Commentary

Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.

– Benjamin Franklin

Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.

Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.

– Benjamin Franklin

Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.

Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.

– Benjamin Franklin

Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.

Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The cardiovascular comorbidities associated with psoriasis have been well documented; however, the mechanism by which psoriasis increases the risk for cardiovascular disease (CVD) remains unclear. Elevated systemic inflammatory cytokines and mediators may play a key role in their association, which prompts the questions: Do systemic medications have a protective effect? Do patients on systemic antipsoriatic treatment have a decreased risk for major adverse cardiovascular events (MACEs) compared with untreated patients?

We believe the shared inflammatory processes involved in psoriasis and atherosclerosis formation are potential targets for therapy in reducing the incidence of CVD and its associated complications. A growing amount of evidence suggests cardioprotective effects associated with antipsoriatic treatments such as tumor necrosis factor (TNF) inhibitors and methotrexate. Gkalpakiotis et al¹ demonstrated a reduction in serum E-selectin (mean [standard deviation], 53.04 [23.54] ng/mL vs 35.32 [8.70] ng/mL; P<.001) and IL-22 (25.11 [19.9] pg/mL vs 12.83 [8.42] pg/mL; P<.001) after 3 months of adalimumab administration in patients with moderate to severe psoriasis. Both E-selectin and IL-22 are associated with the development of atherosclerosis, endothelial dysfunction, and an increased incidence of CVD. Similarly, Wu et al² demonstrated a statistically significant reduction (–5.04 mg/dL [95% confidence interval [CI], –8.24 to –2.12; P<.01) in C-reactive protein in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis after concurrent use of methotrexate and TNF inhibitors.

Solomon et al³ compared the rate of newly diagnosed diabetes mellitus among psoriasis and rheumatoid arthritis patients treated with TNF inhibitors, methotrexate, hydroxychloroquine, and other nonbiologic disease-modifying antirheumatic drugs. The authors’ findings suggest that those who take a TNF inhibitor (hazard ratio [HR], 0.62; 95% CI, 0.42-0.91) and hydroxychloroquine (HR, 0.54; 95% CI, 0.36-0.80) are at lower risk for diabetes mellitus compared to those treated with nonbiologic disease-modifying antirheumatic drugs. Conversely, the methotrexate (HR, 0.77; 95% CI, 0.53-1.13) cohort did not show a statistically significant reduction in diabetes risk.³

Pina et al⁴ revealed improvement in endothelial function after 6 months of adalimumab use in patients with moderate to severe psoriasis. To evaluate the presence of subclinical endothelial dysfunction, the authors assessed brachial artery reactivity by measuring flow-mediated dilation and carotid artery stiffness by pulse wave velocity. Patients showed an increase in flow-mediated dilation (mean [SD], 6.19% [2.44%] vs 7.46% [2.43%]; P=.008) and reduction in pulse wave velocity (6.28 [1.04] m/s vs 5.69 [1.31] m/s; P=.03) compared to baseline measurements, indicating an improvement of endothelial function.⁴

Ahlehoff et al⁵ observed for improvements in subclinical left ventricular dysfunction in psoriasis patients after treatment with biologics. Using echocardiography, they assessed for changes in diastolic function and left ventricular systolic deformation (defined by global longitudinal strain). Of patients who received 3 months of biologic therapy (TNF inhibitor orIL-12/23 inhibitor) and maintained at minimum a psoriasis area and severity index 50 response, all demonstrated an improvement in diastolic function (mean [SD], 8.1 [2.1] vs 6.7 [1.9]; P<.001) and global longitudinal strain (mean [SD], –16.8% [2.1%] vs –18.3% [2.3%]; P<.001). Of note, patients who did not achieve a psoriasis area and severity index 50 response at follow-up did not exhibit an improvement in subclinical myocardial function.⁵

Moreover, a Danish nationwide study with up to 5-year follow-up evaluated the risk for MACE (ie, cardiovascular death, myocardial infarction, stroke) in patients with severe psoriasis receiving systemic anti-inflammatory medications and nonsystemic therapies including topical treatments, phototherapy, and climate therapy.⁶ Compared to nonsystemic therapies, methotrexate use (HR, 0.53; 95% CI, 0.34-0.83) was associated with a decreased risk for cardiovascular events. However, a protective decreased risk was not found among patients who used systemic cyclosporine (HR, 1.06; 95% CI, 0.26-4.27) or retinoids (HR, 1.80; 95% CI, 1.03-2.96). Any biological drug use had a comparable but nonsignificant reduction of cardiovascular events (HR, 0.58; 95% CI, 0.30-1.10). After multivariable adjustment, TNF inhibitors were associated with a statistically significant decreased risk for cardiovascular events (HR, 0.46; 95% CI, 0.22-0.98; P=.04) compared to nonsystemic therapies. The IL-12/23 inhibitor did not demonstrate this relationship (HR, 1.52; 95% CI, 0.47-4.94).⁶

Lastly, Wu et al⁷ compared the risk for MACE (ie, myocardial infarction, stroke, unstable angina, transient ischemic attack) between patients with psoriasis who received TNF inhibitors or methotrexate. The TNF inhibitor and methotrexate cohorts were observed for a median of 12 months and 9 months, respectively. After adjusting for potential confounding factors, they found a 45% reduction (HR, 0.55; 95% CI, 0.45-0.67) in cardiovascular event risk in the TNF inhibitor cohort compared with the methotrexate cohort. Notably, analyses also showed comparatively fewer cardiovascular events in the TNF inhibitor cohort throughout all time points—6, 12, 18, 24, 60 months—in the observation period. Regression analysis revealed an 11% reduction in cardiovascular events (HR, 0.89; 95% CI, 0.80-0.98) with each additional 6 months of cumulative TNF inhibitor exposure.

