Commentary

Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann of the Miami-based Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”

In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, April 2002), and a book for consumers, “The Skin Type Solution” (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

[email protected]

On Twitter @whitneymcknight

Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann of the Miami-based Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”

In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, April 2002), and a book for consumers, “The Skin Type Solution” (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

[email protected]

On Twitter @whitneymcknight

Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann of the Miami-based Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”

In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, April 2002), and a book for consumers, “The Skin Type Solution” (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

[email protected]

On Twitter @whitneymcknight

Ten years ago, urodynamics were widely viewed as the gold standard for evaluating urinary incontinence. We often turned to such testing to confirm or reject the findings of our basic evaluation before determining the best type of treatment – especially before proceeding with primary anti-incontinence surgery.

What has emerged in recent years is a body of evidence that tells us otherwise. We now know that urodynamics do not give us all the answers, and that we can be much more judicious with its use.

A good history followed by a thorough physical examination and some office tests often enables us to make sound treatment recommendations without costly and potentially uncomfortable urodynamic testing. The key lies in discerning complicated and uncomplicated cases. For patients deemed to have uncomplicated stress urinary incontinence (SUI) – especially those who have failed conservative management – we can comfortably recommend surgical repair without urodynamic testing.

Identifying uncomplicated SUI

The history is the most important part of the evaluation for incontinence. Every patient who answers “yes” to a basic opening question about whether she has any concerns about bladder control should be asked a series of questions that will enable the physician to fully understand her symptoms, their severity, and their impact on her life and daily activities.

It is critical to determine whether you are dealing with pure SUI, pure urge incontinence (UI), or SUI with a component of UI. Mixed incontinence is quite prevalent. An analysis of recent National Health and Nutrition Examination Survey (NHANES) data showed that of those women reporting incontinence symptoms, almost 50% reported pure SUI, and 34% reported mixed incontinence (J. Urol. 2008;179: 656-61). Other studies similarly have shown prevalence rates of mixed incontinence above 30%.

The International Urogynecological Association (IUGA) recommends the use of validated questionnaires to assess incontinence and the relative contribution of UI and SUI symptoms. Some physicians do find the organized and structured format of questionnaires helpful in their practices. Others have incorporated questions from various tools into history-taking templates on their electronic medical records. Still others have made them part of a mental checklist for history taking.

The short-form version of the Urogenital Distress Inventory (UDI-6), for instance, asks the patient whether she experiences – and how much she is bothered by – the following: frequent urination; leakage related to a feeling of urgency; leakage related to activity, coughing, or sneezing; small amount of leakage; difficulty emptying the bladder; and pain or discomfort in the lower abdominal or genital area.

The Incontinence Impact Questionnaire can be used to further assess the impact of symptoms. The short-form IIQ (the IIQ-7) asks, for instance, about the extent to which urine leakage has affected household chores, physical recreation, social activities, or emotional health.

Since the UDI and IIQ were developed about 20 years ago, at least several other urinary incontinence questionnaires have been developed and validated. Whether or not questionnaires are utilized as official tools, history taking should capture their essence and provide you with enough information to ascertain the type of incontinence, frequency of occurrence, severity, and effect on daily life.

The history also must assess the possibility of voiding dysfunction. Positive responses to questions about nocturia, hesitancy, and the need to immediately revoid, for instance, point toward complicated SUI and the need for further assessment before embarking on surgical treatment for SUI.

Patients who have uncomplicated SUI, on the other hand, will answer negatively to questions about symptoms of predominant urgency, functional impairment, continuous leakage, and/or incomplete emptying. They also will not have had recurrent urinary tract infections or medical conditions that can affect lower urinary tract function (such as neurologic disease and poorly controlled diabetes).

The physical exam

Along with the history, the physical exam is important for identifying complicated SUI and confirming which cases of SUI are truly uncomplicated. Evaluation should include a cough stress test to confirm leakage from the urethra under stress, an assessment of urethral mobility, and an assessment for pelvic organ prolapse.

The cough stress test is usually done with the patient in the supine or semirecumbent lithotomy position. If you strongly suspect stress incontinence but have a negative result, consider the following:

• Make sure the patient has a comfortably full bladder.

• Many women will contract their pelvic floor muscles when coughing to try to avoid leaking. You can apply pressure against the posterior vaginal wall either digitally or with half of the bivalve speculum to keep the patient from activating her muscles.

• The cough test can be performed in the standing position.

 

Assessing urethral mobility similarly involves simple observation while the patient is in a supine lithotomy position and straining. A Q-tip test or the Pelvic Organ Prolapse Quantification (POP-Q) system may be used, but visualization and palpation also are completely acceptable.

Just as the absence of urethral mobility is a red flag, so is prolapse beyond the hymen. This patient could potentially have urethral kinking, which can mask the severity of SUI or be a source of retention. Either finding the absence of urethral mobility or the presence of POP beyond the hymen moves the case from the uncomplicated to complicated category and signals the need for further evaluation with urodynamics or other tests.

These and other findings for uncomplicated versus complicated SUI are outlined in a committee opinion issued recently by the American College of Obstetricians and Gynecologists and the American Urogynecologic Society (Committee Opinion No. 603, Obstet .Gynecol. 2014;123:1403-7).

As the ACOG-AUGS recommendations point out, urinalysis is part of the minimum work-up for stress incontinence. Measurement of postvoid residual urine volume also becomes important when midurethral sling surgery is being contemplated for uncomplicated SUI. A normal volume rules out potential bladder-emptying abnormalities and provides final assurance that the patient is a good candidate for surgical repair.

Recent research on urodynamics

Evidence that a simple office-based incontinence evaluation without preoperative urodynamic testing is appropriate for uncomplicated predominant SUI comes largely from two recent randomized noninferiority trials.

