses “practice to the full extent of their education and training,” as recommended by the Institute of Medicine.⁹

Limitations

This article reported on the experience of a geriatric team that implemented an interdisciplinary telehealth-based consultation program. Facilitators and barriers to program execution may be limited to the local site and VA. The survey following the session was developed by the VA SCAN-ECHO program and was not specific to this local program. Limitations of the chart review include a short follow-up of only 6 months after the program. Many of the behavioral changes or educational recommendations might have been discussed but were not documented. Also services done by non-VA providers might not have been documented and, therefore, would not have been included in this chart review.

Conclusions

The geriatric team decided to discontinue the Geriatric SCAN-ECHO program. The key metric for program success was number of cases reviewed. Only 1 to 2 cases were reviewed every other month. Participation in the program markedly increased when the specific learning needs of PACT teams were addressed; however, most cases were referred to GRECC due to the case complexity and were not appropriate for the SCAN-ECHO format. The chart review, patient and caregiver contact, and presentation preparation required the program staff to invest a significant amount time. It took 3 to 4 hours for the staff to prepare for each case. Furthermore, adherence to recommendations was also poor.

Case-based education and training without follow-up of the recommendations likely is not the best approach to improve care of older veterans in the primary care setting. The authors hope that focusing on specific practice changes and working directly with PACTs and specific team members will be more productive and result in improved outcomes for older veterans. Due to the complexity of geriatric cases involving physical, cognitive, and emotional vulnerabilities, these cases may be better handled by direct multidisciplinary examinations.

Acknowledgments
Funding for this project was supported by the Veterans Health Administration Office of Specialty Care Services T-21 funding initiative.

The emergence of hepatitis C (HCV) treatment regimens in the past 5 years has resulted in a major paradigm shift in the management of those infected with this virus. The 2011 approval of boceprevir and telaprevir was associated with a higher virologic response (50%-75%) and a shorter length of therapy depending on the patient population. Despite these gains, first generation direct-acting antivirals (DAAs) required multiple doses, had a higher pill burden with numerous drug interactions, and adverse effects (AEs). In addition, viral resistance limited the full use of the first generation DAAs for all genotypes.

Sofosbuvir, simeprevir, and ledipasvir-sofosbuvir (second generation DAAs) boast even higher (> 90%) sustained virologic response rates (SVR) and more tolerable AE profiles especially anemia, depression, and gastrointestinal symptoms compared with the first generation DAAs. At the time of treatment for this case study, sofosbuvir/ledipasvir was not commercially available. Sofosbuvir in combination with simeprevir with or without ribavirin was one of the preferred treatment options for chronic HCV.¹

Unlike the first generation DAAs, which have been associated with a decline in renal function compared with conventional pegylated interferon and ribavirin, sofosbuvir is extensively renally eliminated by glomerular filtration and active tubular secretion as the metabolite GS-331007. On the other hand, simeprevir is hepatically metabolized.

A PubMed literature search for reports of “simeprevir-induced” or “sofosbuvir-induced with hepatic, renal failure, acute kidney injury” yielded only 1 published case of hepatic decompensation likely related to simeprevir, but no case report of simeprevir and sofosbuvir associated with hepatic decompensation and acute kidney injury.⁴ In this article, the authors describe a case of hepatic decompensation and acute kidney injury caused by simeprevir/sofosbuvir initiation for chronic HCV that required intensive care and dialysis.

Case Report

The patient was a 62-year-old African American man with chronic HCV, genotype 1b, TT IL28B, and 4,980,000 IU baseline viral load. He was treatment naïve with biopsy proven compensated cirrhosis, and Child-Turcotte-Pugh class A with a pretreatment model for end-stage liver disease score of 12. His past medical history included hypertension, chronic kidney disease (CKD) (baseline serum creatinine [SCr] 1.4-1.8 mg/dL), benign prostatic hypertrophy, depression, obesity (30.6 body mass index, 246 lb), and psoriasis. In addition, the patient was on the following maintenance medications: allopurinol, bupropion, diltiazem, sustained-release and immediate-release morphine, sennosides, and terazosin.

In September 2014, the patient was diagnosed with biopsy-confirmed hepatocellular carcinoma (HCC) Barcelona clinic liver cancer stage B T3aN0M0 stage III. He was considered for transarterial chemoembolization (TACE), but treatment was withheld due to subsequent increase in liver function tests (LFTs) with total bilirubin (TB) 2.9 mg/dL, direct bilirubin (DB) 1.8 mg/dL, aspartate aminotransferase test (AST) 130 U/L, and alanine aminotransferase test (ALT) 188 U/L (baseline: TB 1.1 mg/dL, AST 69 U/L, and ALT 76 U/L). These results were thought to be the result of worsening hepatic function from untreated HCV, therefore, treatment was initiated.

The patient was started on simeprevir 150 mg orally daily and sofosbuvir 400 mg orally daily with an estimated baseline creatinine clearance of 67 mL/min per Cockcroft-Gault equation.⁵ Two days after therapy initiation, the patient presented to the emergency department with the following symptoms: hiccups, nausea, vomiting, and abdominal pain. Laboratory results showed 10.85 mg/dL SCr and 91 mg/dL blood urea nitrogen (BUN), TB increased to 14.6 mg/dL with AST of 325 U/L and ALT 277 U/L. The patient reported no use of acetaminophen, alcohol, nonsteroidal anti-inflammatory drugs, or other nephrotoxic agents.

Upon admission, the patient was diagnosed with drug-induced hepatitis and acute kidney injury (AKI). Simeprevir/sofosbuvir was discontinued along with allopurinol, bupropion, lisinopril, and morphine. An abdominal ultrasound was negative for obstructive uropathy. The patient did not respond to fluid boluses. A nephrologist was consulted, and dialysis was initiated. The patient underwent dialysis for 3 days and his LFTs and SCr levels started trending downward (Figures 1 to 5).

The patient was discharged after 8 days. After 3 weeks, the SCr decreased to 2.29 mg/dL, BUN was 26 mg/dL, TB was 2 mg/dL, DB was 0.9 mg/dL, AST was 73 U/L, and ALT was 81 U/L. Weekly laboratory values continued to improve following discharge but did not return to baseline levels. The patient remained off HCV treatment.

Discussion

The patient had baseline CKD with SCr > 1.5 mg/dL; however, the significant decline in renal function and worsening hepatic function were thought to be the result of external factors. Although hepatorenal syndrome was considered, the authors suspected that the AKI and hepatic decompensation were related to simeprevir/sofosbuvir regimens due to their presumed relationship and probability analysis. Osinusi and colleagues noted a decline in renal function in a patient who received ledipasvir/sofosbuvir for 6 weeks in an open-label pilot study.⁶ Stine and colleagues also reported on cases of simeprevir-related hepatic decompensation.⁴

In this case, the authors employed the Naranjo algorithm adverse drug reaction probability scale to assess whether there was a causal relationship between this event and initiation of simeprevir/sofosbuvir regimen.⁷ The Naranjo score was 4, indicating a possible link between simeprevir/sofosbuvir initiation and hepatic decompensation and AKI. This case may be the first postmarketing report of significant hepatic decompensation and AKI related to simeprevir/sofosbuvir.

Unlike simeprevir, which undergoes extensive oxidative metabolism by CYP3A in the liver and has negligible renal clearance with < 1% of the dose recovered in the urine, sofosbuvir is extensively metabolized by the kidneys with an active metabolite, GS-331007, and about 80% of the dose is recovered in urine (78% as GS-331007; 3.5% as sofosbuvir).^8,9 The potential for drug-drug interaction also was assessed because simeprevir is extensively metabolized by the hepatic cytochrome CYP34 system and possibly CYP2C8 and CYP2C19. Clinically significant interactions could have occurred with diltiazem and morphine, because the coadministration of these medications along with simeprevir, an inhibitor of P-glycoprotein (P-gp), and intestinal CYP3A4, may result in increased diltiazem and morphine plasma concentrations.

Of note, because sofosbuvir is a substrate of P-gp, it may have its serum concentration increased by simeprevir. Inducers and inhibitors of P-gp may alter the plasma concentration of sofosbuvir. The major metabolite, GS-331007, is not a substrate of P-gp. Drugs that induce P-gp may reduce the therapeutic effect of sofosbuvir; however, the FDA-labeling suggests that inhibitors of P-gp may be coadministered with sofosbuvir.

According to simeprevir prescribing information, drug interaction studies have demonstrated that moderate CYP3A4 inhibitors, such as diltiazem (although coadministration have not been studied), increased the maximum serum concentration (C_max), minumum serum concentration (C_min), and AUC of simeprevir.⁷ As a result, concurrent use of simeprevir with a moderate CYP3A4 inhibitors is not recommended. Morphine and simeprevir interaction also is possible via the P-gp inhibition of simeprevir. Morphine concentration may have increased and metabolites may have accumulated, leading to urinary retention and elevated creatinine. In addition, decreased oral intake and subsequent nausea/vomiting may have compounded the renal insult.

Conclusion

Given that updated HCV treatment guidelines include simeprevir/sofosbuvir as an alternative treatment option, clinicians should be aware of hepatic decompensation with markedly elevated bilirubin and AKI during simeprevir and sofosbuvir treatment. Careful consideration is needed prior to the initiation of simeprevir/sofosbuvir, particularly in patients with advanced liver disease or known HCC and baseline renal impairment.

The emergence of hepatitis C (HCV) treatment regimens in the past 5 years has resulted in a major paradigm shift in the management of those infected with this virus. The 2011 approval of boceprevir and telaprevir was associated with a higher virologic response (50%-75%) and a shorter length of therapy depending on the patient population. Despite these gains, first generation direct-acting antivirals (DAAs) required multiple doses, had a higher pill burden with numerous drug interactions, and adverse effects (AEs). In addition, viral resistance limited the full use of the first generation DAAs for all genotypes.

Sofosbuvir, simeprevir, and ledipasvir-sofosbuvir (second generation DAAs) boast even higher (> 90%) sustained virologic response rates (SVR) and more tolerable AE profiles especially anemia, depression, and gastrointestinal symptoms compared with the first generation DAAs. At the time of treatment for this case study, sofosbuvir/ledipasvir was not commercially available. Sofosbuvir in combination with simeprevir with or without ribavirin was one of the preferred treatment options for chronic HCV.¹

Unlike the first generation DAAs, which have been associated with a decline in renal function compared with conventional pegylated interferon and ribavirin, sofosbuvir is extensively renally eliminated by glomerular filtration and active tubular secretion as the metabolite GS-331007. On the other hand, simeprevir is hepatically metabolized.

A PubMed literature search for reports of “simeprevir-induced” or “sofosbuvir-induced with hepatic, renal failure, acute kidney injury” yielded only 1 published case of hepatic decompensation likely related to simeprevir, but no case report of simeprevir and sofosbuvir associated with hepatic decompensation and acute kidney injury.⁴ In this article, the authors describe a case of hepatic decompensation and acute kidney injury caused by simeprevir/sofosbuvir initiation for chronic HCV that required intensive care and dialysis.

Case Report

The patient was a 62-year-old African American man with chronic HCV, genotype 1b, TT IL28B, and 4,980,000 IU baseline viral load. He was treatment naïve with biopsy proven compensated cirrhosis, and Child-Turcotte-Pugh class A with a pretreatment model for end-stage liver disease score of 12. His past medical history included hypertension, chronic kidney disease (CKD) (baseline serum creatinine [SCr] 1.4-1.8 mg/dL), benign prostatic hypertrophy, depression, obesity (30.6 body mass index, 246 lb), and psoriasis. In addition, the patient was on the following maintenance medications: allopurinol, bupropion, diltiazem, sustained-release and immediate-release morphine, sennosides, and terazosin.

In September 2014, the patient was diagnosed with biopsy-confirmed hepatocellular carcinoma (HCC) Barcelona clinic liver cancer stage B T3aN0M0 stage III. He was considered for transarterial chemoembolization (TACE), but treatment was withheld due to subsequent increase in liver function tests (LFTs) with total bilirubin (TB) 2.9 mg/dL, direct bilirubin (DB) 1.8 mg/dL, aspartate aminotransferase test (AST) 130 U/L, and alanine aminotransferase test (ALT) 188 U/L (baseline: TB 1.1 mg/dL, AST 69 U/L, and ALT 76 U/L). These results were thought to be the result of worsening hepatic function from untreated HCV, therefore, treatment was initiated.