The current sum of evidence suggests cardioprotective effects of TNF inhibitor and methotrexate use. However, given the cumulative systemic toxicity and inferior cutaneous efficacy of methotrexate, TNF inhibitors will likely play a more significant role going forward. The role of methotrexate may be for its simultaneous use with biologic therapies to limit immunogenicity. Newer biologic agents such as IL-12/23 and IL-17 inhibitors have not yet been as extensively studied for their effects on cardiovascular risk as their TNF inhibitor counterparts. However, because of their shared ability to target specific immunological pathways, it is plausible that IL-12/23 and IL-17 agents may exhibit cardioprotective effects.⁸

Patients with psoriasis should be counseled and educated about the increased risk for CVD and its associated morbidity and mortality risk. Screening for modifiable risk factors and recommending therapeutic lifestyle changes also is appropriate. Future studies should help define the role of specific systemic drugs in reducing the risk for CVD in patients with psoriasis. Despite the expanding amount of evidence in the current literature implicating the use of TNF inhibitors for cardiovascular risk prevention, there is still a need for long-term, randomized, placebo-controlled trials to provide more authoritative evidence-based recommendations.

The cardiovascular comorbidities associated with psoriasis have been well documented; however, the mechanism by which psoriasis increases the risk for cardiovascular disease (CVD) remains unclear. Elevated systemic inflammatory cytokines and mediators may play a key role in their association, which prompts the questions: Do systemic medications have a protective effect? Do patients on systemic antipsoriatic treatment have a decreased risk for major adverse cardiovascular events (MACEs) compared with untreated patients?

We believe the shared inflammatory processes involved in psoriasis and atherosclerosis formation are potential targets for therapy in reducing the incidence of CVD and its associated complications. A growing amount of evidence suggests cardioprotective effects associated with antipsoriatic treatments such as tumor necrosis factor (TNF) inhibitors and methotrexate. Gkalpakiotis et al¹ demonstrated a reduction in serum E-selectin (mean [standard deviation], 53.04 [23.54] ng/mL vs 35.32 [8.70] ng/mL; P<.001) and IL-22 (25.11 [19.9] pg/mL vs 12.83 [8.42] pg/mL; P<.001) after 3 months of adalimumab administration in patients with moderate to severe psoriasis. Both E-selectin and IL-22 are associated with the development of atherosclerosis, endothelial dysfunction, and an increased incidence of CVD. Similarly, Wu et al² demonstrated a statistically significant reduction (–5.04 mg/dL [95% confidence interval [CI], –8.24 to –2.12; P<.01) in C-reactive protein in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis after concurrent use of methotrexate and TNF inhibitors.

Solomon et al³ compared the rate of newly diagnosed diabetes mellitus among psoriasis and rheumatoid arthritis patients treated with TNF inhibitors, methotrexate, hydroxychloroquine, and other nonbiologic disease-modifying antirheumatic drugs. The authors’ findings suggest that those who take a TNF inhibitor (hazard ratio [HR], 0.62; 95% CI, 0.42-0.91) and hydroxychloroquine (HR, 0.54; 95% CI, 0.36-0.80) are at lower risk for diabetes mellitus compared to those treated with nonbiologic disease-modifying antirheumatic drugs. Conversely, the methotrexate (HR, 0.77; 95% CI, 0.53-1.13) cohort did not show a statistically significant reduction in diabetes risk.³

Pina et al⁴ revealed improvement in endothelial function after 6 months of adalimumab use in patients with moderate to severe psoriasis. To evaluate the presence of subclinical endothelial dysfunction, the authors assessed brachial artery reactivity by measuring flow-mediated dilation and carotid artery stiffness by pulse wave velocity. Patients showed an increase in flow-mediated dilation (mean [SD], 6.19% [2.44%] vs 7.46% [2.43%]; P=.008) and reduction in pulse wave velocity (6.28 [1.04] m/s vs 5.69 [1.31] m/s; P=.03) compared to baseline measurements, indicating an improvement of endothelial function.⁴

Ahlehoff et al⁵ observed for improvements in subclinical left ventricular dysfunction in psoriasis patients after treatment with biologics. Using echocardiography, they assessed for changes in diastolic function and left ventricular systolic deformation (defined by global longitudinal strain). Of patients who received 3 months of biologic therapy (TNF inhibitor orIL-12/23 inhibitor) and maintained at minimum a psoriasis area and severity index 50 response, all demonstrated an improvement in diastolic function (mean [SD], 8.1 [2.1] vs 6.7 [1.9]; P<.001) and global longitudinal strain (mean [SD], –16.8% [2.1%] vs –18.3% [2.3%]; P<.001). Of note, patients who did not achieve a psoriasis area and severity index 50 response at follow-up did not exhibit an improvement in subclinical myocardial function.⁵

Moreover, a Danish nationwide study with up to 5-year follow-up evaluated the risk for MACE (ie, cardiovascular death, myocardial infarction, stroke) in patients with severe psoriasis receiving systemic anti-inflammatory medications and nonsystemic therapies including topical treatments, phototherapy, and climate therapy.⁶ Compared to nonsystemic therapies, methotrexate use (HR, 0.53; 95% CI, 0.34-0.83) was associated with a decreased risk for cardiovascular events. However, a protective decreased risk was not found among patients who used systemic cyclosporine (HR, 1.06; 95% CI, 0.26-4.27) or retinoids (HR, 1.80; 95% CI, 1.03-2.96). Any biological drug use had a comparable but nonsignificant reduction of cardiovascular events (HR, 0.58; 95% CI, 0.30-1.10). After multivariable adjustment, TNF inhibitors were associated with a statistically significant decreased risk for cardiovascular events (HR, 0.46; 95% CI, 0.22-0.98; P=.04) compared to nonsystemic therapies. The IL-12/23 inhibitor did not demonstrate this relationship (HR, 1.52; 95% CI, 0.47-4.94).⁶

Lastly, Wu et al⁷ compared the risk for MACE (ie, myocardial infarction, stroke, unstable angina, transient ischemic attack) between patients with psoriasis who received TNF inhibitors or methotrexate. The TNF inhibitor and methotrexate cohorts were observed for a median of 12 months and 9 months, respectively. After adjusting for potential confounding factors, they found a 45% reduction (HR, 0.55; 95% CI, 0.45-0.67) in cardiovascular event risk in the TNF inhibitor cohort compared with the methotrexate cohort. Notably, analyses also showed comparatively fewer cardiovascular events in the TNF inhibitor cohort throughout all time points—6, 12, 18, 24, 60 months—in the observation period. Regression analysis revealed an 11% reduction in cardiovascular events (HR, 0.89; 95% CI, 0.80-0.98) with each additional 6 months of cumulative TNF inhibitor exposure.