One of these trials – a study from the Urinary Incontinence Treatment Network in the United States, known as the VALUE trial – randomized 630 women with uncomplicated SUI to pretreatment work-up with or without urodynamics. Treatment success at 12 months was similar for the two groups (approximately 77%).

This finding, the authors wrote, suggests that for women with uncomplicated SUI, a “basic office evaluation” (i.e., a positive provocative stress test, a normal postvoiding residual volume, an assessment or urethral mobility, and a negative urinalysis) is a “sufficient preoperative work-up” (N. Engl. J. Med. 2012;366:1987-97).

The diagnosis of SUI as made by office evaluation was confirmed in 97% of women who underwent urodynamic testing, and while there were some adjustments in diagnosis after urodynamics, there were no major changes in treatment decision making after the testing. Approximately 93% of women in both groups underwent midurethral sling surgery.

The second trial, a Dutch study, focused on women who had already undergone urodynamic testing and been shown to have discordant findings on urodynamics and their history and clinical exam. The women – all of whom had uncomplicated predominant SUI – were randomized to undergo immediate midurethral sling surgery or receive individually tailored treatment (including sling surgery, behavioral and physical therapy, pessary, and anticholinergics).

At 1 year, there was no clinically significant difference between the two groups in patients’ assessment of their symptoms as measured by the UDI. The authors concluded that “an immediate midurethral sling operation is not inferior to individually tailored treatment based on urodynamic findings” and that “urodynamics should no longer be advised routinely before primary surgery in these patients” (Obstet. Gynecol. 2013;121:999-1008).

When urge incontinence is involved

Urodynamic testing was never believed to be perfect, but these and other studies have highlighted its imperfections. Urodynamics creates an artificial condition in the bladder, in effect, and some of the findings will involve artifact. A systematic review of studies that compared diagnoses based on symptoms with diagnoses after urodynamic investigation was interesting in this regard; while the review did not assess impact on treatment, it showed that there is poor agreement between clinical symptoms and urodynamic-based diagnoses (Neurourol. Urodyn. 2011;30:495-502).

Certainly, women with complicated SUI – as well as women who have recurrent SUI after a prior surgical intervention – require further assessment, which likely includes multichannel urodynamic testing.

Urodynamics also can play a useful role in decision making and counseling for some patients whose incontinence is predominately SUI, but is believed to involve some degree of urinary urgency. Patients with mixed urinary incontinence fare worse after midurethral sling procedures compared with patients who have SUI alone, and I counsel my patients accordingly, emphasizing that the sling will not address aspects of their incontinence related to urgency. When I sense that a patient may have unreasonably high expectations for surgery, urodynamic testing can provide some perspective on possible postoperative outcomes.

Treatment for UI or overactive bladder often may be initiated after simple office-based evaluation, just as with SUI. The goal, similarly, is to discern relatively uncomplicated or straightforward cases from complicated ones. Urologic, medical, and neurologic histories should be obtained, for instance, and retention issues (which can aggravate UI) should be ruled out through the measurement of postvoid residual urine volume.

 

Just as with SUI, evaluation of suspected UI more often than not involves careful history taking and clinical probing. A voiding diary can sometimes be helpful; I send patients home with such a tool when the history is inconclusive or I suspect behavioral (excessive fluid intake) or functional issues as significant factors in bladder control.

It is important to keep in mind that patients with severe SUI may have urinary frequency as a learned response. Such patients appear to have overactive bladder in addition to SUI, but may actually be urinating frequently because they’ve learned that doing so results in less leakage. In our practice we’ve observed that patients with a learned response tend not to have nocturia, while those with overactive bladder do report nocturia.

Dr. Culbertson had no relevant financial disclosures.

Dr. Culbertson is a professor in the department of obstetrics and gynecology at the University of Chicago.

Ten years ago, urodynamics were widely viewed as the gold standard for evaluating urinary incontinence. We often turned to such testing to confirm or reject the findings of our basic evaluation before determining the best type of treatment – especially before proceeding with primary anti-incontinence surgery.

What has emerged in recent years is a body of evidence that tells us otherwise. We now know that urodynamics do not give us all the answers, and that we can be much more judicious with its use.

A good history followed by a thorough physical examination and some office tests often enables us to make sound treatment recommendations without costly and potentially uncomfortable urodynamic testing. The key lies in discerning complicated and uncomplicated cases. For patients deemed to have uncomplicated stress urinary incontinence (SUI) – especially those who have failed conservative management – we can comfortably recommend surgical repair without urodynamic testing.

Identifying uncomplicated SUI

The history is the most important part of the evaluation for incontinence. Every patient who answers “yes” to a basic opening question about whether she has any concerns about bladder control should be asked a series of questions that will enable the physician to fully understand her symptoms, their severity, and their impact on her life and daily activities.

It is critical to determine whether you are dealing with pure SUI, pure urge incontinence (UI), or SUI with a component of UI. Mixed incontinence is quite prevalent. An analysis of recent National Health and Nutrition Examination Survey (NHANES) data showed that of those women reporting incontinence symptoms, almost 50% reported pure SUI, and 34% reported mixed incontinence (J. Urol. 2008;179: 656-61). Other studies similarly have shown prevalence rates of mixed incontinence above 30%.

The International Urogynecological Association (IUGA) recommends the use of validated questionnaires to assess incontinence and the relative contribution of UI and SUI symptoms. Some physicians do find the organized and structured format of questionnaires helpful in their practices. Others have incorporated questions from various tools into history-taking templates on their electronic medical records. Still others have made them part of a mental checklist for history taking.