The patient was started on simeprevir 150 mg orally daily and sofosbuvir 400 mg orally daily with an estimated baseline creatinine clearance of 67 mL/min per Cockcroft-Gault equation.⁵ Two days after therapy initiation, the patient presented to the emergency department with the following symptoms: hiccups, nausea, vomiting, and abdominal pain. Laboratory results showed 10.85 mg/dL SCr and 91 mg/dL blood urea nitrogen (BUN), TB increased to 14.6 mg/dL with AST of 325 U/L and ALT 277 U/L. The patient reported no use of acetaminophen, alcohol, nonsteroidal anti-inflammatory drugs, or other nephrotoxic agents.

Upon admission, the patient was diagnosed with drug-induced hepatitis and acute kidney injury (AKI). Simeprevir/sofosbuvir was discontinued along with allopurinol, bupropion, lisinopril, and morphine. An abdominal ultrasound was negative for obstructive uropathy. The patient did not respond to fluid boluses. A nephrologist was consulted, and dialysis was initiated. The patient underwent dialysis for 3 days and his LFTs and SCr levels started trending downward (Figures 1 to 5).

The patient was discharged after 8 days. After 3 weeks, the SCr decreased to 2.29 mg/dL, BUN was 26 mg/dL, TB was 2 mg/dL, DB was 0.9 mg/dL, AST was 73 U/L, and ALT was 81 U/L. Weekly laboratory values continued to improve following discharge but did not return to baseline levels. The patient remained off HCV treatment.

Discussion

The patient had baseline CKD with SCr > 1.5 mg/dL; however, the significant decline in renal function and worsening hepatic function were thought to be the result of external factors. Although hepatorenal syndrome was considered, the authors suspected that the AKI and hepatic decompensation were related to simeprevir/sofosbuvir regimens due to their presumed relationship and probability analysis. Osinusi and colleagues noted a decline in renal function in a patient who received ledipasvir/sofosbuvir for 6 weeks in an open-label pilot study.⁶ Stine and colleagues also reported on cases of simeprevir-related hepatic decompensation.⁴

In this case, the authors employed the Naranjo algorithm adverse drug reaction probability scale to assess whether there was a causal relationship between this event and initiation of simeprevir/sofosbuvir regimen.⁷ The Naranjo score was 4, indicating a possible link between simeprevir/sofosbuvir initiation and hepatic decompensation and AKI. This case may be the first postmarketing report of significant hepatic decompensation and AKI related to simeprevir/sofosbuvir.

Unlike simeprevir, which undergoes extensive oxidative metabolism by CYP3A in the liver and has negligible renal clearance with < 1% of the dose recovered in the urine, sofosbuvir is extensively metabolized by the kidneys with an active metabolite, GS-331007, and about 80% of the dose is recovered in urine (78% as GS-331007; 3.5% as sofosbuvir).^8,9 The potential for drug-drug interaction also was assessed because simeprevir is extensively metabolized by the hepatic cytochrome CYP34 system and possibly CYP2C8 and CYP2C19. Clinically significant interactions could have occurred with diltiazem and morphine, because the coadministration of these medications along with simeprevir, an inhibitor of P-glycoprotein (P-gp), and intestinal CYP3A4, may result in increased diltiazem and morphine plasma concentrations.

Of note, because sofosbuvir is a substrate of P-gp, it may have its serum concentration increased by simeprevir. Inducers and inhibitors of P-gp may alter the plasma concentration of sofosbuvir. The major metabolite, GS-331007, is not a substrate of P-gp. Drugs that induce P-gp may reduce the therapeutic effect of sofosbuvir; however, the FDA-labeling suggests that inhibitors of P-gp may be coadministered with sofosbuvir.

According to simeprevir prescribing information, drug interaction studies have demonstrated that moderate CYP3A4 inhibitors, such as diltiazem (although coadministration have not been studied), increased the maximum serum concentration (C_max), minumum serum concentration (C_min), and AUC of simeprevir.⁷ As a result, concurrent use of simeprevir with a moderate CYP3A4 inhibitors is not recommended. Morphine and simeprevir interaction also is possible via the P-gp inhibition of simeprevir. Morphine concentration may have increased and metabolites may have accumulated, leading to urinary retention and elevated creatinine. In addition, decreased oral intake and subsequent nausea/vomiting may have compounded the renal insult.

Conclusion

Given that updated HCV treatment guidelines include simeprevir/sofosbuvir as an alternative treatment option, clinicians should be aware of hepatic decompensation with markedly elevated bilirubin and AKI during simeprevir and sofosbuvir treatment. Careful consideration is needed prior to the initiation of simeprevir/sofosbuvir, particularly in patients with advanced liver disease or known HCC and baseline renal impairment.

The emergence of hepatitis C (HCV) treatment regimens in the past 5 years has resulted in a major paradigm shift in the management of those infected with this virus. The 2011 approval of boceprevir and telaprevir was associated with a higher virologic response (50%-75%) and a shorter length of therapy depending on the patient population. Despite these gains, first generation direct-acting antivirals (DAAs) required multiple doses, had a higher pill burden with numerous drug interactions, and adverse effects (AEs). In addition, viral resistance limited the full use of the first generation DAAs for all genotypes.

Sofosbuvir, simeprevir, and ledipasvir-sofosbuvir (second generation DAAs) boast even higher (> 90%) sustained virologic response rates (SVR) and more tolerable AE profiles especially anemia, depression, and gastrointestinal symptoms compared with the first generation DAAs. At the time of treatment for this case study, sofosbuvir/ledipasvir was not commercially available. Sofosbuvir in combination with simeprevir with or without ribavirin was one of the preferred treatment options for chronic HCV.¹

Unlike the first generation DAAs, which have been associated with a decline in renal function compared with conventional pegylated interferon and ribavirin, sofosbuvir is extensively renally eliminated by glomerular filtration and active tubular secretion as the metabolite GS-331007. On the other hand, simeprevir is hepatically metabolized.

A PubMed literature search for reports of “simeprevir-induced” or “sofosbuvir-induced with hepatic, renal failure, acute kidney injury” yielded only 1 published case of hepatic decompensation likely related to simeprevir, but no case report of simeprevir and sofosbuvir associated with hepatic decompensation and acute kidney injury.⁴ In this article, the authors describe a case of hepatic decompensation and acute kidney injury caused by simeprevir/sofosbuvir initiation for chronic HCV that required intensive care and dialysis.

Case Report

The patient was a 62-year-old African American man with chronic HCV, genotype 1b, TT IL28B, and 4,980,000 IU baseline viral load. He was treatment naïve with biopsy proven compensated cirrhosis, and Child-Turcotte-Pugh class A with a pretreatment model for end-stage liver disease score of 12. His past medical history included hypertension, chronic kidney disease (CKD) (baseline serum creatinine [SCr] 1.4-1.8 mg/dL), benign prostatic hypertrophy, depression, obesity (30.6 body mass index, 246 lb), and psoriasis. In addition, the patient was on the following maintenance medications: allopurinol, bupropion, diltiazem, sustained-release and immediate-release morphine, sennosides, and terazosin.

In September 2014, the patient was diagnosed with biopsy-confirmed hepatocellular carcinoma (HCC) Barcelona clinic liver cancer stage B T3aN0M0 stage III. He was considered for transarterial chemoembolization (TACE), but treatment was withheld due to subsequent increase in liver function tests (LFTs) with total bilirubin (TB) 2.9 mg/dL, direct bilirubin (DB) 1.8 mg/dL, aspartate aminotransferase test (AST) 130 U/L, and alanine aminotransferase test (ALT) 188 U/L (baseline: TB 1.1 mg/dL, AST 69 U/L, and ALT 76 U/L). These results were thought to be the result of worsening hepatic function from untreated HCV, therefore, treatment was initiated.

The patient was started on simeprevir 150 mg orally daily and sofosbuvir 400 mg orally daily with an estimated baseline creatinine clearance of 67 mL/min per Cockcroft-Gault equation.⁵ Two days after therapy initiation, the patient presented to the emergency department with the following symptoms: hiccups, nausea, vomiting, and abdominal pain. Laboratory results showed 10.85 mg/dL SCr and 91 mg/dL blood urea nitrogen (BUN), TB increased to 14.6 mg/dL with AST of 325 U/L and ALT 277 U/L. The patient reported no use of acetaminophen, alcohol, nonsteroidal anti-inflammatory drugs, or other nephrotoxic agents.

Upon admission, the patient was diagnosed with drug-induced hepatitis and acute kidney injury (AKI). Simeprevir/sofosbuvir was discontinued along with allopurinol, bupropion, lisinopril, and morphine. An abdominal ultrasound was negative for obstructive uropathy. The patient did not respond to fluid boluses. A nephrologist was consulted, and dialysis was initiated. The patient underwent dialysis for 3 days and his LFTs and SCr levels started trending downward (Figures 1 to 5).

The patient was discharged after 8 days. After 3 weeks, the SCr decreased to 2.29 mg/dL, BUN was 26 mg/dL, TB was 2 mg/dL, DB was 0.9 mg/dL, AST was 73 U/L, and ALT was 81 U/L. Weekly laboratory values continued to improve following discharge but did not return to baseline levels. The patient remained off HCV treatment.

Discussion

The patient had baseline CKD with SCr > 1.5 mg/dL; however, the significant decline in renal function and worsening hepatic function were thought to be the result of external factors. Although hepatorenal syndrome was considered, the authors suspected that the AKI and hepatic decompensation were related to simeprevir/sofosbuvir regimens due to their presumed relationship and probability analysis. Osinusi and colleagues noted a decline in renal function in a patient who received ledipasvir/sofosbuvir for 6 weeks in an open-label pilot study.⁶ Stine and colleagues also reported on cases of simeprevir-related hepatic decompensation.⁴

In this case, the authors employed the Naranjo algorithm adverse drug reaction probability scale to assess whether there was a causal relationship between this event and initiation of simeprevir/sofosbuvir regimen.⁷ The Naranjo score was 4, indicating a possible link between simeprevir/sofosbuvir initiation and hepatic decompensation and AKI. This case may be the first postmarketing report of significant hepatic decompensation and AKI related to simeprevir/sofosbuvir.

Unlike simeprevir, which undergoes extensive oxidative metabolism by CYP3A in the liver and has negligible renal clearance with < 1% of the dose recovered in the urine, sofosbuvir is extensively metabolized by the kidneys with an active metabolite, GS-331007, and about 80% of the dose is recovered in urine (78% as GS-331007; 3.5% as sofosbuvir).^8,9 The potential for drug-drug interaction also was assessed because simeprevir is extensively metabolized by the hepatic cytochrome CYP34 system and possibly CYP2C8 and CYP2C19. Clinically significant interactions could have occurred with diltiazem and morphine, because the coadministration of these medications along with simeprevir, an inhibitor of P-glycoprotein (P-gp), and intestinal CYP3A4, may result in increased diltiazem and morphine plasma concentrations.

Of note, because sofosbuvir is a substrate of P-gp, it may have its serum concentration increased by simeprevir. Inducers and inhibitors of P-gp may alter the plasma concentration of sofosbuvir. The major metabolite, GS-331007, is not a substrate of P-gp. Drugs that induce P-gp may reduce the therapeutic effect of sofosbuvir; however, the FDA-labeling suggests that inhibitors of P-gp may be coadministered with sofosbuvir.

According to simeprevir prescribing information, drug interaction studies have demonstrated that moderate CYP3A4 inhibitors, such as diltiazem (although coadministration have not been studied), increased the maximum serum concentration (C_max), minumum serum concentration (C_min), and AUC of simeprevir.⁷ As a result, concurrent use of simeprevir with a moderate CYP3A4 inhibitors is not recommended. Morphine and simeprevir interaction also is possible via the P-gp inhibition of simeprevir. Morphine concentration may have increased and metabolites may have accumulated, leading to urinary retention and elevated creatinine. In addition, decreased oral intake and subsequent nausea/vomiting may have compounded the renal insult.

Conclusion

Given that updated HCV treatment guidelines include simeprevir/sofosbuvir as an alternative treatment option, clinicians should be aware of hepatic decompensation with markedly elevated bilirubin and AKI during simeprevir and sofosbuvir treatment. Careful consideration is needed prior to the initiation of simeprevir/sofosbuvir, particularly in patients with advanced liver disease or known HCC and baseline renal impairment.