The current sum of evidence suggests cardioprotective effects of TNF inhibitor and methotrexate use. However, given the cumulative systemic toxicity and inferior cutaneous efficacy of methotrexate, TNF inhibitors will likely play a more significant role going forward. The role of methotrexate may be for its simultaneous use with biologic therapies to limit immunogenicity. Newer biologic agents such as IL-12/23 and IL-17 inhibitors have not yet been as extensively studied for their effects on cardiovascular risk as their TNF inhibitor counterparts. However, because of their shared ability to target specific immunological pathways, it is plausible that IL-12/23 and IL-17 agents may exhibit cardioprotective effects.⁸

Patients with psoriasis should be counseled and educated about the increased risk for CVD and its associated morbidity and mortality risk. Screening for modifiable risk factors and recommending therapeutic lifestyle changes also is appropriate. Future studies should help define the role of specific systemic drugs in reducing the risk for CVD in patients with psoriasis. Despite the expanding amount of evidence in the current literature implicating the use of TNF inhibitors for cardiovascular risk prevention, there is still a need for long-term, randomized, placebo-controlled trials to provide more authoritative evidence-based recommendations.

The cardiovascular comorbidities associated with psoriasis have been well documented; however, the mechanism by which psoriasis increases the risk for cardiovascular disease (CVD) remains unclear. Elevated systemic inflammatory cytokines and mediators may play a key role in their association, which prompts the questions: Do systemic medications have a protective effect? Do patients on systemic antipsoriatic treatment have a decreased risk for major adverse cardiovascular events (MACEs) compared with untreated patients?

We believe the shared inflammatory processes involved in psoriasis and atherosclerosis formation are potential targets for therapy in reducing the incidence of CVD and its associated complications. A growing amount of evidence suggests cardioprotective effects associated with antipsoriatic treatments such as tumor necrosis factor (TNF) inhibitors and methotrexate. Gkalpakiotis et al¹ demonstrated a reduction in serum E-selectin (mean [standard deviation], 53.04 [23.54] ng/mL vs 35.32 [8.70] ng/mL; P<.001) and IL-22 (25.11 [19.9] pg/mL vs 12.83 [8.42] pg/mL; P<.001) after 3 months of adalimumab administration in patients with moderate to severe psoriasis. Both E-selectin and IL-22 are associated with the development of atherosclerosis, endothelial dysfunction, and an increased incidence of CVD. Similarly, Wu et al² demonstrated a statistically significant reduction (–5.04 mg/dL [95% confidence interval [CI], –8.24 to –2.12; P<.01) in C-reactive protein in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis after concurrent use of methotrexate and TNF inhibitors.

Solomon et al³ compared the rate of newly diagnosed diabetes mellitus among psoriasis and rheumatoid arthritis patients treated with TNF inhibitors, methotrexate, hydroxychloroquine, and other nonbiologic disease-modifying antirheumatic drugs. The authors’ findings suggest that those who take a TNF inhibitor (hazard ratio [HR], 0.62; 95% CI, 0.42-0.91) and hydroxychloroquine (HR, 0.54; 95% CI, 0.36-0.80) are at lower risk for diabetes mellitus compared to those treated with nonbiologic disease-modifying antirheumatic drugs. Conversely, the methotrexate (HR, 0.77; 95% CI, 0.53-1.13) cohort did not show a statistically significant reduction in diabetes risk.³

Pina et al⁴ revealed improvement in endothelial function after 6 months of adalimumab use in patients with moderate to severe psoriasis. To evaluate the presence of subclinical endothelial dysfunction, the authors assessed brachial artery reactivity by measuring flow-mediated dilation and carotid artery stiffness by pulse wave velocity. Patients showed an increase in flow-mediated dilation (mean [SD], 6.19% [2.44%] vs 7.46% [2.43%]; P=.008) and reduction in pulse wave velocity (6.28 [1.04] m/s vs 5.69 [1.31] m/s; P=.03) compared to baseline measurements, indicating an improvement of endothelial function.⁴

Ahlehoff et al⁵ observed for improvements in subclinical left ventricular dysfunction in psoriasis patients after treatment with biologics. Using echocardiography, they assessed for changes in diastolic function and left ventricular systolic deformation (defined by global longitudinal strain). Of patients who received 3 months of biologic therapy (TNF inhibitor orIL-12/23 inhibitor) and maintained at minimum a psoriasis area and severity index 50 response, all demonstrated an improvement in diastolic function (mean [SD], 8.1 [2.1] vs 6.7 [1.9]; P<.001) and global longitudinal strain (mean [SD], –16.8% [2.1%] vs –18.3% [2.3%]; P<.001). Of note, patients who did not achieve a psoriasis area and severity index 50 response at follow-up did not exhibit an improvement in subclinical myocardial function.⁵

Moreover, a Danish nationwide study with up to 5-year follow-up evaluated the risk for MACE (ie, cardiovascular death, myocardial infarction, stroke) in patients with severe psoriasis receiving systemic anti-inflammatory medications and nonsystemic therapies including topical treatments, phototherapy, and climate therapy.⁶ Compared to nonsystemic therapies, methotrexate use (HR, 0.53; 95% CI, 0.34-0.83) was associated with a decreased risk for cardiovascular events. However, a protective decreased risk was not found among patients who used systemic cyclosporine (HR, 1.06; 95% CI, 0.26-4.27) or retinoids (HR, 1.80; 95% CI, 1.03-2.96). Any biological drug use had a comparable but nonsignificant reduction of cardiovascular events (HR, 0.58; 95% CI, 0.30-1.10). After multivariable adjustment, TNF inhibitors were associated with a statistically significant decreased risk for cardiovascular events (HR, 0.46; 95% CI, 0.22-0.98; P=.04) compared to nonsystemic therapies. The IL-12/23 inhibitor did not demonstrate this relationship (HR, 1.52; 95% CI, 0.47-4.94).⁶