The short-form version of the Urogenital Distress Inventory (UDI-6), for instance, asks the patient whether she experiences – and how much she is bothered by – the following: frequent urination; leakage related to a feeling of urgency; leakage related to activity, coughing, or sneezing; small amount of leakage; difficulty emptying the bladder; and pain or discomfort in the lower abdominal or genital area.

The Incontinence Impact Questionnaire can be used to further assess the impact of symptoms. The short-form IIQ (the IIQ-7) asks, for instance, about the extent to which urine leakage has affected household chores, physical recreation, social activities, or emotional health.

Since the UDI and IIQ were developed about 20 years ago, at least several other urinary incontinence questionnaires have been developed and validated. Whether or not questionnaires are utilized as official tools, history taking should capture their essence and provide you with enough information to ascertain the type of incontinence, frequency of occurrence, severity, and effect on daily life.

The history also must assess the possibility of voiding dysfunction. Positive responses to questions about nocturia, hesitancy, and the need to immediately revoid, for instance, point toward complicated SUI and the need for further assessment before embarking on surgical treatment for SUI.

Patients who have uncomplicated SUI, on the other hand, will answer negatively to questions about symptoms of predominant urgency, functional impairment, continuous leakage, and/or incomplete emptying. They also will not have had recurrent urinary tract infections or medical conditions that can affect lower urinary tract function (such as neurologic disease and poorly controlled diabetes).

The physical exam

Along with the history, the physical exam is important for identifying complicated SUI and confirming which cases of SUI are truly uncomplicated. Evaluation should include a cough stress test to confirm leakage from the urethra under stress, an assessment of urethral mobility, and an assessment for pelvic organ prolapse.

The cough stress test is usually done with the patient in the supine or semirecumbent lithotomy position. If you strongly suspect stress incontinence but have a negative result, consider the following:

• Make sure the patient has a comfortably full bladder.

• Many women will contract their pelvic floor muscles when coughing to try to avoid leaking. You can apply pressure against the posterior vaginal wall either digitally or with half of the bivalve speculum to keep the patient from activating her muscles.

• The cough test can be performed in the standing position.

 

Assessing urethral mobility similarly involves simple observation while the patient is in a supine lithotomy position and straining. A Q-tip test or the Pelvic Organ Prolapse Quantification (POP-Q) system may be used, but visualization and palpation also are completely acceptable.

Just as the absence of urethral mobility is a red flag, so is prolapse beyond the hymen. This patient could potentially have urethral kinking, which can mask the severity of SUI or be a source of retention. Either finding the absence of urethral mobility or the presence of POP beyond the hymen moves the case from the uncomplicated to complicated category and signals the need for further evaluation with urodynamics or other tests.

These and other findings for uncomplicated versus complicated SUI are outlined in a committee opinion issued recently by the American College of Obstetricians and Gynecologists and the American Urogynecologic Society (Committee Opinion No. 603, Obstet .Gynecol. 2014;123:1403-7).

As the ACOG-AUGS recommendations point out, urinalysis is part of the minimum work-up for stress incontinence. Measurement of postvoid residual urine volume also becomes important when midurethral sling surgery is being contemplated for uncomplicated SUI. A normal volume rules out potential bladder-emptying abnormalities and provides final assurance that the patient is a good candidate for surgical repair.

Recent research on urodynamics

Evidence that a simple office-based incontinence evaluation without preoperative urodynamic testing is appropriate for uncomplicated predominant SUI comes largely from two recent randomized noninferiority trials.

One of these trials – a study from the Urinary Incontinence Treatment Network in the United States, known as the VALUE trial – randomized 630 women with uncomplicated SUI to pretreatment work-up with or without urodynamics. Treatment success at 12 months was similar for the two groups (approximately 77%).

This finding, the authors wrote, suggests that for women with uncomplicated SUI, a “basic office evaluation” (i.e., a positive provocative stress test, a normal postvoiding residual volume, an assessment or urethral mobility, and a negative urinalysis) is a “sufficient preoperative work-up” (N. Engl. J. Med. 2012;366:1987-97).

The diagnosis of SUI as made by office evaluation was confirmed in 97% of women who underwent urodynamic testing, and while there were some adjustments in diagnosis after urodynamics, there were no major changes in treatment decision making after the testing. Approximately 93% of women in both groups underwent midurethral sling surgery.

The second trial, a Dutch study, focused on women who had already undergone urodynamic testing and been shown to have discordant findings on urodynamics and their history and clinical exam. The women – all of whom had uncomplicated predominant SUI – were randomized to undergo immediate midurethral sling surgery or receive individually tailored treatment (including sling surgery, behavioral and physical therapy, pessary, and anticholinergics).

At 1 year, there was no clinically significant difference between the two groups in patients’ assessment of their symptoms as measured by the UDI. The authors concluded that “an immediate midurethral sling operation is not inferior to individually tailored treatment based on urodynamic findings” and that “urodynamics should no longer be advised routinely before primary surgery in these patients” (Obstet. Gynecol. 2013;121:999-1008).

When urge incontinence is involved

Urodynamic testing was never believed to be perfect, but these and other studies have highlighted its imperfections. Urodynamics creates an artificial condition in the bladder, in effect, and some of the findings will involve artifact. A systematic review of studies that compared diagnoses based on symptoms with diagnoses after urodynamic investigation was interesting in this regard; while the review did not assess impact on treatment, it showed that there is poor agreement between clinical symptoms and urodynamic-based diagnoses (Neurourol. Urodyn. 2011;30:495-502).

Certainly, women with complicated SUI – as well as women who have recurrent SUI after a prior surgical intervention – require further assessment, which likely includes multichannel urodynamic testing.