Rightly so, the topics of mechanical tissue extraction and hysterectomy approach have dominated the field of obstetrics and gynecology over the past 12 months and more. A profusion of literature has been published on these subjects. However, there are 2 important topics within the field of minimally invasive gynecologic surgery that deserve our attention as well, and I have chosen to focus on these for this Update.

First, laparoscopic treatment of ovarian endometriomas is one of the most commonly performed gynecologic procedures worldwide. Many women undergoing such surgery are of childbearing age and have the desire for future pregnancy. What are best practices for preserving ovarian function in these women? Two studies recently published in the Journal of Minimally Invasive Gynecology addressed this question.

Second, until recently, the rate of bowel injury at laparoscopic gynecologic surgery has not been well established.¹ Moreover, mechanical bowel preparation is commonly employed in case intestinal injury does occur, despite the lack of evidence that outcomes of these possible injuries can be improved.² Understanding the rate of bowel injury can shed light on the overall value of the perceived benefits of bowel preparation. Therefore, I examine 2 recent systematic reviews that analyze the incidence of bowel injury and the value of bowel prep in gynecologic laparoscopic surgery.

bipolar coagulation inferior to suturing or hemostatic sealant for preserving ovarian function

Song T, Kim WY, Lee KW, Kim KH. Effect on ovarian reserve of hemostasis by bipolar coagulation versus suture during laparoendoscopic single-site cystectomy for ovarian endometriomas. J Minim Invasive Gynecol. 2015;22(3):415−420.

Ata B, Turkgeldi E, Seyhan A, Urman B. Effect of hemostatic method on ovarian reserve following laparoscopic endometrioma excision; comparison of suture, hemostatic sealant, and bipolar dessication. A systematic review and meta-analysis. J Minim Invasive Gynecol. 2015;22(3):363−372.

The customary surgical approach for laparoscopic cystectomy is by mechanical stripping of the cyst wall (FIGURE) and the use of bipolar desiccation for hemostasis. Stripping inevitably leads to removal of healthy ovarian cortex,3 especially in inexperienced hands,⁴ and ovarian follicles inevitably are destroyed during electrosurgical desiccation. When compared with the use of suturing or a hemostatic agent to control bleeding in the ovarian defect, the use of bipolar electrosurgery may harm more of the ovarian cortex, resulting in a comparatively diminished follicular cohort.
 
Possible deleterious effects on the ovarian reserve can be determined with a blood test to measure anti-Müllerian hormone (AMH) levels postoperatively. Produced by the granulosa cells of the ovary, this hormone directly reflects the remaining ovarian egg supply. Lower levels of AMH have been shown to significantly decrease the success rate of in vitro fertilization (IVF), especially in women older than age 35.⁵ Moreover, AMH levels in the late reproductive years can be used as a predictive marker of menopause, with lower levels predicting significantly earlier onset.⁶
 
Data from 2 recent studies, a quasi-randomized trial by Song and colleagues and a systematic review and meta-analysis by Ata and colleagues emphasize that bipolar desiccation for hemostasis may not be best practice for protecting ovarian reserve during laparoscopic ovarian cystectomy for an endometrioma.

AMH levels decline more significantly for women undergoing bipolar desiccation
Song and colleagues conducted a prospective quasi-randomized study of 125 women whose endometriomas were laparoscopically removed via a single-site approach and managed for hemostasis with either bipolar desiccation or suturing of the ovarian defect with a 2-0 barbed suture. All surgeries were conducted by a single surgeon. 

At 3 months postsurgery, mean AMH levels had declined from baseline by 42.2% (interquartile range [IR], 16.5−53.0 ng/mL) in the desiccation group and by 24.6% (IR, 11.6−37.0 ng/mL) in the suture group (P = .001). Multivariate analysis showed that the method used for hemostasis was the only determinant for reduced ovarian reserve.

In their systematic review and meta-analysis, Ata and colleagues included 10 studies--6 qualitative and 4 quantitative. All studies examined the rate of change of serum AMH levels 3 months after laparoscopic removal of an endometrioma.
 
In their qualitative analysis, 5 of the 6 studies reported a significantly greater decrease in ovarian reserve after bipolar desiccation (varying from 13% to 44%) or a strong trend in the same direction. In the sixth study, the desiccation group had a lower decline in absolute AMH level than in the other 5 studies. The authors note that this 2.7% decline was much lower than the values reported for the bipolar desiccation group of any other study. (Those declines ranged between 19% and 58%.)

Although not significant, in all 3 of the included randomized controlled trials (RCTs), the desiccation groups had a greater loss in AMH level than the hemostatic sealant groups, and in 2 of these RCTs, bipolar desiccation groups had a greater loss than the suturing groups.

Among the 213 study participants in the 3 RCTs and the prospective cohort study included in the quantitative meta-analysis, alternative methods to bipolar desiccation were associated with a 6.95% lower decrease in AMH-level decline (95% confidence interval [CI], −13.0% to −0.9%; P = .02).

What this EVIDENCE means for practice
Compared with the use of bipolar electrosurgery to attain hemostasis, the use of a topical biosurgical agent or suturing could be significantly better for protection of the ovarian follicles during laparoscopic ovarian cystectomy for endometrioma. These alternative methods especially could benefit those women desiring future pregnancy who are demonstrated preoperatively to have a low ovarian reserve. As needed, electrosurgery should be sparingly employed for ovarian hemostasis.

Large Study identifies incidence of bowel injury during gynecologic laproscopy

Llarena NC, Shah AB, Milad MP. Bowel injury in gynecologic laparoscopy: a systematic review. Am J Obstet Gynecol. 2015;125(6):1407−1417.

In no aspect of laparoscopic surgery are preventive strategies more cautiously employed than during peritoneal access. Regardless of the applied technique, there is an irreducible risk of injury to the underlying viscera by either adhesions between the underlying bowel and abdominal wall or during the course of pilot error. Moreover, in the best of hands, bowel injury can occur whenever normal anatomic relationships need to be restored using intra-abdominal adhesiolysis. Given the ubiquity, these risks are never out of the surgeon's mind. Gynecologists are obliged to discuss these risks during the informed consent process.

Until recently, the rate of bowel injury has not been well established. Llarena and colleagues recently have conducted the largest systematic review of the medical literature to date for incidence, presentation, mortality, cause, and location of bowel injury associated with laparoscopic surgery while not necessarily distinguishing for the type of bowel injury. Sixty retrospective and 27 prospective studies met inclusion criteria.

The risk of bowel injury overall and defined
Among 474,063 laparoscopic surgeries conducted between 1972 and 2014, 604 bowel injuries were found, for an incidence of 1 in 769, or 0.13% (95% CI, 0.12−0.14%).

The rate of bowel injury varied by procedure, year, study type, and definition of bowel injury. The incidence of injury according to:

• definition, was 1 in 416 (0.24%) for studies that clearly included serosal injuries and enterotomies versus 1 in 833 (0.12%) for studies not clearly defining the type of bowel injury (relative risk [RR], 0.47; 95% CI, 0.38−0.59; P<.001)
• study type, was 1 in 666 (0.15%) for prospective studies versus 1 in 909 (0.11%) for retrospective studies (RR, 0.78; 95% CI, 0.63−0.96; P = .02)
• procedure, was 1 in 3,333 (0.03%; 95% CI, 0.01−0.03%) for sterilization and 1 in 256 (0.39%; 95% CI, 0.35−0.45%) for hysterectomy
• year, for laparoscopic hysterectomy only, was 1 in 222 (0.45%) before the year 2000 and 1 in 294 (0.34%) after 2000 (RR, 0.75; 95% CI, 0.57−0.98; P = .03).

How were injuries caused, found, and managed?
Thirty studies described the laparoscopic instrument used during 366 reported bowel injuries. The majority of injuries (55%) occurred during initial peritoneal access, with the Veress needle or trocar causing the damage. This was followed by electrosurgery (29%), dissection (11%), and forceps or scissors (4.1%).

According to 40 studies describing 307 injuries, bowel injuries most often were managed by converting to laparotomy (80%); only 8% of injuries were managed with laparoscopy and 2% expectantly.

Surgery to repair the bowel injury was delayed in 154 (41%) of 375 cases. The median time to injury discovery was 3 days (range, 1−13 days).

In only 19 cases were the presenting signs and symptoms of bowel injury recorded. Those reported from most to least often were: peritonitis, abdominal pain, fever, abdominal distention, leukocytosis, leukopenia, and septic shock.

Mortality
Mortality as an outcome was only reported in 29 of the total 90 studies; therefore, mortality may be underreported. Overall, however, death occurred in 1 (0.8%) of 125 bowel injuries.

The overall mortality rate from bowel injury--calculated from the only 42 studies that explicitly mentioned mortality as an outcome--was 1 in 125, or 0.8% (95% CI, 0.36%-1.9%). All 5 reported deaths occurred as a result of delayed recognition of bowel injury, which made the mortality rate for unrecognized bowel injury 1 in 31, or 3.2% (95% CI, 1%-7%). No deaths occurred when the bowel injury was noted intraoperatively.

What this EVIDENCE means for practice
In this review of 474,063 laparoscopic procedures, bowel injury occurred in 1 in 769, or 0.13% of procedures. Bowel injury is more apt to occur during more complicated laparoscopic procedures (compared with laparoscopic sterilization procedures, the risk during hysterectomy was greater than 10-fold).
 
Most of the injuries were managed by laparotomic surgery despite the potential to repair bowel injury by laparoscopy. Validating that peritoneal access is a high risk part of laparoscopic surgery, the majority of the injuries occurred during insufflation with a Veress needle or during abdominal access by trocar insertion. Nearly one-third of the injuries were from the use of electrosurgery, which are typically associated with a delay in presentation.

In this study, 41% of the injuries were unrecognized at the time of surgery. All 5 of the reported deaths were associated with a delay in diagnosis, with an overall mortality rate of 1 of 125, or 0.8%. Since all of these deaths were associated with a delay in diagnosis, the rate of mortality in unrecognized bowel injury was 5 of 154, or 3.2%. Among women who experienced delayed diagnosis, only 19 of 154 experienced signs or symptoms diagnostic for an underlying bowel injury, particularly when the small bowel was injured.

Can mechanical bowel prep positively affect outcomes in gynecologic laparoscopy, or should it be discarded?

Arnold A, Aitchison LP, Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal surgery: a systematic review. J Minim Invasive Gynecol. 2015;22(5):737−752.

Popularized for more than 4 decades, the practice of presurgical bowel preparation is predicated on the notion that the presence of less, versus more, feces can minimize bacterial count and thereby reduce peritoneal contamination. Logically then, surgical site infections (SSIs) should be reduced with bowel preparation. Moreover, the surgical view and bowel handling during laparoscopic surgery should be improved, with surgical times consequently reduced.

Surgeons must weigh the putative benefits of mechanical bowel preparation against the unpleasant experience it causes for patients, as well as the risks of dehydration or electrolyte disturbance it may cause. To this day, a considerable percentage of gynecologists and colorectal surgeons routinely prep the bowel after weighing all of these factors, despite the paucity of evidence for the practice's efficacy to reduce SSI and improve surgical outcomes.⁷

The results of this recent systematic review critically question the usefulness of preoperative bowel preparation for abdominal, laparoscopic, and vaginal surgery.

Details of the analysis
The authors evaluated high-quality studies on mechanical bowel preparation to assess evidence for:

• surgeon outcomes, including the surgical field and bowel handling
• operative outcomes, including intraoperative complications and operative times
• patient outcomes, including postoperative complications, overall morbidity, and length of stay. 

The authors identified RCTs and prospective or retrospective cohort studies in various surgical specialties comparing preoperative bowel preparation to no such prep. Forty-three studies met inclusion criteria: 38 compared prep to no prep, and 5 compared prep to a single rectal enema. Five high-grade studies in gynecology were included (n = 795), with 4 of them RCTs of gynecologic laparoscopy (n = 645).
 
Operative field and duration
Of the studies comparing bowel prep with no prep, only the 5 gynecologic ones assessed operative field. Surgical view was perceived as improved in only 1 study. In another, surgeons only could guess allocation half the time.