Lastly, Wu et al⁷ compared the risk for MACE (ie, myocardial infarction, stroke, unstable angina, transient ischemic attack) between patients with psoriasis who received TNF inhibitors or methotrexate. The TNF inhibitor and methotrexate cohorts were observed for a median of 12 months and 9 months, respectively. After adjusting for potential confounding factors, they found a 45% reduction (HR, 0.55; 95% CI, 0.45-0.67) in cardiovascular event risk in the TNF inhibitor cohort compared with the methotrexate cohort. Notably, analyses also showed comparatively fewer cardiovascular events in the TNF inhibitor cohort throughout all time points—6, 12, 18, 24, 60 months—in the observation period. Regression analysis revealed an 11% reduction in cardiovascular events (HR, 0.89; 95% CI, 0.80-0.98) with each additional 6 months of cumulative TNF inhibitor exposure.

The current sum of evidence suggests cardioprotective effects of TNF inhibitor and methotrexate use. However, given the cumulative systemic toxicity and inferior cutaneous efficacy of methotrexate, TNF inhibitors will likely play a more significant role going forward. The role of methotrexate may be for its simultaneous use with biologic therapies to limit immunogenicity. Newer biologic agents such as IL-12/23 and IL-17 inhibitors have not yet been as extensively studied for their effects on cardiovascular risk as their TNF inhibitor counterparts. However, because of their shared ability to target specific immunological pathways, it is plausible that IL-12/23 and IL-17 agents may exhibit cardioprotective effects.⁸

Patients with psoriasis should be counseled and educated about the increased risk for CVD and its associated morbidity and mortality risk. Screening for modifiable risk factors and recommending therapeutic lifestyle changes also is appropriate. Future studies should help define the role of specific systemic drugs in reducing the risk for CVD in patients with psoriasis. Despite the expanding amount of evidence in the current literature implicating the use of TNF inhibitors for cardiovascular risk prevention, there is still a need for long-term, randomized, placebo-controlled trials to provide more authoritative evidence-based recommendations.

Ovarian cancer remains the most deadly gynecologic malignancy in the United States with more than 14,000 deaths in 2016. Yet, the prevalence remains low with approximately 22,000 cases in 2016. Stage at diagnosis is one of the strongest predictors of overall survival. The 5-year overall survival is more than 90% with stage I disease; this drops to 25% for those with distant metastases. Unfortunately, three-quarters of patients have disease spread beyond the ovary at the time ovarian cancer is clinically identified.

In this update, we will review:

• The fundamentals of ovarian cancer screening.

• How to identify patients who would benefit from surveillance.

• The usefulness of tumor markers.

• The results from recent large ovarian cancer screening trials.

Screening is a critical part of secondary prevention through early disease detection, when patients are asymptomatic and treatment can stop progression. Core principles of a good screening test are that the test is noninvasive, tolerable to the patient, and not costly. The disease should pose a major health threat and be detected at a stage at which intervention can impart a survival advantage. Most critically, the test should be sensitive and specific (i.e., detect disease when it is truly present and rarely be positive in the absence of disease).

Screening vs. case finding

A significant distinction should be made between average-risk patients and high-risk patients. Ob.gyns. frequently encounter high-risk patients who would benefit from regular surveillance or case finding (for example, patients with BRCA deleterious mutations or with Lynch syndrome). There are multiple risk factors for ovarian cancer, but the strongest known is family history, which is present in 15% of ovarian cancer patients. Having one relative with ovarian cancer increases the lifetime risk of ovarian cancer up to 5%. When a patient reports having one or more family members with ovarian cancer, it is important to differentiate between a common sporadic presentation and a rare familial cancer syndrome. ACOG Practice Bulletin 103 provides excellent guidance on which patients warrant formal genetic risk assessments by a genetic counselor.²

Tumor markers

During the last 25 years, screening for ovarian cancer in an average-risk population has been evaluated in multiple large prospective studies using serum tumor markers (i.e., CA 125) and ultrasound results.

CA 125 and HE4 tumor markers are frequently elevated in ovarian cancer and have been studied in ovarian cancer screening. However, while having a high sensitivity for detecting disease, they are nonspecific because they are also elevated in numerous benign conditions and therefore have not proven to be a useful screening tool in the average-risk population. There are clinically available tumor marker panels that are not intended for screening. Rather, they clarify the uncertainty of the presurgical adnexal mass evaluation by providing a risk score. High risk scores are generally managed in conjunction with a gynecologic oncology referral.

Multimodal screening

Combined assessment of both ultrasound findings and tumor marker levels shows more promise with respect to prediction of ovarian cancer. However, a systematic review of 25 ovarian cancer screening studies concluded that screening low-risk populations should not be included in clinical practice until randomized trials assessed the effect on mortality and the risk of adverse events. Three large randomized controlled trials have been completed to date.^3,4,5

The U.K. Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) results appear promising. However, the revealing analysis was post hoc since the original study design did not take into account the inherent delayed effect in screening studies. While these results may provide a basis for future successful screening for ovarian cancer, confirmatory further analysis is pending, using additional data over a period of the next 3 years.

Ultimately, we are all excited about the possibility of effective screening protocols for ovarian cancer and await completed analyses of UKCTOCS. Until their benefits are confirmed, screening and preventive measures should be limited to those at high risk for ovarian cancer.

References

1. Hippokratia. 2007 Apr;11(2):63-6.

2. Obstet Gynecol. 2009 Apr;113(4):957-66.

3. Am J Obstet Gynecol. 2005 Nov;193(5):1630-9.

4. Int J Gynecol Cancer. 2008 May-Jun;18(3):414-20.

5. Lancet. 2016 Mar 5;387(10022):945-56.

Dr. Pierce is a gynecologic oncology fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC–Chapel Hill. They reported having no relevant financial disclosures.