Urodynamics also can play a useful role in decision making and counseling for some patients whose incontinence is predominately SUI, but is believed to involve some degree of urinary urgency. Patients with mixed urinary incontinence fare worse after midurethral sling procedures compared with patients who have SUI alone, and I counsel my patients accordingly, emphasizing that the sling will not address aspects of their incontinence related to urgency. When I sense that a patient may have unreasonably high expectations for surgery, urodynamic testing can provide some perspective on possible postoperative outcomes.

Treatment for UI or overactive bladder often may be initiated after simple office-based evaluation, just as with SUI. The goal, similarly, is to discern relatively uncomplicated or straightforward cases from complicated ones. Urologic, medical, and neurologic histories should be obtained, for instance, and retention issues (which can aggravate UI) should be ruled out through the measurement of postvoid residual urine volume.

 

Just as with SUI, evaluation of suspected UI more often than not involves careful history taking and clinical probing. A voiding diary can sometimes be helpful; I send patients home with such a tool when the history is inconclusive or I suspect behavioral (excessive fluid intake) or functional issues as significant factors in bladder control.

It is important to keep in mind that patients with severe SUI may have urinary frequency as a learned response. Such patients appear to have overactive bladder in addition to SUI, but may actually be urinating frequently because they’ve learned that doing so results in less leakage. In our practice we’ve observed that patients with a learned response tend not to have nocturia, while those with overactive bladder do report nocturia.

Dr. Culbertson had no relevant financial disclosures.

Dr. Culbertson is a professor in the department of obstetrics and gynecology at the University of Chicago.

Ten years ago, urodynamics were widely viewed as the gold standard for evaluating urinary incontinence. We often turned to such testing to confirm or reject the findings of our basic evaluation before determining the best type of treatment – especially before proceeding with primary anti-incontinence surgery.

What has emerged in recent years is a body of evidence that tells us otherwise. We now know that urodynamics do not give us all the answers, and that we can be much more judicious with its use.

A good history followed by a thorough physical examination and some office tests often enables us to make sound treatment recommendations without costly and potentially uncomfortable urodynamic testing. The key lies in discerning complicated and uncomplicated cases. For patients deemed to have uncomplicated stress urinary incontinence (SUI) – especially those who have failed conservative management – we can comfortably recommend surgical repair without urodynamic testing.

Identifying uncomplicated SUI

The history is the most important part of the evaluation for incontinence. Every patient who answers “yes” to a basic opening question about whether she has any concerns about bladder control should be asked a series of questions that will enable the physician to fully understand her symptoms, their severity, and their impact on her life and daily activities.

It is critical to determine whether you are dealing with pure SUI, pure urge incontinence (UI), or SUI with a component of UI. Mixed incontinence is quite prevalent. An analysis of recent National Health and Nutrition Examination Survey (NHANES) data showed that of those women reporting incontinence symptoms, almost 50% reported pure SUI, and 34% reported mixed incontinence (J. Urol. 2008;179: 656-61). Other studies similarly have shown prevalence rates of mixed incontinence above 30%.

The International Urogynecological Association (IUGA) recommends the use of validated questionnaires to assess incontinence and the relative contribution of UI and SUI symptoms. Some physicians do find the organized and structured format of questionnaires helpful in their practices. Others have incorporated questions from various tools into history-taking templates on their electronic medical records. Still others have made them part of a mental checklist for history taking.

The short-form version of the Urogenital Distress Inventory (UDI-6), for instance, asks the patient whether she experiences – and how much she is bothered by – the following: frequent urination; leakage related to a feeling of urgency; leakage related to activity, coughing, or sneezing; small amount of leakage; difficulty emptying the bladder; and pain or discomfort in the lower abdominal or genital area.

The Incontinence Impact Questionnaire can be used to further assess the impact of symptoms. The short-form IIQ (the IIQ-7) asks, for instance, about the extent to which urine leakage has affected household chores, physical recreation, social activities, or emotional health.

Since the UDI and IIQ were developed about 20 years ago, at least several other urinary incontinence questionnaires have been developed and validated. Whether or not questionnaires are utilized as official tools, history taking should capture their essence and provide you with enough information to ascertain the type of incontinence, frequency of occurrence, severity, and effect on daily life.

The history also must assess the possibility of voiding dysfunction. Positive responses to questions about nocturia, hesitancy, and the need to immediately revoid, for instance, point toward complicated SUI and the need for further assessment before embarking on surgical treatment for SUI.

Patients who have uncomplicated SUI, on the other hand, will answer negatively to questions about symptoms of predominant urgency, functional impairment, continuous leakage, and/or incomplete emptying. They also will not have had recurrent urinary tract infections or medical conditions that can affect lower urinary tract function (such as neurologic disease and poorly controlled diabetes).

The physical exam

Along with the history, the physical exam is important for identifying complicated SUI and confirming which cases of SUI are truly uncomplicated. Evaluation should include a cough stress test to confirm leakage from the urethra under stress, an assessment of urethral mobility, and an assessment for pelvic organ prolapse.

The cough stress test is usually done with the patient in the supine or semirecumbent lithotomy position. If you strongly suspect stress incontinence but have a negative result, consider the following:

• Make sure the patient has a comfortably full bladder.

• Many women will contract their pelvic floor muscles when coughing to try to avoid leaking. You can apply pressure against the posterior vaginal wall either digitally or with half of the bivalve speculum to keep the patient from activating her muscles.

• The cough test can be performed in the standing position.

 

Assessing urethral mobility similarly involves simple observation while the patient is in a supine lithotomy position and straining. A Q-tip test or the Pelvic Organ Prolapse Quantification (POP-Q) system may be used, but visualization and palpation also are completely acceptable.