Sixteen studies evaluated impact of mechanical bowel preparation on duration of surgery: 1 high-quality study found a significant reduction in OR time with bowel prep, and 1 moderate-quality study found longer operative time with bowel prep.

Patient outcomes
Of all studies assessing patient outcomes, 3 high-quality studies of colorectal patients (n = 490) found increased complications from prep versus no prep, including anastomotic dehiscence (P = .05), abdominal complications (P = .028), and infectious complications (P = .05).

Length of stay was assessed in 26 studies, with 4 reporting longer hospital stay with bowel prep and the remaining finding no difference between prep and no prep.

Across all specialties, only 2 studies reported improved outcomes with mechanical bowel preparation. One was a high-quality study reporting reduced 30-day morbidity (P = .018) and infectious complication rates (P = .018), and the other was a moderate-quality study that found reduced SSI (P = .0001) and organ space infection (P = .024) in patients undergoing bowel prep.

Mechanical bowel preparation vs enema
Bowel prep was compared with a single rectal enema in 5 studies. In 2 of these, patient outcomes were worse with enema. One high-quality study of 294 patients reported increased intra-abdominal fecal soiling (P = .008) in the enema group. (The surgeons believed that bowel preparation was more likely to be inadequate in this group, 25% compared with 6%, P<.05.) Whereas there was no statistical difference in the incidence of anastomotic leak between these groups, there was higher reoperation rate in the enema-only group where leakage was diagnosed (6 [4.1%] vs 0, respectively; P = .013).

Bowel prep and preoperative and postoperative symptoms
Six high-quality studies reported on the impact of mechanical bowel preparation on patient symptoms, such as nausea, weakness, abdominal distention, and satisfaction before and after surgery. In all but 1 study patients had significantly greater discomfort with bowel preparation. In 2 of the 6 studies, patients had more diarrhea (P  =  .0003), a delay in the first bowel movement (P = .001), and a slower return to normal diet (P = .004).

What this EVIDENCE means for practice
The theory behind mechanical bowel preparation is not supported by the evidence. Despite the fact that the bowel is not customarily entered, up to 50% of gynecologic surgeons employ bowel preparation, with the hope of improving visualization and decreasing risk of an anastomotic leak. The colorectal studies in this review demonstrate no evidence for decreased anastomotic leak or infectious complications. By extrapolation, there is no evidence that using preoperative bowel prep bestows any benefit if bowel injury occurs inadvertently and if resection or reanastomosis is then required.
 
Among the 7 studies examining bowel prep in laparoscopy (4 gynecology, 3 urology, and 1 colorectal), only data from 1 demonstrated an improved surgical field (and in this case only by 1 out of 10 on a Likert scale). The impact of mechanical bowel preparation on the visual field is the same for diagnostic or complex laparoscopic surgeries. One high-quality study with deep endometriosis resection demonstrated no change in the operative field as reflected by no practical differences in OR time or complications.

Preparing the bowel for surgery is an intrusive process that reduces patient satisfaction by inducing weakness, abdominal distention, nausea, vomiting, hunger, and thirst. Whereas this systematic analysis failed to confirm any benefit of the process, it provides evidence for the potential for harm. Mechanical bowel preparation should be discarded as a routine preoperative treatment for patients undergoing minimally invasive gynecologic surgery.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Rightly so, the topics of mechanical tissue extraction and hysterectomy approach have dominated the field of obstetrics and gynecology over the past 12 months and more. A profusion of literature has been published on these subjects. However, there are 2 important topics within the field of minimally invasive gynecologic surgery that deserve our attention as well, and I have chosen to focus on these for this Update.

First, laparoscopic treatment of ovarian endometriomas is one of the most commonly performed gynecologic procedures worldwide. Many women undergoing such surgery are of childbearing age and have the desire for future pregnancy. What are best practices for preserving ovarian function in these women? Two studies recently published in the Journal of Minimally Invasive Gynecology addressed this question.

Second, until recently, the rate of bowel injury at laparoscopic gynecologic surgery has not been well established.¹ Moreover, mechanical bowel preparation is commonly employed in case intestinal injury does occur, despite the lack of evidence that outcomes of these possible injuries can be improved.² Understanding the rate of bowel injury can shed light on the overall value of the perceived benefits of bowel preparation. Therefore, I examine 2 recent systematic reviews that analyze the incidence of bowel injury and the value of bowel prep in gynecologic laparoscopic surgery.

bipolar coagulation inferior to suturing or hemostatic sealant for preserving ovarian function

Song T, Kim WY, Lee KW, Kim KH. Effect on ovarian reserve of hemostasis by bipolar coagulation versus suture during laparoendoscopic single-site cystectomy for ovarian endometriomas. J Minim Invasive Gynecol. 2015;22(3):415−420.

Ata B, Turkgeldi E, Seyhan A, Urman B. Effect of hemostatic method on ovarian reserve following laparoscopic endometrioma excision; comparison of suture, hemostatic sealant, and bipolar dessication. A systematic review and meta-analysis. J Minim Invasive Gynecol. 2015;22(3):363−372.

The customary surgical approach for laparoscopic cystectomy is by mechanical stripping of the cyst wall (FIGURE) and the use of bipolar desiccation for hemostasis. Stripping inevitably leads to removal of healthy ovarian cortex,3 especially in inexperienced hands,⁴ and ovarian follicles inevitably are destroyed during electrosurgical desiccation. When compared with the use of suturing or a hemostatic agent to control bleeding in the ovarian defect, the use of bipolar electrosurgery may harm more of the ovarian cortex, resulting in a comparatively diminished follicular cohort.
 
Possible deleterious effects on the ovarian reserve can be determined with a blood test to measure anti-Müllerian hormone (AMH) levels postoperatively. Produced by the granulosa cells of the ovary, this hormone directly reflects the remaining ovarian egg supply. Lower levels of AMH have been shown to significantly decrease the success rate of in vitro fertilization (IVF), especially in women older than age 35.⁵ Moreover, AMH levels in the late reproductive years can be used as a predictive marker of menopause, with lower levels predicting significantly earlier onset.⁶
 
Data from 2 recent studies, a quasi-randomized trial by Song and colleagues and a systematic review and meta-analysis by Ata and colleagues emphasize that bipolar desiccation for hemostasis may not be best practice for protecting ovarian reserve during laparoscopic ovarian cystectomy for an endometrioma.

AMH levels decline more significantly for women undergoing bipolar desiccation
Song and colleagues conducted a prospective quasi-randomized study of 125 women whose endometriomas were laparoscopically removed via a single-site approach and managed for hemostasis with either bipolar desiccation or suturing of the ovarian defect with a 2-0 barbed suture. All surgeries were conducted by a single surgeon. 

At 3 months postsurgery, mean AMH levels had declined from baseline by 42.2% (interquartile range [IR], 16.5−53.0 ng/mL) in the desiccation group and by 24.6% (IR, 11.6−37.0 ng/mL) in the suture group (P = .001). Multivariate analysis showed that the method used for hemostasis was the only determinant for reduced ovarian reserve.

In their systematic review and meta-analysis, Ata and colleagues included 10 studies--6 qualitative and 4 quantitative. All studies examined the rate of change of serum AMH levels 3 months after laparoscopic removal of an endometrioma.
 
In their qualitative analysis, 5 of the 6 studies reported a significantly greater decrease in ovarian reserve after bipolar desiccation (varying from 13% to 44%) or a strong trend in the same direction. In the sixth study, the desiccation group had a lower decline in absolute AMH level than in the other 5 studies. The authors note that this 2.7% decline was much lower than the values reported for the bipolar desiccation group of any other study. (Those declines ranged between 19% and 58%.)

Although not significant, in all 3 of the included randomized controlled trials (RCTs), the desiccation groups had a greater loss in AMH level than the hemostatic sealant groups, and in 2 of these RCTs, bipolar desiccation groups had a greater loss than the suturing groups.

Among the 213 study participants in the 3 RCTs and the prospective cohort study included in the quantitative meta-analysis, alternative methods to bipolar desiccation were associated with a 6.95% lower decrease in AMH-level decline (95% confidence interval [CI], −13.0% to −0.9%; P = .02).

What this EVIDENCE means for practice
Compared with the use of bipolar electrosurgery to attain hemostasis, the use of a topical biosurgical agent or suturing could be significantly better for protection of the ovarian follicles during laparoscopic ovarian cystectomy for endometrioma. These alternative methods especially could benefit those women desiring future pregnancy who are demonstrated preoperatively to have a low ovarian reserve. As needed, electrosurgery should be sparingly employed for ovarian hemostasis.

Large Study identifies incidence of bowel injury during gynecologic laproscopy

Llarena NC, Shah AB, Milad MP. Bowel injury in gynecologic laparoscopy: a systematic review. Am J Obstet Gynecol. 2015;125(6):1407−1417.

In no aspect of laparoscopic surgery are preventive strategies more cautiously employed than during peritoneal access. Regardless of the applied technique, there is an irreducible risk of injury to the underlying viscera by either adhesions between the underlying bowel and abdominal wall or during the course of pilot error. Moreover, in the best of hands, bowel injury can occur whenever normal anatomic relationships need to be restored using intra-abdominal adhesiolysis. Given the ubiquity, these risks are never out of the surgeon's mind. Gynecologists are obliged to discuss these risks during the informed consent process.

Until recently, the rate of bowel injury has not been well established. Llarena and colleagues recently have conducted the largest systematic review of the medical literature to date for incidence, presentation, mortality, cause, and location of bowel injury associated with laparoscopic surgery while not necessarily distinguishing for the type of bowel injury. Sixty retrospective and 27 prospective studies met inclusion criteria.

The risk of bowel injury overall and defined
Among 474,063 laparoscopic surgeries conducted between 1972 and 2014, 604 bowel injuries were found, for an incidence of 1 in 769, or 0.13% (95% CI, 0.12−0.14%).

The rate of bowel injury varied by procedure, year, study type, and definition of bowel injury. The incidence of injury according to:

• definition, was 1 in 416 (0.24%) for studies that clearly included serosal injuries and enterotomies versus 1 in 833 (0.12%) for studies not clearly defining the type of bowel injury (relative risk [RR], 0.47; 95% CI, 0.38−0.59; P<.001)
• study type, was 1 in 666 (0.15%) for prospective studies versus 1 in 909 (0.11%) for retrospective studies (RR, 0.78; 95% CI, 0.63−0.96; P = .02)
• procedure, was 1 in 3,333 (0.03%; 95% CI, 0.01−0.03%) for sterilization and 1 in 256 (0.39%; 95% CI, 0.35−0.45%) for hysterectomy
• year, for laparoscopic hysterectomy only, was 1 in 222 (0.45%) before the year 2000 and 1 in 294 (0.34%) after 2000 (RR, 0.75; 95% CI, 0.57−0.98; P = .03).

How were injuries caused, found, and managed?
Thirty studies described the laparoscopic instrument used during 366 reported bowel injuries. The majority of injuries (55%) occurred during initial peritoneal access, with the Veress needle or trocar causing the damage. This was followed by electrosurgery (29%), dissection (11%), and forceps or scissors (4.1%).

According to 40 studies describing 307 injuries, bowel injuries most often were managed by converting to laparotomy (80%); only 8% of injuries were managed with laparoscopy and 2% expectantly.

Surgery to repair the bowel injury was delayed in 154 (41%) of 375 cases. The median time to injury discovery was 3 days (range, 1−13 days).

In only 19 cases were the presenting signs and symptoms of bowel injury recorded. Those reported from most to least often were: peritonitis, abdominal pain, fever, abdominal distention, leukocytosis, leukopenia, and septic shock.

Mortality
Mortality as an outcome was only reported in 29 of the total 90 studies; therefore, mortality may be underreported. Overall, however, death occurred in 1 (0.8%) of 125 bowel injuries.

The overall mortality rate from bowel injury--calculated from the only 42 studies that explicitly mentioned mortality as an outcome--was 1 in 125, or 0.8% (95% CI, 0.36%-1.9%). All 5 reported deaths occurred as a result of delayed recognition of bowel injury, which made the mortality rate for unrecognized bowel injury 1 in 31, or 3.2% (95% CI, 1%-7%). No deaths occurred when the bowel injury was noted intraoperatively.