Ovarian cancer remains the most deadly gynecologic malignancy in the United States with more than 14,000 deaths in 2016. Yet, the prevalence remains low with approximately 22,000 cases in 2016. Stage at diagnosis is one of the strongest predictors of overall survival. The 5-year overall survival is more than 90% with stage I disease; this drops to 25% for those with distant metastases. Unfortunately, three-quarters of patients have disease spread beyond the ovary at the time ovarian cancer is clinically identified.

In this update, we will review:

• The fundamentals of ovarian cancer screening.

• How to identify patients who would benefit from surveillance.

• The usefulness of tumor markers.

• The results from recent large ovarian cancer screening trials.

Screening is a critical part of secondary prevention through early disease detection, when patients are asymptomatic and treatment can stop progression. Core principles of a good screening test are that the test is noninvasive, tolerable to the patient, and not costly. The disease should pose a major health threat and be detected at a stage at which intervention can impart a survival advantage. Most critically, the test should be sensitive and specific (i.e., detect disease when it is truly present and rarely be positive in the absence of disease).

Screening vs. case finding

A significant distinction should be made between average-risk patients and high-risk patients. Ob.gyns. frequently encounter high-risk patients who would benefit from regular surveillance or case finding (for example, patients with BRCA deleterious mutations or with Lynch syndrome). There are multiple risk factors for ovarian cancer, but the strongest known is family history, which is present in 15% of ovarian cancer patients. Having one relative with ovarian cancer increases the lifetime risk of ovarian cancer up to 5%. When a patient reports having one or more family members with ovarian cancer, it is important to differentiate between a common sporadic presentation and a rare familial cancer syndrome. ACOG Practice Bulletin 103 provides excellent guidance on which patients warrant formal genetic risk assessments by a genetic counselor.²

Tumor markers

During the last 25 years, screening for ovarian cancer in an average-risk population has been evaluated in multiple large prospective studies using serum tumor markers (i.e., CA 125) and ultrasound results.

CA 125 and HE4 tumor markers are frequently elevated in ovarian cancer and have been studied in ovarian cancer screening. However, while having a high sensitivity for detecting disease, they are nonspecific because they are also elevated in numerous benign conditions and therefore have not proven to be a useful screening tool in the average-risk population. There are clinically available tumor marker panels that are not intended for screening. Rather, they clarify the uncertainty of the presurgical adnexal mass evaluation by providing a risk score. High risk scores are generally managed in conjunction with a gynecologic oncology referral.

Multimodal screening

Combined assessment of both ultrasound findings and tumor marker levels shows more promise with respect to prediction of ovarian cancer. However, a systematic review of 25 ovarian cancer screening studies concluded that screening low-risk populations should not be included in clinical practice until randomized trials assessed the effect on mortality and the risk of adverse events. Three large randomized controlled trials have been completed to date.^3,4,5

The U.K. Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) results appear promising. However, the revealing analysis was post hoc since the original study design did not take into account the inherent delayed effect in screening studies. While these results may provide a basis for future successful screening for ovarian cancer, confirmatory further analysis is pending, using additional data over a period of the next 3 years.

Ultimately, we are all excited about the possibility of effective screening protocols for ovarian cancer and await completed analyses of UKCTOCS. Until their benefits are confirmed, screening and preventive measures should be limited to those at high risk for ovarian cancer.

References

1. Hippokratia. 2007 Apr;11(2):63-6.

2. Obstet Gynecol. 2009 Apr;113(4):957-66.

3. Am J Obstet Gynecol. 2005 Nov;193(5):1630-9.

4. Int J Gynecol Cancer. 2008 May-Jun;18(3):414-20.

5. Lancet. 2016 Mar 5;387(10022):945-56.

Dr. Pierce is a gynecologic oncology fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC–Chapel Hill. They reported having no relevant financial disclosures.

Ovarian cancer remains the most deadly gynecologic malignancy in the United States with more than 14,000 deaths in 2016. Yet, the prevalence remains low with approximately 22,000 cases in 2016. Stage at diagnosis is one of the strongest predictors of overall survival. The 5-year overall survival is more than 90% with stage I disease; this drops to 25% for those with distant metastases. Unfortunately, three-quarters of patients have disease spread beyond the ovary at the time ovarian cancer is clinically identified.

In this update, we will review:

• The fundamentals of ovarian cancer screening.

• How to identify patients who would benefit from surveillance.

• The usefulness of tumor markers.

• The results from recent large ovarian cancer screening trials.

Screening is a critical part of secondary prevention through early disease detection, when patients are asymptomatic and treatment can stop progression. Core principles of a good screening test are that the test is noninvasive, tolerable to the patient, and not costly. The disease should pose a major health threat and be detected at a stage at which intervention can impart a survival advantage. Most critically, the test should be sensitive and specific (i.e., detect disease when it is truly present and rarely be positive in the absence of disease).

Screening vs. case finding

A significant distinction should be made between average-risk patients and high-risk patients. Ob.gyns. frequently encounter high-risk patients who would benefit from regular surveillance or case finding (for example, patients with BRCA deleterious mutations or with Lynch syndrome). There are multiple risk factors for ovarian cancer, but the strongest known is family history, which is present in 15% of ovarian cancer patients. Having one relative with ovarian cancer increases the lifetime risk of ovarian cancer up to 5%. When a patient reports having one or more family members with ovarian cancer, it is important to differentiate between a common sporadic presentation and a rare familial cancer syndrome. ACOG Practice Bulletin 103 provides excellent guidance on which patients warrant formal genetic risk assessments by a genetic counselor.²

Tumor markers

During the last 25 years, screening for ovarian cancer in an average-risk population has been evaluated in multiple large prospective studies using serum tumor markers (i.e., CA 125) and ultrasound results.

CA 125 and HE4 tumor markers are frequently elevated in ovarian cancer and have been studied in ovarian cancer screening. However, while having a high sensitivity for detecting disease, they are nonspecific because they are also elevated in numerous benign conditions and therefore have not proven to be a useful screening tool in the average-risk population. There are clinically available tumor marker panels that are not intended for screening. Rather, they clarify the uncertainty of the presurgical adnexal mass evaluation by providing a risk score. High risk scores are generally managed in conjunction with a gynecologic oncology referral.