Just as the absence of urethral mobility is a red flag, so is prolapse beyond the hymen. This patient could potentially have urethral kinking, which can mask the severity of SUI or be a source of retention. Either finding the absence of urethral mobility or the presence of POP beyond the hymen moves the case from the uncomplicated to complicated category and signals the need for further evaluation with urodynamics or other tests.

These and other findings for uncomplicated versus complicated SUI are outlined in a committee opinion issued recently by the American College of Obstetricians and Gynecologists and the American Urogynecologic Society (Committee Opinion No. 603, Obstet .Gynecol. 2014;123:1403-7).

As the ACOG-AUGS recommendations point out, urinalysis is part of the minimum work-up for stress incontinence. Measurement of postvoid residual urine volume also becomes important when midurethral sling surgery is being contemplated for uncomplicated SUI. A normal volume rules out potential bladder-emptying abnormalities and provides final assurance that the patient is a good candidate for surgical repair.

Recent research on urodynamics

Evidence that a simple office-based incontinence evaluation without preoperative urodynamic testing is appropriate for uncomplicated predominant SUI comes largely from two recent randomized noninferiority trials.

One of these trials – a study from the Urinary Incontinence Treatment Network in the United States, known as the VALUE trial – randomized 630 women with uncomplicated SUI to pretreatment work-up with or without urodynamics. Treatment success at 12 months was similar for the two groups (approximately 77%).

This finding, the authors wrote, suggests that for women with uncomplicated SUI, a “basic office evaluation” (i.e., a positive provocative stress test, a normal postvoiding residual volume, an assessment or urethral mobility, and a negative urinalysis) is a “sufficient preoperative work-up” (N. Engl. J. Med. 2012;366:1987-97).

The diagnosis of SUI as made by office evaluation was confirmed in 97% of women who underwent urodynamic testing, and while there were some adjustments in diagnosis after urodynamics, there were no major changes in treatment decision making after the testing. Approximately 93% of women in both groups underwent midurethral sling surgery.

The second trial, a Dutch study, focused on women who had already undergone urodynamic testing and been shown to have discordant findings on urodynamics and their history and clinical exam. The women – all of whom had uncomplicated predominant SUI – were randomized to undergo immediate midurethral sling surgery or receive individually tailored treatment (including sling surgery, behavioral and physical therapy, pessary, and anticholinergics).

At 1 year, there was no clinically significant difference between the two groups in patients’ assessment of their symptoms as measured by the UDI. The authors concluded that “an immediate midurethral sling operation is not inferior to individually tailored treatment based on urodynamic findings” and that “urodynamics should no longer be advised routinely before primary surgery in these patients” (Obstet. Gynecol. 2013;121:999-1008).

When urge incontinence is involved

Urodynamic testing was never believed to be perfect, but these and other studies have highlighted its imperfections. Urodynamics creates an artificial condition in the bladder, in effect, and some of the findings will involve artifact. A systematic review of studies that compared diagnoses based on symptoms with diagnoses after urodynamic investigation was interesting in this regard; while the review did not assess impact on treatment, it showed that there is poor agreement between clinical symptoms and urodynamic-based diagnoses (Neurourol. Urodyn. 2011;30:495-502).

Certainly, women with complicated SUI – as well as women who have recurrent SUI after a prior surgical intervention – require further assessment, which likely includes multichannel urodynamic testing.

Urodynamics also can play a useful role in decision making and counseling for some patients whose incontinence is predominately SUI, but is believed to involve some degree of urinary urgency. Patients with mixed urinary incontinence fare worse after midurethral sling procedures compared with patients who have SUI alone, and I counsel my patients accordingly, emphasizing that the sling will not address aspects of their incontinence related to urgency. When I sense that a patient may have unreasonably high expectations for surgery, urodynamic testing can provide some perspective on possible postoperative outcomes.

Treatment for UI or overactive bladder often may be initiated after simple office-based evaluation, just as with SUI. The goal, similarly, is to discern relatively uncomplicated or straightforward cases from complicated ones. Urologic, medical, and neurologic histories should be obtained, for instance, and retention issues (which can aggravate UI) should be ruled out through the measurement of postvoid residual urine volume.

 

Just as with SUI, evaluation of suspected UI more often than not involves careful history taking and clinical probing. A voiding diary can sometimes be helpful; I send patients home with such a tool when the history is inconclusive or I suspect behavioral (excessive fluid intake) or functional issues as significant factors in bladder control.

It is important to keep in mind that patients with severe SUI may have urinary frequency as a learned response. Such patients appear to have overactive bladder in addition to SUI, but may actually be urinating frequently because they’ve learned that doing so results in less leakage. In our practice we’ve observed that patients with a learned response tend not to have nocturia, while those with overactive bladder do report nocturia.

Dr. Culbertson had no relevant financial disclosures.

Dr. Culbertson is a professor in the department of obstetrics and gynecology at the University of Chicago.

It is clear at this point that physicians are not friends of electronic health records (EHRs). The predominant sentiment is that EHRs are costly (1/3 of providers are buying their second EHR system) and are poorly functional. Much has been said about the failures of EHRs. The shortcomings discussed have ranged from lack of cost benefits to interoperability with medical devices and security of interoperability with medical devices. Decreasing provider productivity and direct patient interaction time are also of concern. These opinions were raised in a ‘Medical Economics’ survey as well as a study by Rand Corporation. Interestingly, physicians do not desire to return to paper records. I will discuss what I call “The Five Important ‘I’s” of EHRs.

1. EHRs are not INTUITIVE. Navigating an EHR is akin to guessing what is behind Door Number 2 of “Let’s Make a Deal.” Documentation does not follow a provider’s thought process or the interaction workflow. It is built to meet regulatory and billing requirements. Many physicians are required to learn and be facile with different EHRs if they go to different hospitals. The AMA has called for a design overhaul of EHRs.