What this EVIDENCE means for practice
In this review of 474,063 laparoscopic procedures, bowel injury occurred in 1 in 769, or 0.13% of procedures. Bowel injury is more apt to occur during more complicated laparoscopic procedures (compared with laparoscopic sterilization procedures, the risk during hysterectomy was greater than 10-fold).
 
Most of the injuries were managed by laparotomic surgery despite the potential to repair bowel injury by laparoscopy. Validating that peritoneal access is a high risk part of laparoscopic surgery, the majority of the injuries occurred during insufflation with a Veress needle or during abdominal access by trocar insertion. Nearly one-third of the injuries were from the use of electrosurgery, which are typically associated with a delay in presentation.

In this study, 41% of the injuries were unrecognized at the time of surgery. All 5 of the reported deaths were associated with a delay in diagnosis, with an overall mortality rate of 1 of 125, or 0.8%. Since all of these deaths were associated with a delay in diagnosis, the rate of mortality in unrecognized bowel injury was 5 of 154, or 3.2%. Among women who experienced delayed diagnosis, only 19 of 154 experienced signs or symptoms diagnostic for an underlying bowel injury, particularly when the small bowel was injured.

Can mechanical bowel prep positively affect outcomes in gynecologic laparoscopy, or should it be discarded?

Arnold A, Aitchison LP, Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal surgery: a systematic review. J Minim Invasive Gynecol. 2015;22(5):737−752.

Popularized for more than 4 decades, the practice of presurgical bowel preparation is predicated on the notion that the presence of less, versus more, feces can minimize bacterial count and thereby reduce peritoneal contamination. Logically then, surgical site infections (SSIs) should be reduced with bowel preparation. Moreover, the surgical view and bowel handling during laparoscopic surgery should be improved, with surgical times consequently reduced.

Surgeons must weigh the putative benefits of mechanical bowel preparation against the unpleasant experience it causes for patients, as well as the risks of dehydration or electrolyte disturbance it may cause. To this day, a considerable percentage of gynecologists and colorectal surgeons routinely prep the bowel after weighing all of these factors, despite the paucity of evidence for the practice's efficacy to reduce SSI and improve surgical outcomes.⁷

The results of this recent systematic review critically question the usefulness of preoperative bowel preparation for abdominal, laparoscopic, and vaginal surgery.

Details of the analysis
The authors evaluated high-quality studies on mechanical bowel preparation to assess evidence for:

• surgeon outcomes, including the surgical field and bowel handling
• operative outcomes, including intraoperative complications and operative times
• patient outcomes, including postoperative complications, overall morbidity, and length of stay. 

The authors identified RCTs and prospective or retrospective cohort studies in various surgical specialties comparing preoperative bowel preparation to no such prep. Forty-three studies met inclusion criteria: 38 compared prep to no prep, and 5 compared prep to a single rectal enema. Five high-grade studies in gynecology were included (n = 795), with 4 of them RCTs of gynecologic laparoscopy (n = 645).
 
Operative field and duration
Of the studies comparing bowel prep with no prep, only the 5 gynecologic ones assessed operative field. Surgical view was perceived as improved in only 1 study. In another, surgeons only could guess allocation half the time.

Sixteen studies evaluated impact of mechanical bowel preparation on duration of surgery: 1 high-quality study found a significant reduction in OR time with bowel prep, and 1 moderate-quality study found longer operative time with bowel prep.

Patient outcomes
Of all studies assessing patient outcomes, 3 high-quality studies of colorectal patients (n = 490) found increased complications from prep versus no prep, including anastomotic dehiscence (P = .05), abdominal complications (P = .028), and infectious complications (P = .05).

Length of stay was assessed in 26 studies, with 4 reporting longer hospital stay with bowel prep and the remaining finding no difference between prep and no prep.

Across all specialties, only 2 studies reported improved outcomes with mechanical bowel preparation. One was a high-quality study reporting reduced 30-day morbidity (P = .018) and infectious complication rates (P = .018), and the other was a moderate-quality study that found reduced SSI (P = .0001) and organ space infection (P = .024) in patients undergoing bowel prep.

Mechanical bowel preparation vs enema
Bowel prep was compared with a single rectal enema in 5 studies. In 2 of these, patient outcomes were worse with enema. One high-quality study of 294 patients reported increased intra-abdominal fecal soiling (P = .008) in the enema group. (The surgeons believed that bowel preparation was more likely to be inadequate in this group, 25% compared with 6%, P<.05.) Whereas there was no statistical difference in the incidence of anastomotic leak between these groups, there was higher reoperation rate in the enema-only group where leakage was diagnosed (6 [4.1%] vs 0, respectively; P = .013).

Bowel prep and preoperative and postoperative symptoms
Six high-quality studies reported on the impact of mechanical bowel preparation on patient symptoms, such as nausea, weakness, abdominal distention, and satisfaction before and after surgery. In all but 1 study patients had significantly greater discomfort with bowel preparation. In 2 of the 6 studies, patients had more diarrhea (P  =  .0003), a delay in the first bowel movement (P = .001), and a slower return to normal diet (P = .004).

What this EVIDENCE means for practice
The theory behind mechanical bowel preparation is not supported by the evidence. Despite the fact that the bowel is not customarily entered, up to 50% of gynecologic surgeons employ bowel preparation, with the hope of improving visualization and decreasing risk of an anastomotic leak. The colorectal studies in this review demonstrate no evidence for decreased anastomotic leak or infectious complications. By extrapolation, there is no evidence that using preoperative bowel prep bestows any benefit if bowel injury occurs inadvertently and if resection or reanastomosis is then required.
 
Among the 7 studies examining bowel prep in laparoscopy (4 gynecology, 3 urology, and 1 colorectal), only data from 1 demonstrated an improved surgical field (and in this case only by 1 out of 10 on a Likert scale). The impact of mechanical bowel preparation on the visual field is the same for diagnostic or complex laparoscopic surgeries. One high-quality study with deep endometriosis resection demonstrated no change in the operative field as reflected by no practical differences in OR time or complications.

Preparing the bowel for surgery is an intrusive process that reduces patient satisfaction by inducing weakness, abdominal distention, nausea, vomiting, hunger, and thirst. Whereas this systematic analysis failed to confirm any benefit of the process, it provides evidence for the potential for harm. Mechanical bowel preparation should be discarded as a routine preoperative treatment for patients undergoing minimally invasive gynecologic surgery.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Rightly so, the topics of mechanical tissue extraction and hysterectomy approach have dominated the field of obstetrics and gynecology over the past 12 months and more. A profusion of literature has been published on these subjects. However, there are 2 important topics within the field of minimally invasive gynecologic surgery that deserve our attention as well, and I have chosen to focus on these for this Update.

First, laparoscopic treatment of ovarian endometriomas is one of the most commonly performed gynecologic procedures worldwide. Many women undergoing such surgery are of childbearing age and have the desire for future pregnancy. What are best practices for preserving ovarian function in these women? Two studies recently published in the Journal of Minimally Invasive Gynecology addressed this question.

Second, until recently, the rate of bowel injury at laparoscopic gynecologic surgery has not been well established.¹ Moreover, mechanical bowel preparation is commonly employed in case intestinal injury does occur, despite the lack of evidence that outcomes of these possible injuries can be improved.² Understanding the rate of bowel injury can shed light on the overall value of the perceived benefits of bowel preparation. Therefore, I examine 2 recent systematic reviews that analyze the incidence of bowel injury and the value of bowel prep in gynecologic laparoscopic surgery.

bipolar coagulation inferior to suturing or hemostatic sealant for preserving ovarian function

Song T, Kim WY, Lee KW, Kim KH. Effect on ovarian reserve of hemostasis by bipolar coagulation versus suture during laparoendoscopic single-site cystectomy for ovarian endometriomas. J Minim Invasive Gynecol. 2015;22(3):415−420.

Ata B, Turkgeldi E, Seyhan A, Urman B. Effect of hemostatic method on ovarian reserve following laparoscopic endometrioma excision; comparison of suture, hemostatic sealant, and bipolar dessication. A systematic review and meta-analysis. J Minim Invasive Gynecol. 2015;22(3):363−372.

The customary surgical approach for laparoscopic cystectomy is by mechanical stripping of the cyst wall (FIGURE) and the use of bipolar desiccation for hemostasis. Stripping inevitably leads to removal of healthy ovarian cortex,3 especially in inexperienced hands,⁴ and ovarian follicles inevitably are destroyed during electrosurgical desiccation. When compared with the use of suturing or a hemostatic agent to control bleeding in the ovarian defect, the use of bipolar electrosurgery may harm more of the ovarian cortex, resulting in a comparatively diminished follicular cohort.
 
Possible deleterious effects on the ovarian reserve can be determined with a blood test to measure anti-Müllerian hormone (AMH) levels postoperatively. Produced by the granulosa cells of the ovary, this hormone directly reflects the remaining ovarian egg supply. Lower levels of AMH have been shown to significantly decrease the success rate of in vitro fertilization (IVF), especially in women older than age 35.⁵ Moreover, AMH levels in the late reproductive years can be used as a predictive marker of menopause, with lower levels predicting significantly earlier onset.⁶
 
Data from 2 recent studies, a quasi-randomized trial by Song and colleagues and a systematic review and meta-analysis by Ata and colleagues emphasize that bipolar desiccation for hemostasis may not be best practice for protecting ovarian reserve during laparoscopic ovarian cystectomy for an endometrioma.

AMH levels decline more significantly for women undergoing bipolar desiccation
Song and colleagues conducted a prospective quasi-randomized study of 125 women whose endometriomas were laparoscopically removed via a single-site approach and managed for hemostasis with either bipolar desiccation or suturing of the ovarian defect with a 2-0 barbed suture. All surgeries were conducted by a single surgeon. 

At 3 months postsurgery, mean AMH levels had declined from baseline by 42.2% (interquartile range [IR], 16.5−53.0 ng/mL) in the desiccation group and by 24.6% (IR, 11.6−37.0 ng/mL) in the suture group (P = .001). Multivariate analysis showed that the method used for hemostasis was the only determinant for reduced ovarian reserve.

In their systematic review and meta-analysis, Ata and colleagues included 10 studies--6 qualitative and 4 quantitative. All studies examined the rate of change of serum AMH levels 3 months after laparoscopic removal of an endometrioma.
 
In their qualitative analysis, 5 of the 6 studies reported a significantly greater decrease in ovarian reserve after bipolar desiccation (varying from 13% to 44%) or a strong trend in the same direction. In the sixth study, the desiccation group had a lower decline in absolute AMH level than in the other 5 studies. The authors note that this 2.7% decline was much lower than the values reported for the bipolar desiccation group of any other study. (Those declines ranged between 19% and 58%.)

Although not significant, in all 3 of the included randomized controlled trials (RCTs), the desiccation groups had a greater loss in AMH level than the hemostatic sealant groups, and in 2 of these RCTs, bipolar desiccation groups had a greater loss than the suturing groups.

Among the 213 study participants in the 3 RCTs and the prospective cohort study included in the quantitative meta-analysis, alternative methods to bipolar desiccation were associated with a 6.95% lower decrease in AMH-level decline (95% confidence interval [CI], −13.0% to −0.9%; P = .02).

What this EVIDENCE means for practice
Compared with the use of bipolar electrosurgery to attain hemostasis, the use of a topical biosurgical agent or suturing could be significantly better for protection of the ovarian follicles during laparoscopic ovarian cystectomy for endometrioma. These alternative methods especially could benefit those women desiring future pregnancy who are demonstrated preoperatively to have a low ovarian reserve. As needed, electrosurgery should be sparingly employed for ovarian hemostasis.

Large Study identifies incidence of bowel injury during gynecologic laproscopy

Llarena NC, Shah AB, Milad MP. Bowel injury in gynecologic laparoscopy: a systematic review. Am J Obstet Gynecol. 2015;125(6):1407−1417.

In no aspect of laparoscopic surgery are preventive strategies more cautiously employed than during peritoneal access. Regardless of the applied technique, there is an irreducible risk of injury to the underlying viscera by either adhesions between the underlying bowel and abdominal wall or during the course of pilot error. Moreover, in the best of hands, bowel injury can occur whenever normal anatomic relationships need to be restored using intra-abdominal adhesiolysis. Given the ubiquity, these risks are never out of the surgeon's mind. Gynecologists are obliged to discuss these risks during the informed consent process.