Multimodal screening

Combined assessment of both ultrasound findings and tumor marker levels shows more promise with respect to prediction of ovarian cancer. However, a systematic review of 25 ovarian cancer screening studies concluded that screening low-risk populations should not be included in clinical practice until randomized trials assessed the effect on mortality and the risk of adverse events. Three large randomized controlled trials have been completed to date.^3,4,5

The U.K. Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) results appear promising. However, the revealing analysis was post hoc since the original study design did not take into account the inherent delayed effect in screening studies. While these results may provide a basis for future successful screening for ovarian cancer, confirmatory further analysis is pending, using additional data over a period of the next 3 years.

Ultimately, we are all excited about the possibility of effective screening protocols for ovarian cancer and await completed analyses of UKCTOCS. Until their benefits are confirmed, screening and preventive measures should be limited to those at high risk for ovarian cancer.

References

1. Hippokratia. 2007 Apr;11(2):63-6.

2. Obstet Gynecol. 2009 Apr;113(4):957-66.

3. Am J Obstet Gynecol. 2005 Nov;193(5):1630-9.

4. Int J Gynecol Cancer. 2008 May-Jun;18(3):414-20.

5. Lancet. 2016 Mar 5;387(10022):945-56.

Dr. Pierce is a gynecologic oncology fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC–Chapel Hill. They reported having no relevant financial disclosures.

The term full practice authority (FPA) means different things to different clinicians. Some think it is a code phrase for “independent practice,” while others regard it as the ability to practice to the fullest extent of their education and licensure. The American Association of Nurse Practitioners (AANP) defines FPA as the “collection of state practice and licensure laws that allow for NPs to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.”¹ Whatever the definition, it is an emotionally packed phrase for NPs, PAs, and our physician colleagues.

While NP and PA scope of practice is largely dictated by state laws and regulations, it is also impacted by other factors, including employment agreements, practice setting, and billing requirements of Medicare and other third-party payers.² In the past decade, there has been increasing support for eliminating barriers to practice. Advocates say the current supply of health care services is unnecessarily limited—a problem that will increase as our population ages and people live longer with chronic conditions. With the health care system under constant pressure, many believe that all clinicians should be able to provide care to the full scope of their education and expertise.

Proponents of FPA, including the Institute of Medicine and the National Governors Association, cite improved access to and efficiency of care and reduced costs as the main motivations for lifting practice restrictions.^3,4 In an extensive document, the RAND Corporation called for states to relax scope-of-practice restrictions for NPs.⁵ Findings from the Federal Trade Commission assert that NPs are safe and effective as independent providers of health care services within the scope of their training and licensure.⁶

Meanwhile, opponents—such as the American Academy of Family Physicians (AAFP) and the American Medical Association—express concerns about the lack of clinical education compared to physicians, as well as patient choice and fragmentation of care.⁷ Back in 2010, the AAFP objected to statements from the National Board of Medical Examiners (NBME), which alleged that physicians and nurse clinicians have comparable scopes of practice; NBME further suggested that licensing authorities for both professions “should be required to create common means of assessing proficiency for entry to and continuation in practice.”⁸ Osteopathic physicians pushed back on FPA, worried that NPs would be confused with physicians.⁹ But as NPs have clarified, their license is an extension of their RN license; they do not need physician endorsement for the advanced component.

What goes without saying is that NPs and PAs play a large and expanding role in the American health care delivery system. NPs constitute the fastest-growing segment of the primary care workforce in the United States. And because they are proven to be highly educated clinicians who take responsibility for their clinical decisions, many states are relaxing scope-of-practice restrictions to allow them to provide more extensive services to their patients. Currently, 21 states and the District of Columbia allow FPA for NPs.¹⁰ Furthermore, in a recent landmark decision, the US Department of Veterans Affairs (VA) announced new rules granting Advanced Practice Registered Nurses (APRNs) FPA within the VA system.¹¹

In contrast to the varying degrees of autonomy with which NPs practice, PAs provide medical services exclusively under the delegation of physicians. Although many function in autonomous practices, PAs have no authority to function independently or to provide services unless assigned by and under the auspices of a supervising physician.¹² This should not come as a surprise, since PAs have always touted that the profession was created for physicians, by ­physicians.

But as NPs have advanced their FPA agenda, many PAs have asked, “What about us?” Brian Sady, a PA from Nevada, has been advocating FPA for many years to enhance the accessibility and quality of care in his rural state.¹³

In fact, the American Academy of Physician Assistants has been lobbying the VA to grant FPA to PAs in parity with their recent action regarding NPs.¹⁴ And now, the Academy has gone a step further with the creation of the Joint Task Force on PA Practice Authority. Their raison d’etre is to develop a proposal that supports the elimination of regulations that require PAs to have and/or report supervisory, collaborating, or other specific relationships with a physician in order to practice.¹⁵ This is a significant change of direction for the PA profession and is stimulating a great deal of discussion.

In order to accomplish their goal, the task force must emphasize the PA profession’s continued commitment to team-based practice. Interestingly, Michigan recently enacted a law that distinguishes participating physicians from supervising physicians in order to better reflect the PA and physician roles within the team. The law removes physician responsibility for PA practice, making each member of the health care team responsible for his or her own decisions. It also removes the ratio restriction that limited the number of PAs with whom a physician may practice. By recognizing PAs as full prescribers, rather than limiting their care to “delegated prescriptive authority,” the law grants PAs more autonomy to serve patients.¹⁶

PAs are regulated by the state medical board or a subset of it—only five states have a PA-specific board—whereas NPs have always practiced under the auspices of their state nursing board. If the task force proposals are adopted by the AAPA House of Delegates, they will support the creation of autonomous state boards with a majority of PA members to regulate practice. (Iowa is currently the only state PA board that has a majority of PA members.)

Some argue that FPA for PAs would disrupt the current PA-physician relationship. Others contend that FPA for PAs will strengthen that relationship and balance the respect, support, and professionalism that enable PAs to consistently provide high-quality care.