2. EHRs are IMPOSING. Providers are spending an inordinate amount of time with the EHR and less with patients. Most providers do not receive adequate training time, which is inversely related to privacy and security breaches. EHRs are inflexible and progressive practices with ambitious patient quality initiatives cannot implement them because of IT issues.

3. EHRs have limited INTEROPERABILITY. At a recent session of the Office of the National Coordinator at the annual conference of the American Health Information Management Association, Chief Science Officer Doug Fridsma laid out an ambitious vision of what he calls the “Learning Healthcare System” which comprises the building blocks of health IT systems. This will result in improved interoperability by way of the system adapting to change with encounters.

4. EHRs need INSIGHTFUL analytics. Data without good analytics is almost useless. Clinical decision support tools make EHRs pertinent insomuch as they can incorporate accepted practice guidelines as well as customized “best practice” decision support. These follow provider workflows and make the tool more intuitive. Add to this proscribing analytics that actually recommend (not prescribe) tests or treatment plans, and one ends up with a physician’s friend.

5. EHRs must INCLUDE robust portals. Robust patient portals will be critical in creating a true patient-centric health care system. Most portals used today are proprietary to the customer’s EHR vendor because of its low cost. There are some excellent third-party portals that have the ability to corral data from different providers who might have different EHR vendors. In addition, they are places to communicate multimedia content including video consultations.

While this list is not inclusive of all issues regarding EHRs, it serves as a focal point for discussion by clinicians about them. A 6th ‘I’ might be ‘IMMOBILE.’ A physician running back and forth to computer stations from patient beds creates self-evident inefficiencies. Presently available (not offered by most all vendors) mobile versions of EHRs have their own drawbacks. The small screen on a smartphone is a severe limitation, though many physicians do use tablets. That being said, in a 2013 cited survey by Black Book, only 8% of physician responders used the mobile EHR for purposes of ePrescribing, accessing records, ordering tests, or viewing results. As a champion of digital health technologies, I can only be frustrated about the vision I and many others have for their use. However, as with most technologies (and few have been as disruptive as EHRs) adoption in health care is slow. I look forward to leaders like Doug Fridsma and organizations like HIMSS, which has excellent representation by clinicians to help bring about necessary changes.

It is clear at this point that physicians are not friends of electronic health records (EHRs). The predominant sentiment is that EHRs are costly (1/3 of providers are buying their second EHR system) and are poorly functional. Much has been said about the failures of EHRs. The shortcomings discussed have ranged from lack of cost benefits to interoperability with medical devices and security of interoperability with medical devices. Decreasing provider productivity and direct patient interaction time are also of concern. These opinions were raised in a ‘Medical Economics’ survey as well as a study by Rand Corporation. Interestingly, physicians do not desire to return to paper records. I will discuss what I call “The Five Important ‘I’s” of EHRs.

1. EHRs are not INTUITIVE. Navigating an EHR is akin to guessing what is behind Door Number 2 of “Let’s Make a Deal.” Documentation does not follow a provider’s thought process or the interaction workflow. It is built to meet regulatory and billing requirements. Many physicians are required to learn and be facile with different EHRs if they go to different hospitals. The AMA has called for a design overhaul of EHRs.

2. EHRs are IMPOSING. Providers are spending an inordinate amount of time with the EHR and less with patients. Most providers do not receive adequate training time, which is inversely related to privacy and security breaches. EHRs are inflexible and progressive practices with ambitious patient quality initiatives cannot implement them because of IT issues.

3. EHRs have limited INTEROPERABILITY. At a recent session of the Office of the National Coordinator at the annual conference of the American Health Information Management Association, Chief Science Officer Doug Fridsma laid out an ambitious vision of what he calls the “Learning Healthcare System” which comprises the building blocks of health IT systems. This will result in improved interoperability by way of the system adapting to change with encounters.

4. EHRs need INSIGHTFUL analytics. Data without good analytics is almost useless. Clinical decision support tools make EHRs pertinent insomuch as they can incorporate accepted practice guidelines as well as customized “best practice” decision support. These follow provider workflows and make the tool more intuitive. Add to this proscribing analytics that actually recommend (not prescribe) tests or treatment plans, and one ends up with a physician’s friend.

5. EHRs must INCLUDE robust portals. Robust patient portals will be critical in creating a true patient-centric health care system. Most portals used today are proprietary to the customer’s EHR vendor because of its low cost. There are some excellent third-party portals that have the ability to corral data from different providers who might have different EHR vendors. In addition, they are places to communicate multimedia content including video consultations.

While this list is not inclusive of all issues regarding EHRs, it serves as a focal point for discussion by clinicians about them. A 6th ‘I’ might be ‘IMMOBILE.’ A physician running back and forth to computer stations from patient beds creates self-evident inefficiencies. Presently available (not offered by most all vendors) mobile versions of EHRs have their own drawbacks. The small screen on a smartphone is a severe limitation, though many physicians do use tablets. That being said, in a 2013 cited survey by Black Book, only 8% of physician responders used the mobile EHR for purposes of ePrescribing, accessing records, ordering tests, or viewing results. As a champion of digital health technologies, I can only be frustrated about the vision I and many others have for their use. However, as with most technologies (and few have been as disruptive as EHRs) adoption in health care is slow. I look forward to leaders like Doug Fridsma and organizations like HIMSS, which has excellent representation by clinicians to help bring about necessary changes.