Until recently, the rate of bowel injury has not been well established. Llarena and colleagues recently have conducted the largest systematic review of the medical literature to date for incidence, presentation, mortality, cause, and location of bowel injury associated with laparoscopic surgery while not necessarily distinguishing for the type of bowel injury. Sixty retrospective and 27 prospective studies met inclusion criteria.

The risk of bowel injury overall and defined
Among 474,063 laparoscopic surgeries conducted between 1972 and 2014, 604 bowel injuries were found, for an incidence of 1 in 769, or 0.13% (95% CI, 0.12−0.14%).

The rate of bowel injury varied by procedure, year, study type, and definition of bowel injury. The incidence of injury according to:

• definition, was 1 in 416 (0.24%) for studies that clearly included serosal injuries and enterotomies versus 1 in 833 (0.12%) for studies not clearly defining the type of bowel injury (relative risk [RR], 0.47; 95% CI, 0.38−0.59; P<.001)
• study type, was 1 in 666 (0.15%) for prospective studies versus 1 in 909 (0.11%) for retrospective studies (RR, 0.78; 95% CI, 0.63−0.96; P = .02)
• procedure, was 1 in 3,333 (0.03%; 95% CI, 0.01−0.03%) for sterilization and 1 in 256 (0.39%; 95% CI, 0.35−0.45%) for hysterectomy
• year, for laparoscopic hysterectomy only, was 1 in 222 (0.45%) before the year 2000 and 1 in 294 (0.34%) after 2000 (RR, 0.75; 95% CI, 0.57−0.98; P = .03).

How were injuries caused, found, and managed?
Thirty studies described the laparoscopic instrument used during 366 reported bowel injuries. The majority of injuries (55%) occurred during initial peritoneal access, with the Veress needle or trocar causing the damage. This was followed by electrosurgery (29%), dissection (11%), and forceps or scissors (4.1%).

According to 40 studies describing 307 injuries, bowel injuries most often were managed by converting to laparotomy (80%); only 8% of injuries were managed with laparoscopy and 2% expectantly.

Surgery to repair the bowel injury was delayed in 154 (41%) of 375 cases. The median time to injury discovery was 3 days (range, 1−13 days).

In only 19 cases were the presenting signs and symptoms of bowel injury recorded. Those reported from most to least often were: peritonitis, abdominal pain, fever, abdominal distention, leukocytosis, leukopenia, and septic shock.

Mortality
Mortality as an outcome was only reported in 29 of the total 90 studies; therefore, mortality may be underreported. Overall, however, death occurred in 1 (0.8%) of 125 bowel injuries.

The overall mortality rate from bowel injury--calculated from the only 42 studies that explicitly mentioned mortality as an outcome--was 1 in 125, or 0.8% (95% CI, 0.36%-1.9%). All 5 reported deaths occurred as a result of delayed recognition of bowel injury, which made the mortality rate for unrecognized bowel injury 1 in 31, or 3.2% (95% CI, 1%-7%). No deaths occurred when the bowel injury was noted intraoperatively.

What this EVIDENCE means for practice
In this review of 474,063 laparoscopic procedures, bowel injury occurred in 1 in 769, or 0.13% of procedures. Bowel injury is more apt to occur during more complicated laparoscopic procedures (compared with laparoscopic sterilization procedures, the risk during hysterectomy was greater than 10-fold).
 
Most of the injuries were managed by laparotomic surgery despite the potential to repair bowel injury by laparoscopy. Validating that peritoneal access is a high risk part of laparoscopic surgery, the majority of the injuries occurred during insufflation with a Veress needle or during abdominal access by trocar insertion. Nearly one-third of the injuries were from the use of electrosurgery, which are typically associated with a delay in presentation.

In this study, 41% of the injuries were unrecognized at the time of surgery. All 5 of the reported deaths were associated with a delay in diagnosis, with an overall mortality rate of 1 of 125, or 0.8%. Since all of these deaths were associated with a delay in diagnosis, the rate of mortality in unrecognized bowel injury was 5 of 154, or 3.2%. Among women who experienced delayed diagnosis, only 19 of 154 experienced signs or symptoms diagnostic for an underlying bowel injury, particularly when the small bowel was injured.

Can mechanical bowel prep positively affect outcomes in gynecologic laparoscopy, or should it be discarded?

Arnold A, Aitchison LP, Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal surgery: a systematic review. J Minim Invasive Gynecol. 2015;22(5):737−752.

Popularized for more than 4 decades, the practice of presurgical bowel preparation is predicated on the notion that the presence of less, versus more, feces can minimize bacterial count and thereby reduce peritoneal contamination. Logically then, surgical site infections (SSIs) should be reduced with bowel preparation. Moreover, the surgical view and bowel handling during laparoscopic surgery should be improved, with surgical times consequently reduced.

Surgeons must weigh the putative benefits of mechanical bowel preparation against the unpleasant experience it causes for patients, as well as the risks of dehydration or electrolyte disturbance it may cause. To this day, a considerable percentage of gynecologists and colorectal surgeons routinely prep the bowel after weighing all of these factors, despite the paucity of evidence for the practice's efficacy to reduce SSI and improve surgical outcomes.⁷

The results of this recent systematic review critically question the usefulness of preoperative bowel preparation for abdominal, laparoscopic, and vaginal surgery.

Details of the analysis
The authors evaluated high-quality studies on mechanical bowel preparation to assess evidence for:

• surgeon outcomes, including the surgical field and bowel handling
• operative outcomes, including intraoperative complications and operative times
• patient outcomes, including postoperative complications, overall morbidity, and length of stay. 

The authors identified RCTs and prospective or retrospective cohort studies in various surgical specialties comparing preoperative bowel preparation to no such prep. Forty-three studies met inclusion criteria: 38 compared prep to no prep, and 5 compared prep to a single rectal enema. Five high-grade studies in gynecology were included (n = 795), with 4 of them RCTs of gynecologic laparoscopy (n = 645).
 
Operative field and duration
Of the studies comparing bowel prep with no prep, only the 5 gynecologic ones assessed operative field. Surgical view was perceived as improved in only 1 study. In another, surgeons only could guess allocation half the time.

Sixteen studies evaluated impact of mechanical bowel preparation on duration of surgery: 1 high-quality study found a significant reduction in OR time with bowel prep, and 1 moderate-quality study found longer operative time with bowel prep.

Patient outcomes
Of all studies assessing patient outcomes, 3 high-quality studies of colorectal patients (n = 490) found increased complications from prep versus no prep, including anastomotic dehiscence (P = .05), abdominal complications (P = .028), and infectious complications (P = .05).

Length of stay was assessed in 26 studies, with 4 reporting longer hospital stay with bowel prep and the remaining finding no difference between prep and no prep.

Across all specialties, only 2 studies reported improved outcomes with mechanical bowel preparation. One was a high-quality study reporting reduced 30-day morbidity (P = .018) and infectious complication rates (P = .018), and the other was a moderate-quality study that found reduced SSI (P = .0001) and organ space infection (P = .024) in patients undergoing bowel prep.

Mechanical bowel preparation vs enema
Bowel prep was compared with a single rectal enema in 5 studies. In 2 of these, patient outcomes were worse with enema. One high-quality study of 294 patients reported increased intra-abdominal fecal soiling (P = .008) in the enema group. (The surgeons believed that bowel preparation was more likely to be inadequate in this group, 25% compared with 6%, P<.05.) Whereas there was no statistical difference in the incidence of anastomotic leak between these groups, there was higher reoperation rate in the enema-only group where leakage was diagnosed (6 [4.1%] vs 0, respectively; P = .013).

Bowel prep and preoperative and postoperative symptoms
Six high-quality studies reported on the impact of mechanical bowel preparation on patient symptoms, such as nausea, weakness, abdominal distention, and satisfaction before and after surgery. In all but 1 study patients had significantly greater discomfort with bowel preparation. In 2 of the 6 studies, patients had more diarrhea (P  =  .0003), a delay in the first bowel movement (P = .001), and a slower return to normal diet (P = .004).

What this EVIDENCE means for practice
The theory behind mechanical bowel preparation is not supported by the evidence. Despite the fact that the bowel is not customarily entered, up to 50% of gynecologic surgeons employ bowel preparation, with the hope of improving visualization and decreasing risk of an anastomotic leak. The colorectal studies in this review demonstrate no evidence for decreased anastomotic leak or infectious complications. By extrapolation, there is no evidence that using preoperative bowel prep bestows any benefit if bowel injury occurs inadvertently and if resection or reanastomosis is then required.
 
Among the 7 studies examining bowel prep in laparoscopy (4 gynecology, 3 urology, and 1 colorectal), only data from 1 demonstrated an improved surgical field (and in this case only by 1 out of 10 on a Likert scale). The impact of mechanical bowel preparation on the visual field is the same for diagnostic or complex laparoscopic surgeries. One high-quality study with deep endometriosis resection demonstrated no change in the operative field as reflected by no practical differences in OR time or complications.

Preparing the bowel for surgery is an intrusive process that reduces patient satisfaction by inducing weakness, abdominal distention, nausea, vomiting, hunger, and thirst. Whereas this systematic analysis failed to confirm any benefit of the process, it provides evidence for the potential for harm. Mechanical bowel preparation should be discarded as a routine preoperative treatment for patients undergoing minimally invasive gynecologic surgery.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

On February 21 to 24, 2016, the Association of Academic Chairs of Emergency Medicine (AACEM) held its 8th annual retreat in Tempe, Arizona. The AACEM is comprised of full, acting, interim, and emeritus chairs and directors of departments of emergency medicine (EM) who work to improve and support academic departments of EM in the advancement of health care through high-quality education and research.

During that event, AACEM President Greg Volturo, MD, organized a panel discussion of EM leaders to provide an update on their organizations’ recent activities. This panel included representatives from seven prominent EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents’ Association (EMRA),  and Society for Academic Emergency Medicine (SAEM).

The following is the first of a two-part article that provides highlights from that discussion, with reports from the AAEM, AAEM/RSA, ABEM, and ACEP. Part 2 will appear in the May issue and will include reports from the CORD, EMRA, and SAEM.

American Academy of Emergency Medicine

Kevin G. Rodgers, MD, FAAEM, President AAEM

Due Process. AAEM highlighted the problem of the lack of due process for many emergency physicians (EPs). By agreeing to waive their rights to due process when signing contracts with some contract management companies, EPs can unwittingly give their employers the power to terminate them without cause and without notice. AAEM is working with Centers for Medicare & Medicaid Services (CMS) and several congressmen to amend the Medicare Rules for Participation to include an “unwaivable due process guarantee.” In addition, AAEM is requesting an addition to the current Code of Federal Regulation to ensure EPs are entitled “to a fair hearing and appellate review through hospital medical staff mechanisms before any termination or restriction of their professional activity or medical staff privileges. These rights cannot be denied through a third party contract.”

AAEM Residency Visitation Program. AAEM is committed to visiting every EM residency program once every 3 to 4 years, similar to the ACEP and ABEM programs. Residency programs will have the opportunity to select from a list of well-known EM speakers; they will deliver a clinically oriented lecture, followed by a presentation on AAEM. The cost of the program is borne completely by AAEM.

AAEM Physician Group (AAEM-PG). This program was announced at the 2016 AAEM Scientific Assembly. AAEM-PG establishes and supports EM practices where physicians can operate democratically and have an equal voice. It is a practice that is run by the local physicians for the physicians. AAEM-PG will help guide new as well as established EM groups, providing for physicians’ autonomy, fair and equitable practice environments, and career and group longevity.

AAEM Resident and Student Association

Victoria Weston, MD, AAEM/RSA President

Overview. Started in 2005, AAEM/RAS now has over 3,500 members and 58 EM residency programs with 100% participation. Benefits of membership include access to EM:RAP and The Journal of Emergency Medicine, access and opportunities to contribute to an RSA peer-reviewed blog and Modern Resident, and free registration for the AAEM Annual Scientific Assembly. As part of the AAEM Scientific Assembly, AAEM/RSA coordinates a day-long education track in collaboration with the AAEM Young Physician Section, an In-Training Exam review, and a Career Fair and Social.