Both NPs and PAs assert that they have, throughout 50 years, demonstrated a commitment to competent, quality care for patients. By defining the future of our professions, we make our professions more accountable, preserve our positive relationships with physicians and other members of the health care team, decrease unnecessary administrative burdens on physicians and employers, and most importantly, increase access to quality care for our patients. Share your expectations and opinions regarding professional autonomy with me at ­[email protected].

The term full practice authority (FPA) means different things to different clinicians. Some think it is a code phrase for “independent practice,” while others regard it as the ability to practice to the fullest extent of their education and licensure. The American Association of Nurse Practitioners (AANP) defines FPA as the “collection of state practice and licensure laws that allow for NPs to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.”¹ Whatever the definition, it is an emotionally packed phrase for NPs, PAs, and our physician colleagues.

While NP and PA scope of practice is largely dictated by state laws and regulations, it is also impacted by other factors, including employment agreements, practice setting, and billing requirements of Medicare and other third-party payers.² In the past decade, there has been increasing support for eliminating barriers to practice. Advocates say the current supply of health care services is unnecessarily limited—a problem that will increase as our population ages and people live longer with chronic conditions. With the health care system under constant pressure, many believe that all clinicians should be able to provide care to the full scope of their education and expertise.

Proponents of FPA, including the Institute of Medicine and the National Governors Association, cite improved access to and efficiency of care and reduced costs as the main motivations for lifting practice restrictions.^3,4 In an extensive document, the RAND Corporation called for states to relax scope-of-practice restrictions for NPs.⁵ Findings from the Federal Trade Commission assert that NPs are safe and effective as independent providers of health care services within the scope of their training and licensure.⁶

Meanwhile, opponents—such as the American Academy of Family Physicians (AAFP) and the American Medical Association—express concerns about the lack of clinical education compared to physicians, as well as patient choice and fragmentation of care.⁷ Back in 2010, the AAFP objected to statements from the National Board of Medical Examiners (NBME), which alleged that physicians and nurse clinicians have comparable scopes of practice; NBME further suggested that licensing authorities for both professions “should be required to create common means of assessing proficiency for entry to and continuation in practice.”⁸ Osteopathic physicians pushed back on FPA, worried that NPs would be confused with physicians.⁹ But as NPs have clarified, their license is an extension of their RN license; they do not need physician endorsement for the advanced component.

What goes without saying is that NPs and PAs play a large and expanding role in the American health care delivery system. NPs constitute the fastest-growing segment of the primary care workforce in the United States. And because they are proven to be highly educated clinicians who take responsibility for their clinical decisions, many states are relaxing scope-of-practice restrictions to allow them to provide more extensive services to their patients. Currently, 21 states and the District of Columbia allow FPA for NPs.¹⁰ Furthermore, in a recent landmark decision, the US Department of Veterans Affairs (VA) announced new rules granting Advanced Practice Registered Nurses (APRNs) FPA within the VA system.¹¹

In contrast to the varying degrees of autonomy with which NPs practice, PAs provide medical services exclusively under the delegation of physicians. Although many function in autonomous practices, PAs have no authority to function independently or to provide services unless assigned by and under the auspices of a supervising physician.¹² This should not come as a surprise, since PAs have always touted that the profession was created for physicians, by ­physicians.

But as NPs have advanced their FPA agenda, many PAs have asked, “What about us?” Brian Sady, a PA from Nevada, has been advocating FPA for many years to enhance the accessibility and quality of care in his rural state.¹³

In fact, the American Academy of Physician Assistants has been lobbying the VA to grant FPA to PAs in parity with their recent action regarding NPs.¹⁴ And now, the Academy has gone a step further with the creation of the Joint Task Force on PA Practice Authority. Their raison d’etre is to develop a proposal that supports the elimination of regulations that require PAs to have and/or report supervisory, collaborating, or other specific relationships with a physician in order to practice.¹⁵ This is a significant change of direction for the PA profession and is stimulating a great deal of discussion.

In order to accomplish their goal, the task force must emphasize the PA profession’s continued commitment to team-based practice. Interestingly, Michigan recently enacted a law that distinguishes participating physicians from supervising physicians in order to better reflect the PA and physician roles within the team. The law removes physician responsibility for PA practice, making each member of the health care team responsible for his or her own decisions. It also removes the ratio restriction that limited the number of PAs with whom a physician may practice. By recognizing PAs as full prescribers, rather than limiting their care to “delegated prescriptive authority,” the law grants PAs more autonomy to serve patients.¹⁶

PAs are regulated by the state medical board or a subset of it—only five states have a PA-specific board—whereas NPs have always practiced under the auspices of their state nursing board. If the task force proposals are adopted by the AAPA House of Delegates, they will support the creation of autonomous state boards with a majority of PA members to regulate practice. (Iowa is currently the only state PA board that has a majority of PA members.)

Some argue that FPA for PAs would disrupt the current PA-physician relationship. Others contend that FPA for PAs will strengthen that relationship and balance the respect, support, and professionalism that enable PAs to consistently provide high-quality care.

Both NPs and PAs assert that they have, throughout 50 years, demonstrated a commitment to competent, quality care for patients. By defining the future of our professions, we make our professions more accountable, preserve our positive relationships with physicians and other members of the health care team, decrease unnecessary administrative burdens on physicians and employers, and most importantly, increase access to quality care for our patients. Share your expectations and opinions regarding professional autonomy with me at ­[email protected].

The term full practice authority (FPA) means different things to different clinicians. Some think it is a code phrase for “independent practice,” while others regard it as the ability to practice to the fullest extent of their education and licensure. The American Association of Nurse Practitioners (AANP) defines FPA as the “collection of state practice and licensure laws that allow for NPs to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.”¹ Whatever the definition, it is an emotionally packed phrase for NPs, PAs, and our physician colleagues.