It is clear at this point that physicians are not friends of electronic health records (EHRs). The predominant sentiment is that EHRs are costly (1/3 of providers are buying their second EHR system) and are poorly functional. Much has been said about the failures of EHRs. The shortcomings discussed have ranged from lack of cost benefits to interoperability with medical devices and security of interoperability with medical devices. Decreasing provider productivity and direct patient interaction time are also of concern. These opinions were raised in a ‘Medical Economics’ survey as well as a study by Rand Corporation. Interestingly, physicians do not desire to return to paper records. I will discuss what I call “The Five Important ‘I’s” of EHRs.

1. EHRs are not INTUITIVE. Navigating an EHR is akin to guessing what is behind Door Number 2 of “Let’s Make a Deal.” Documentation does not follow a provider’s thought process or the interaction workflow. It is built to meet regulatory and billing requirements. Many physicians are required to learn and be facile with different EHRs if they go to different hospitals. The AMA has called for a design overhaul of EHRs.

2. EHRs are IMPOSING. Providers are spending an inordinate amount of time with the EHR and less with patients. Most providers do not receive adequate training time, which is inversely related to privacy and security breaches. EHRs are inflexible and progressive practices with ambitious patient quality initiatives cannot implement them because of IT issues.

3. EHRs have limited INTEROPERABILITY. At a recent session of the Office of the National Coordinator at the annual conference of the American Health Information Management Association, Chief Science Officer Doug Fridsma laid out an ambitious vision of what he calls the “Learning Healthcare System” which comprises the building blocks of health IT systems. This will result in improved interoperability by way of the system adapting to change with encounters.

4. EHRs need INSIGHTFUL analytics. Data without good analytics is almost useless. Clinical decision support tools make EHRs pertinent insomuch as they can incorporate accepted practice guidelines as well as customized “best practice” decision support. These follow provider workflows and make the tool more intuitive. Add to this proscribing analytics that actually recommend (not prescribe) tests or treatment plans, and one ends up with a physician’s friend.

5. EHRs must INCLUDE robust portals. Robust patient portals will be critical in creating a true patient-centric health care system. Most portals used today are proprietary to the customer’s EHR vendor because of its low cost. There are some excellent third-party portals that have the ability to corral data from different providers who might have different EHR vendors. In addition, they are places to communicate multimedia content including video consultations.

While this list is not inclusive of all issues regarding EHRs, it serves as a focal point for discussion by clinicians about them. A 6th ‘I’ might be ‘IMMOBILE.’ A physician running back and forth to computer stations from patient beds creates self-evident inefficiencies. Presently available (not offered by most all vendors) mobile versions of EHRs have their own drawbacks. The small screen on a smartphone is a severe limitation, though many physicians do use tablets. That being said, in a 2013 cited survey by Black Book, only 8% of physician responders used the mobile EHR for purposes of ePrescribing, accessing records, ordering tests, or viewing results. As a champion of digital health technologies, I can only be frustrated about the vision I and many others have for their use. However, as with most technologies (and few have been as disruptive as EHRs) adoption in health care is slow. I look forward to leaders like Doug Fridsma and organizations like HIMSS, which has excellent representation by clinicians to help bring about necessary changes.

As Chief of Family Medicine at our hospital, I have been spending a lot of time reviewing visit notes. The Joint Commission requires Ongoing Professional Performance Evaluations (OPPEs), which for family physicians includes quality of documentation of office visit notes. Judging quality, beyond the presence or absence of the usual suspects—history of present illness; pertinent medical, family, and social histories; physical exam; meds; problem list; assessment; and plan—is difficult because there are no standard, objective criteria. After reviewing many charts from several organizations, however, I’m concerned that 3 important elements of documentation are getting short shrift in our increasingly computerized and regulated environment: the history of present illness, the assessment, and the plan.

I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone. Clicking on a checklist of symptoms seldom provides sufficient information about the patient’s illness. “Hypertension” and “type 2 diabetes” are not assessments; they are diagnoses that do not tell the person reading the electronic health record (EHR) how the patient is doing. A diagnosis of “abdominal pain” without a prioritized differential is inadequate, especially in court.

Why is visit documentation too often inadequate? I am convinced it is rarely due to clinician incompetence, laziness, or lack of knowledge, but nearly always due to a combination of inadequate EHR formats and billing documentation requirements that encourage quantity rather than quality. Documentation is no longer driven by the essential need to record the care provided.

I’m sure a lot of you are nodding your heads in agreement. You all know what those EHR notes look like—cluttered with cut-and-pasted information drawn from prior encounters that document no end of details regarding medical, family, and social histories, facts that are often completely irrelevant to the reason the patient is in the office today. And unless one meticulously updates those other elements of the patient’s record, this information pulled into the note may be inaccurate.

I am not the only one complaining. The American Medical Association just published Improving Care: Priorities to Improve Electronic Health Record Usability,¹ which outlines 8 priorities for EHR improvement. The first is to “Enhance physicians’ ability to provide high-quality patient care.” I could not agree more. I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone.

Something has got to change.

So tell me: Have any of you figured out how to use your EHR to enhance the quality of your documentation?

As Chief of Family Medicine at our hospital, I have been spending a lot of time reviewing visit notes. The Joint Commission requires Ongoing Professional Performance Evaluations (OPPEs), which for family physicians includes quality of documentation of office visit notes. Judging quality, beyond the presence or absence of the usual suspects—history of present illness; pertinent medical, family, and social histories; physical exam; meds; problem list; assessment; and plan—is difficult because there are no standard, objective criteria. After reviewing many charts from several organizations, however, I’m concerned that 3 important elements of documentation are getting short shrift in our increasingly computerized and regulated environment: the history of present illness, the assessment, and the plan.

I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone. Clicking on a checklist of symptoms seldom provides sufficient information about the patient’s illness. “Hypertension” and “type 2 diabetes” are not assessments; they are diagnoses that do not tell the person reading the electronic health record (EHR) how the patient is doing. A diagnosis of “abdominal pain” without a prioritized differential is inadequate, especially in court.