Congressional Elective. Members of AAEM/RSA can apply to be selected for a one-month “Congressional Elective” with Congressmen Raul Ruiz and Joe Heck, the only two EPs currently in Congress, to teach EPs the process of creating health-policy legislation on Capitol Hill. For 4 weeks, residents work directly in their congressional office and learn to work with constituents to develop relevant health-policy legislation. Residents learn to present legislative briefs, proposals, and research in a productive, succinct, and time-efficient manner. AAEM/RSA also offers an annual Advocacy Day, where residents and students have the opportunity to meet with members of Congress and/or senior congressional staff on Capitol Hill; this year it will be held on June 14, 2016 in Washington, DC.

Toxicology Mobile App. The AAEM/RSA Toxicology mobile app will soon be available for purchase, and is compatible with both iPhone and Android technology. You can search by subject, browse chapters of AAEM/RSA’s Toxicology Handbook, or contact Poison Control with a single click.

American Board of Emergency Medicine

Francis L. Counselman, MD, Immediate Past President, ABEM

Enhanced Oral (eOral) Certification Examination. ABEM has completed its second eOral examination; the third is scheduled for April 2016. Three of the examination cases are now in the new eOral format, which uses a computer monitor, patient avatar, picture archiving and communication system (PACS)-quality radiographs, and dynamic rhythm strips. Feedback from test-takers and examiners has been quite positive. ABEM will be moving more cases to the eOral format in the near future.

ABEM Director of Medical Affairs. ABEM has named its first ever Director of Medical Affairs (DMA): Melissa A. Barton, MD. Dr Barton is a former EM Residency Program Director and has been an ABEM Oral Examiner for the past 10 years. She is the recipient of several teaching and leadership awards. Dr Barton will focus on clinically oriented special projects and represent ABEM’s interests to external organizations.

Emergency Medicine Subspecialties. EM now has 13 subspecialty opportunities for EPs; that’s more than double the number from just 5 years ago. Emergency Medical Services (EMS) now has the most ABEM diplomates (445), followed by Medical Toxicology (367) and Pediatric Emergency Medicine (245).

Lifelong Learning and Self-Assessment (LLSA) Test Accessibility. To provide LLSA readings that better match a diplomate’s area of practice, the EMS and Medical Toxicology LLSA readings and tests can now be used by any diplomate to fulfill his or her Maintenance of Certification (MOC) Part II requirements. Pediatric EM LLSA readings and tests will eventually be made available to all diplomates at a later date. All LLSAs can be accessed through the ABEM Web site (https://www.abem.org).

Maintenance of Certification (MOC) Adds Value. In a survey of ABEM diplomates taking the 2014 ConCert Examination, 92.5% found value in maintaining their ABEM certification. In a follow-up survey in 2015, 90.4% stated their medical knowledge was reinforced and/or increased by preparing and taking the ConCert Examination. In addition to being relevant to our diplomates’ practice, ABEM has worked hard to control MOC costs. ABEM has not increased its fees for the last 5 years for the LLSAs; for all remaining examinations, there has been no fee increase for the past 4 years. When compared to all other boards, the expense of the ABEM MOC Program is at the median, costing EPs approximately $265 per year, or about $5 each week.

American College of Emergency Physicians

Jay A. Kaplan, MD, FACEP, ACEP President

Physician Burnout. Unfortunately, EM leads all specialties in the frequency of physician burnout. Emergency physicians must be aware of burnout, and take proactive steps to avoid it. To help EPs, ACEP has organized an “Emergency Medicine Wellness Week.” Prevention tips include eating well, getting the proper amount of sleep, regular exercise, and improving the work environment. In 2016, Wellness Week ran from January 24 to 30; there is a continuing focus on building resilience and preventing compassion fatigue.

Out of Network (OON) Balance Billing. Insurance companies know that it is solely the cost of insurance premiums that consumers pay attention to, not deductibles or exactly what the insurance covers. Those same insurance companies have been adept at portraying physicians as the cause of “surprise billing.” Emergency physicians need to change the conversation from “surprise billing” to “surprise coverage.” We need to talk about fair coverage for our patients, rather than asking for fair payment for physicians (the latter will follow the former and legislators believe that physicians are already fairly paid). ACEP is considering legal action against CMS and the Center for Consumer Information and Insurance Oversight regarding their final rule on “the greatest of three,” which establishes guidelines for how physicians are to be paid for services rendered.

Pay for Performance and Value-based Reimbursement. ACEP has created a joint task force with the Emergency Department Practice Management Association to create a toolbox for EPs to navigate the changing reimbursement landscape. This includes model legislation and best practices, and there is exploration regarding developing alternative payment models for EM.

Opioid Epidemic. ACEP is a participant in the White House working group exploring this epidemic and identifying strategies to combat this national problem. ACEP has sent a letter to CMS and Health and Human Services (HHS) requesting removal of the pain questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Emergency physicians should not be penalized on these surveys for not prescribing narcotic analgesics to patients who could be treated appropriately with nonnarcotic medications. ACEP similarly is considering sending a letter to The Joint Commission requesting removal of their emphasis on pain as the “fifth vital sign.”

Mass Casualty Incidents. ACEP has created a “New High-Threat High-Casualty Task Force” to identify best practice recommendations for provision of emergency care in high-threat environments and identify current clinical and operational knowledge gaps surrounding the issue. This in turn will help prioritize future ACEP research objectives based on these gaps. In addition, a white paper is being prepared, highlighting current national efforts and recommending clinical practice guidelines for adults and pediatric patients, as well as a future strategy for ACEP engagement as a national leader in the area of high-threat emergency care.

Diversity. There is a recognized need to increase the diversity in our current and future EM leadership. To that end, ACEP sponsored a Diversity Summit on April 14, 2016 in Dallas to explore these issues and make recommendations.

Emergency Quality Network. ACEP, along with 38 other health care organizations, received a grant in the CMS Transforming Clinical Practice Initiative to help physicians achieve large-scale health transformation. Areas of EM focus include: improving outcomes for patients with sepsis; reducing avoidable imaging in low-risk patients through implementation of ACEP’s Choosing Wisely campaign; and improving the value of ED chest pain evaluation in low-risk patients by reducing avoidable testing and admissions.

Editor’s Note: Part 2 of this article will appear in the May 2016 issue of Emergency Medicine and will feature reports from the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine (SAEM). Have a comment or question about this article? Let us know: [email protected].

On February 21 to 24, 2016, the Association of Academic Chairs of Emergency Medicine (AACEM) held its 8th annual retreat in Tempe, Arizona. The AACEM is comprised of full, acting, interim, and emeritus chairs and directors of departments of emergency medicine (EM) who work to improve and support academic departments of EM in the advancement of health care through high-quality education and research.

During that event, AACEM President Greg Volturo, MD, organized a panel discussion of EM leaders to provide an update on their organizations’ recent activities. This panel included representatives from seven prominent EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents’ Association (EMRA),  and Society for Academic Emergency Medicine (SAEM).

The following is the first of a two-part article that provides highlights from that discussion, with reports from the AAEM, AAEM/RSA, ABEM, and ACEP. Part 2 will appear in the May issue and will include reports from the CORD, EMRA, and SAEM.

American Academy of Emergency Medicine

Kevin G. Rodgers, MD, FAAEM, President AAEM

Due Process. AAEM highlighted the problem of the lack of due process for many emergency physicians (EPs). By agreeing to waive their rights to due process when signing contracts with some contract management companies, EPs can unwittingly give their employers the power to terminate them without cause and without notice. AAEM is working with Centers for Medicare & Medicaid Services (CMS) and several congressmen to amend the Medicare Rules for Participation to include an “unwaivable due process guarantee.” In addition, AAEM is requesting an addition to the current Code of Federal Regulation to ensure EPs are entitled “to a fair hearing and appellate review through hospital medical staff mechanisms before any termination or restriction of their professional activity or medical staff privileges. These rights cannot be denied through a third party contract.”

AAEM Residency Visitation Program. AAEM is committed to visiting every EM residency program once every 3 to 4 years, similar to the ACEP and ABEM programs. Residency programs will have the opportunity to select from a list of well-known EM speakers; they will deliver a clinically oriented lecture, followed by a presentation on AAEM. The cost of the program is borne completely by AAEM.

AAEM Physician Group (AAEM-PG). This program was announced at the 2016 AAEM Scientific Assembly. AAEM-PG establishes and supports EM practices where physicians can operate democratically and have an equal voice. It is a practice that is run by the local physicians for the physicians. AAEM-PG will help guide new as well as established EM groups, providing for physicians’ autonomy, fair and equitable practice environments, and career and group longevity.

AAEM Resident and Student Association

Victoria Weston, MD, AAEM/RSA President

Overview. Started in 2005, AAEM/RAS now has over 3,500 members and 58 EM residency programs with 100% participation. Benefits of membership include access to EM:RAP and The Journal of Emergency Medicine, access and opportunities to contribute to an RSA peer-reviewed blog and Modern Resident, and free registration for the AAEM Annual Scientific Assembly. As part of the AAEM Scientific Assembly, AAEM/RSA coordinates a day-long education track in collaboration with the AAEM Young Physician Section, an In-Training Exam review, and a Career Fair and Social.

Congressional Elective. Members of AAEM/RSA can apply to be selected for a one-month “Congressional Elective” with Congressmen Raul Ruiz and Joe Heck, the only two EPs currently in Congress, to teach EPs the process of creating health-policy legislation on Capitol Hill. For 4 weeks, residents work directly in their congressional office and learn to work with constituents to develop relevant health-policy legislation. Residents learn to present legislative briefs, proposals, and research in a productive, succinct, and time-efficient manner. AAEM/RSA also offers an annual Advocacy Day, where residents and students have the opportunity to meet with members of Congress and/or senior congressional staff on Capitol Hill; this year it will be held on June 14, 2016 in Washington, DC.

Toxicology Mobile App. The AAEM/RSA Toxicology mobile app will soon be available for purchase, and is compatible with both iPhone and Android technology. You can search by subject, browse chapters of AAEM/RSA’s Toxicology Handbook, or contact Poison Control with a single click.

American Board of Emergency Medicine

Francis L. Counselman, MD, Immediate Past President, ABEM

Enhanced Oral (eOral) Certification Examination. ABEM has completed its second eOral examination; the third is scheduled for April 2016. Three of the examination cases are now in the new eOral format, which uses a computer monitor, patient avatar, picture archiving and communication system (PACS)-quality radiographs, and dynamic rhythm strips. Feedback from test-takers and examiners has been quite positive. ABEM will be moving more cases to the eOral format in the near future.

ABEM Director of Medical Affairs. ABEM has named its first ever Director of Medical Affairs (DMA): Melissa A. Barton, MD. Dr Barton is a former EM Residency Program Director and has been an ABEM Oral Examiner for the past 10 years. She is the recipient of several teaching and leadership awards. Dr Barton will focus on clinically oriented special projects and represent ABEM’s interests to external organizations.

Emergency Medicine Subspecialties. EM now has 13 subspecialty opportunities for EPs; that’s more than double the number from just 5 years ago. Emergency Medical Services (EMS) now has the most ABEM diplomates (445), followed by Medical Toxicology (367) and Pediatric Emergency Medicine (245).

Lifelong Learning and Self-Assessment (LLSA) Test Accessibility. To provide LLSA readings that better match a diplomate’s area of practice, the EMS and Medical Toxicology LLSA readings and tests can now be used by any diplomate to fulfill his or her Maintenance of Certification (MOC) Part II requirements. Pediatric EM LLSA readings and tests will eventually be made available to all diplomates at a later date. All LLSAs can be accessed through the ABEM Web site (https://www.abem.org).

Maintenance of Certification (MOC) Adds Value. In a survey of ABEM diplomates taking the 2014 ConCert Examination, 92.5% found value in maintaining their ABEM certification. In a follow-up survey in 2015, 90.4% stated their medical knowledge was reinforced and/or increased by preparing and taking the ConCert Examination. In addition to being relevant to our diplomates’ practice, ABEM has worked hard to control MOC costs. ABEM has not increased its fees for the last 5 years for the LLSAs; for all remaining examinations, there has been no fee increase for the past 4 years. When compared to all other boards, the expense of the ABEM MOC Program is at the median, costing EPs approximately $265 per year, or about $5 each week.