While NP and PA scope of practice is largely dictated by state laws and regulations, it is also impacted by other factors, including employment agreements, practice setting, and billing requirements of Medicare and other third-party payers.² In the past decade, there has been increasing support for eliminating barriers to practice. Advocates say the current supply of health care services is unnecessarily limited—a problem that will increase as our population ages and people live longer with chronic conditions. With the health care system under constant pressure, many believe that all clinicians should be able to provide care to the full scope of their education and expertise.

Proponents of FPA, including the Institute of Medicine and the National Governors Association, cite improved access to and efficiency of care and reduced costs as the main motivations for lifting practice restrictions.^3,4 In an extensive document, the RAND Corporation called for states to relax scope-of-practice restrictions for NPs.⁵ Findings from the Federal Trade Commission assert that NPs are safe and effective as independent providers of health care services within the scope of their training and licensure.⁶

Meanwhile, opponents—such as the American Academy of Family Physicians (AAFP) and the American Medical Association—express concerns about the lack of clinical education compared to physicians, as well as patient choice and fragmentation of care.⁷ Back in 2010, the AAFP objected to statements from the National Board of Medical Examiners (NBME), which alleged that physicians and nurse clinicians have comparable scopes of practice; NBME further suggested that licensing authorities for both professions “should be required to create common means of assessing proficiency for entry to and continuation in practice.”⁸ Osteopathic physicians pushed back on FPA, worried that NPs would be confused with physicians.⁹ But as NPs have clarified, their license is an extension of their RN license; they do not need physician endorsement for the advanced component.

What goes without saying is that NPs and PAs play a large and expanding role in the American health care delivery system. NPs constitute the fastest-growing segment of the primary care workforce in the United States. And because they are proven to be highly educated clinicians who take responsibility for their clinical decisions, many states are relaxing scope-of-practice restrictions to allow them to provide more extensive services to their patients. Currently, 21 states and the District of Columbia allow FPA for NPs.¹⁰ Furthermore, in a recent landmark decision, the US Department of Veterans Affairs (VA) announced new rules granting Advanced Practice Registered Nurses (APRNs) FPA within the VA system.¹¹

In contrast to the varying degrees of autonomy with which NPs practice, PAs provide medical services exclusively under the delegation of physicians. Although many function in autonomous practices, PAs have no authority to function independently or to provide services unless assigned by and under the auspices of a supervising physician.¹² This should not come as a surprise, since PAs have always touted that the profession was created for physicians, by ­physicians.

But as NPs have advanced their FPA agenda, many PAs have asked, “What about us?” Brian Sady, a PA from Nevada, has been advocating FPA for many years to enhance the accessibility and quality of care in his rural state.¹³

In fact, the American Academy of Physician Assistants has been lobbying the VA to grant FPA to PAs in parity with their recent action regarding NPs.¹⁴ And now, the Academy has gone a step further with the creation of the Joint Task Force on PA Practice Authority. Their raison d’etre is to develop a proposal that supports the elimination of regulations that require PAs to have and/or report supervisory, collaborating, or other specific relationships with a physician in order to practice.¹⁵ This is a significant change of direction for the PA profession and is stimulating a great deal of discussion.

In order to accomplish their goal, the task force must emphasize the PA profession’s continued commitment to team-based practice. Interestingly, Michigan recently enacted a law that distinguishes participating physicians from supervising physicians in order to better reflect the PA and physician roles within the team. The law removes physician responsibility for PA practice, making each member of the health care team responsible for his or her own decisions. It also removes the ratio restriction that limited the number of PAs with whom a physician may practice. By recognizing PAs as full prescribers, rather than limiting their care to “delegated prescriptive authority,” the law grants PAs more autonomy to serve patients.¹⁶

PAs are regulated by the state medical board or a subset of it—only five states have a PA-specific board—whereas NPs have always practiced under the auspices of their state nursing board. If the task force proposals are adopted by the AAPA House of Delegates, they will support the creation of autonomous state boards with a majority of PA members to regulate practice. (Iowa is currently the only state PA board that has a majority of PA members.)

Some argue that FPA for PAs would disrupt the current PA-physician relationship. Others contend that FPA for PAs will strengthen that relationship and balance the respect, support, and professionalism that enable PAs to consistently provide high-quality care.

Both NPs and PAs assert that they have, throughout 50 years, demonstrated a commitment to competent, quality care for patients. By defining the future of our professions, we make our professions more accountable, preserve our positive relationships with physicians and other members of the health care team, decrease unnecessary administrative burdens on physicians and employers, and most importantly, increase access to quality care for our patients. Share your expectations and opinions regarding professional autonomy with me at ­[email protected].

In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.

According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.

By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period. 

In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.

EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction. 

In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.

According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.

By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period. 

In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.

EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction. 

In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.

According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.

By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period. 

In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.

EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction. 

The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.

Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.

Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.

Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.

Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.

Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.

Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.

Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.

“The Pill” – as it is often referred to – was introduced in May of 1950.¹ At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.¹ Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.

Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.

Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.

©areeya_ann/Thinkstock.com

References

1. Can Fam Physician. 2012 Dec;58(12):e757–60.

2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.

3. Obstet Gynecol. 2009;114:1428-31.

4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.

5. Pediatr Rev. 2008;29(11);386-97.

6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.

7. Obstet Gynecol. 2005 Sep;106(3):492-501.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.

“The Pill” – as it is often referred to – was introduced in May of 1950.¹ At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.¹ Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.

Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.

Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.

©areeya_ann/Thinkstock.com

References

1. Can Fam Physician. 2012 Dec;58(12):e757–60.

2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.

3. Obstet Gynecol. 2009;114:1428-31.

4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.

5. Pediatr Rev. 2008;29(11);386-97.

6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.

7. Obstet Gynecol. 2005 Sep;106(3):492-501.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.

“The Pill” – as it is often referred to – was introduced in May of 1950.¹ At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.¹ Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.

Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.

Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.

©areeya_ann/Thinkstock.com

References

1. Can Fam Physician. 2012 Dec;58(12):e757–60.

2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.

3. Obstet Gynecol. 2009;114:1428-31.

4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.

5. Pediatr Rev. 2008;29(11);386-97.

6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.

7. Obstet Gynecol. 2005 Sep;106(3):492-501.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.