American College of Emergency Physicians

Jay A. Kaplan, MD, FACEP, ACEP President

Physician Burnout. Unfortunately, EM leads all specialties in the frequency of physician burnout. Emergency physicians must be aware of burnout, and take proactive steps to avoid it. To help EPs, ACEP has organized an “Emergency Medicine Wellness Week.” Prevention tips include eating well, getting the proper amount of sleep, regular exercise, and improving the work environment. In 2016, Wellness Week ran from January 24 to 30; there is a continuing focus on building resilience and preventing compassion fatigue.

Out of Network (OON) Balance Billing. Insurance companies know that it is solely the cost of insurance premiums that consumers pay attention to, not deductibles or exactly what the insurance covers. Those same insurance companies have been adept at portraying physicians as the cause of “surprise billing.” Emergency physicians need to change the conversation from “surprise billing” to “surprise coverage.” We need to talk about fair coverage for our patients, rather than asking for fair payment for physicians (the latter will follow the former and legislators believe that physicians are already fairly paid). ACEP is considering legal action against CMS and the Center for Consumer Information and Insurance Oversight regarding their final rule on “the greatest of three,” which establishes guidelines for how physicians are to be paid for services rendered.

Pay for Performance and Value-based Reimbursement. ACEP has created a joint task force with the Emergency Department Practice Management Association to create a toolbox for EPs to navigate the changing reimbursement landscape. This includes model legislation and best practices, and there is exploration regarding developing alternative payment models for EM.

Opioid Epidemic. ACEP is a participant in the White House working group exploring this epidemic and identifying strategies to combat this national problem. ACEP has sent a letter to CMS and Health and Human Services (HHS) requesting removal of the pain questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Emergency physicians should not be penalized on these surveys for not prescribing narcotic analgesics to patients who could be treated appropriately with nonnarcotic medications. ACEP similarly is considering sending a letter to The Joint Commission requesting removal of their emphasis on pain as the “fifth vital sign.”

Mass Casualty Incidents. ACEP has created a “New High-Threat High-Casualty Task Force” to identify best practice recommendations for provision of emergency care in high-threat environments and identify current clinical and operational knowledge gaps surrounding the issue. This in turn will help prioritize future ACEP research objectives based on these gaps. In addition, a white paper is being prepared, highlighting current national efforts and recommending clinical practice guidelines for adults and pediatric patients, as well as a future strategy for ACEP engagement as a national leader in the area of high-threat emergency care.

Diversity. There is a recognized need to increase the diversity in our current and future EM leadership. To that end, ACEP sponsored a Diversity Summit on April 14, 2016 in Dallas to explore these issues and make recommendations.

Emergency Quality Network. ACEP, along with 38 other health care organizations, received a grant in the CMS Transforming Clinical Practice Initiative to help physicians achieve large-scale health transformation. Areas of EM focus include: improving outcomes for patients with sepsis; reducing avoidable imaging in low-risk patients through implementation of ACEP’s Choosing Wisely campaign; and improving the value of ED chest pain evaluation in low-risk patients by reducing avoidable testing and admissions.

Editor’s Note: Part 2 of this article will appear in the May 2016 issue of Emergency Medicine and will feature reports from the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine (SAEM). Have a comment or question about this article? Let us know: [email protected].

On February 21 to 24, 2016, the Association of Academic Chairs of Emergency Medicine (AACEM) held its 8th annual retreat in Tempe, Arizona. The AACEM is comprised of full, acting, interim, and emeritus chairs and directors of departments of emergency medicine (EM) who work to improve and support academic departments of EM in the advancement of health care through high-quality education and research.

During that event, AACEM President Greg Volturo, MD, organized a panel discussion of EM leaders to provide an update on their organizations’ recent activities. This panel included representatives from seven prominent EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents’ Association (EMRA),  and Society for Academic Emergency Medicine (SAEM).

The following is the first of a two-part article that provides highlights from that discussion, with reports from the AAEM, AAEM/RSA, ABEM, and ACEP. Part 2 will appear in the May issue and will include reports from the CORD, EMRA, and SAEM.

American Academy of Emergency Medicine

Kevin G. Rodgers, MD, FAAEM, President AAEM

Due Process. AAEM highlighted the problem of the lack of due process for many emergency physicians (EPs). By agreeing to waive their rights to due process when signing contracts with some contract management companies, EPs can unwittingly give their employers the power to terminate them without cause and without notice. AAEM is working with Centers for Medicare & Medicaid Services (CMS) and several congressmen to amend the Medicare Rules for Participation to include an “unwaivable due process guarantee.” In addition, AAEM is requesting an addition to the current Code of Federal Regulation to ensure EPs are entitled “to a fair hearing and appellate review through hospital medical staff mechanisms before any termination or restriction of their professional activity or medical staff privileges. These rights cannot be denied through a third party contract.”

AAEM Residency Visitation Program. AAEM is committed to visiting every EM residency program once every 3 to 4 years, similar to the ACEP and ABEM programs. Residency programs will have the opportunity to select from a list of well-known EM speakers; they will deliver a clinically oriented lecture, followed by a presentation on AAEM. The cost of the program is borne completely by AAEM.

AAEM Physician Group (AAEM-PG). This program was announced at the 2016 AAEM Scientific Assembly. AAEM-PG establishes and supports EM practices where physicians can operate democratically and have an equal voice. It is a practice that is run by the local physicians for the physicians. AAEM-PG will help guide new as well as established EM groups, providing for physicians’ autonomy, fair and equitable practice environments, and career and group longevity.

AAEM Resident and Student Association

Victoria Weston, MD, AAEM/RSA President

Overview. Started in 2005, AAEM/RAS now has over 3,500 members and 58 EM residency programs with 100% participation. Benefits of membership include access to EM:RAP and The Journal of Emergency Medicine, access and opportunities to contribute to an RSA peer-reviewed blog and Modern Resident, and free registration for the AAEM Annual Scientific Assembly. As part of the AAEM Scientific Assembly, AAEM/RSA coordinates a day-long education track in collaboration with the AAEM Young Physician Section, an In-Training Exam review, and a Career Fair and Social.

Congressional Elective. Members of AAEM/RSA can apply to be selected for a one-month “Congressional Elective” with Congressmen Raul Ruiz and Joe Heck, the only two EPs currently in Congress, to teach EPs the process of creating health-policy legislation on Capitol Hill. For 4 weeks, residents work directly in their congressional office and learn to work with constituents to develop relevant health-policy legislation. Residents learn to present legislative briefs, proposals, and research in a productive, succinct, and time-efficient manner. AAEM/RSA also offers an annual Advocacy Day, where residents and students have the opportunity to meet with members of Congress and/or senior congressional staff on Capitol Hill; this year it will be held on June 14, 2016 in Washington, DC.

Toxicology Mobile App. The AAEM/RSA Toxicology mobile app will soon be available for purchase, and is compatible with both iPhone and Android technology. You can search by subject, browse chapters of AAEM/RSA’s Toxicology Handbook, or contact Poison Control with a single click.

American Board of Emergency Medicine

Francis L. Counselman, MD, Immediate Past President, ABEM

Enhanced Oral (eOral) Certification Examination. ABEM has completed its second eOral examination; the third is scheduled for April 2016. Three of the examination cases are now in the new eOral format, which uses a computer monitor, patient avatar, picture archiving and communication system (PACS)-quality radiographs, and dynamic rhythm strips. Feedback from test-takers and examiners has been quite positive. ABEM will be moving more cases to the eOral format in the near future.

ABEM Director of Medical Affairs. ABEM has named its first ever Director of Medical Affairs (DMA): Melissa A. Barton, MD. Dr Barton is a former EM Residency Program Director and has been an ABEM Oral Examiner for the past 10 years. She is the recipient of several teaching and leadership awards. Dr Barton will focus on clinically oriented special projects and represent ABEM’s interests to external organizations.

Emergency Medicine Subspecialties. EM now has 13 subspecialty opportunities for EPs; that’s more than double the number from just 5 years ago. Emergency Medical Services (EMS) now has the most ABEM diplomates (445), followed by Medical Toxicology (367) and Pediatric Emergency Medicine (245).

Lifelong Learning and Self-Assessment (LLSA) Test Accessibility. To provide LLSA readings that better match a diplomate’s area of practice, the EMS and Medical Toxicology LLSA readings and tests can now be used by any diplomate to fulfill his or her Maintenance of Certification (MOC) Part II requirements. Pediatric EM LLSA readings and tests will eventually be made available to all diplomates at a later date. All LLSAs can be accessed through the ABEM Web site (https://www.abem.org).

Maintenance of Certification (MOC) Adds Value. In a survey of ABEM diplomates taking the 2014 ConCert Examination, 92.5% found value in maintaining their ABEM certification. In a follow-up survey in 2015, 90.4% stated their medical knowledge was reinforced and/or increased by preparing and taking the ConCert Examination. In addition to being relevant to our diplomates’ practice, ABEM has worked hard to control MOC costs. ABEM has not increased its fees for the last 5 years for the LLSAs; for all remaining examinations, there has been no fee increase for the past 4 years. When compared to all other boards, the expense of the ABEM MOC Program is at the median, costing EPs approximately $265 per year, or about $5 each week.

American College of Emergency Physicians

Jay A. Kaplan, MD, FACEP, ACEP President

Physician Burnout. Unfortunately, EM leads all specialties in the frequency of physician burnout. Emergency physicians must be aware of burnout, and take proactive steps to avoid it. To help EPs, ACEP has organized an “Emergency Medicine Wellness Week.” Prevention tips include eating well, getting the proper amount of sleep, regular exercise, and improving the work environment. In 2016, Wellness Week ran from January 24 to 30; there is a continuing focus on building resilience and preventing compassion fatigue.

Out of Network (OON) Balance Billing. Insurance companies know that it is solely the cost of insurance premiums that consumers pay attention to, not deductibles or exactly what the insurance covers. Those same insurance companies have been adept at portraying physicians as the cause of “surprise billing.” Emergency physicians need to change the conversation from “surprise billing” to “surprise coverage.” We need to talk about fair coverage for our patients, rather than asking for fair payment for physicians (the latter will follow the former and legislators believe that physicians are already fairly paid). ACEP is considering legal action against CMS and the Center for Consumer Information and Insurance Oversight regarding their final rule on “the greatest of three,” which establishes guidelines for how physicians are to be paid for services rendered.

Pay for Performance and Value-based Reimbursement. ACEP has created a joint task force with the Emergency Department Practice Management Association to create a toolbox for EPs to navigate the changing reimbursement landscape. This includes model legislation and best practices, and there is exploration regarding developing alternative payment models for EM.

Opioid Epidemic. ACEP is a participant in the White House working group exploring this epidemic and identifying strategies to combat this national problem. ACEP has sent a letter to CMS and Health and Human Services (HHS) requesting removal of the pain questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Emergency physicians should not be penalized on these surveys for not prescribing narcotic analgesics to patients who could be treated appropriately with nonnarcotic medications. ACEP similarly is considering sending a letter to The Joint Commission requesting removal of their emphasis on pain as the “fifth vital sign.”

Mass Casualty Incidents. ACEP has created a “New High-Threat High-Casualty Task Force” to identify best practice recommendations for provision of emergency care in high-threat environments and identify current clinical and operational knowledge gaps surrounding the issue. This in turn will help prioritize future ACEP research objectives based on these gaps. In addition, a white paper is being prepared, highlighting current national efforts and recommending clinical practice guidelines for adults and pediatric patients, as well as a future strategy for ACEP engagement as a national leader in the area of high-threat emergency care.

Diversity. There is a recognized need to increase the diversity in our current and future EM leadership. To that end, ACEP sponsored a Diversity Summit on April 14, 2016 in Dallas to explore these issues and make recommendations.

Emergency Quality Network. ACEP, along with 38 other health care organizations, received a grant in the CMS Transforming Clinical Practice Initiative to help physicians achieve large-scale health transformation. Areas of EM focus include: improving outcomes for patients with sepsis; reducing avoidable imaging in low-risk patients through implementation of ACEP’s Choosing Wisely campaign; and improving the value of ED chest pain evaluation in low-risk patients by reducing avoidable testing and admissions.

Editor’s Note: Part 2 of this article will appear in the May 2016 issue of Emergency Medicine and will feature reports from the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine (SAEM). Have a comment or question about this article? Let us know: [email protected].