Why is visit documentation too often inadequate? I am convinced it is rarely due to clinician incompetence, laziness, or lack of knowledge, but nearly always due to a combination of inadequate EHR formats and billing documentation requirements that encourage quantity rather than quality. Documentation is no longer driven by the essential need to record the care provided.

I’m sure a lot of you are nodding your heads in agreement. You all know what those EHR notes look like—cluttered with cut-and-pasted information drawn from prior encounters that document no end of details regarding medical, family, and social histories, facts that are often completely irrelevant to the reason the patient is in the office today. And unless one meticulously updates those other elements of the patient’s record, this information pulled into the note may be inaccurate.

I am not the only one complaining. The American Medical Association just published Improving Care: Priorities to Improve Electronic Health Record Usability,¹ which outlines 8 priorities for EHR improvement. The first is to “Enhance physicians’ ability to provide high-quality patient care.” I could not agree more. I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone.

Something has got to change.

So tell me: Have any of you figured out how to use your EHR to enhance the quality of your documentation?

As Chief of Family Medicine at our hospital, I have been spending a lot of time reviewing visit notes. The Joint Commission requires Ongoing Professional Performance Evaluations (OPPEs), which for family physicians includes quality of documentation of office visit notes. Judging quality, beyond the presence or absence of the usual suspects—history of present illness; pertinent medical, family, and social histories; physical exam; meds; problem list; assessment; and plan—is difficult because there are no standard, objective criteria. After reviewing many charts from several organizations, however, I’m concerned that 3 important elements of documentation are getting short shrift in our increasingly computerized and regulated environment: the history of present illness, the assessment, and the plan.

I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone. Clicking on a checklist of symptoms seldom provides sufficient information about the patient’s illness. “Hypertension” and “type 2 diabetes” are not assessments; they are diagnoses that do not tell the person reading the electronic health record (EHR) how the patient is doing. A diagnosis of “abdominal pain” without a prioritized differential is inadequate, especially in court.

Why is visit documentation too often inadequate? I am convinced it is rarely due to clinician incompetence, laziness, or lack of knowledge, but nearly always due to a combination of inadequate EHR formats and billing documentation requirements that encourage quantity rather than quality. Documentation is no longer driven by the essential need to record the care provided.

I’m sure a lot of you are nodding your heads in agreement. You all know what those EHR notes look like—cluttered with cut-and-pasted information drawn from prior encounters that document no end of details regarding medical, family, and social histories, facts that are often completely irrelevant to the reason the patient is in the office today. And unless one meticulously updates those other elements of the patient’s record, this information pulled into the note may be inaccurate.

I am not the only one complaining. The American Medical Association just published Improving Care: Priorities to Improve Electronic Health Record Usability,¹ which outlines 8 priorities for EHR improvement. The first is to “Enhance physicians’ ability to provide high-quality patient care.” I could not agree more. I think today’s EHRs are like an old-fashioned crank phone and what we really need is an iPhone.

Something has got to change.

So tell me: Have any of you figured out how to use your EHR to enhance the quality of your documentation?

I recently attended the International Interscience Conference of Infectious Diseases and Vaccines, and I would like to share some of the presentations from the session entitled “Hot Topics in Vaccines.”

CNS complications of varicella-zoster virus infection

Dr. Michelle Science of the Hospital for Sick Children, Toronto, and her associates described the spectrum of CNS complications of varicella-zoster virus (VZV) in children admitted to the hospital during 1999-2012 (J. Pediatr. 2014;165:779-85). Clinical syndromes included 26 cases of acute cerebellar ataxia, 17 of encephalitis, 16 isolated seizures, 10 strokes, 10 cases of meningitis, 2 cases of Guillain-Barré syndrome, 2 cases of acute disseminated encephalomyelitis, and 1 case of Ramsay Hunt syndrome. In children with acute nonstroke complications, neurologic symptoms occurred a median 5 days after the onset of rash, but neurologic symptoms predated the onset of rash in five cases and in two cases there were no exanthems. Time between rash onset and stroke ranged from 2 to 26 weeks (median 16 weeks). There were three deaths among the 17 (18%) children with encephalitis. Among the 39 children with follow-up at 1 year, residual neurologic sequelae occurred in 9 (23%). Only four of the children had received a VZV vaccine. Although an effective vaccine exists, neurologic complications of VZV infection continue to occur.

Timely versus delayed early childhood vaccination and seizures

Dr. Simon J. Hambidge of Denver Health, Colorado, and his associates studied a cohort of 323,247 U.S. children from the Vaccine Safety Datalink born during 2004-2008 for an association between the timing of childhood vaccination and the first occurrence of seizures (Pediatrics 2014;133(6):e1492-9). In the first year, there was no association between the timing of infant vaccination and postvaccination seizures. In the second year, the incidence rate ratio for seizures after receiving the first MMR dose at 12-15 months was 2.7, compared with a rate of 6.5 after an MMR dose at 16-23 months; thus there were more seizures when MMR was delayed. The incidence rate ratio for seizures after receiving the first measles-mumps-rubella-varicella vaccine (MMRV) dose at 12-15 months was 4.95, compared with 9.80 after an MMRV dose at 16-23 months. Again, there were more seizures when MMRV was delayed. These findings suggest that on-time vaccination is as safe with regard to seizures as delayed vaccination in year 1, and that delayed vaccination in year 2 is linked to more postvaccination seizures than on-time vaccination with MMR and that risk is doubled with MMRV.

Effective messages in vaccine promotion: a randomized trial

Brendan Nyhan, Ph.D., of Dartmouth College, Hanover, N.H., and his associates tested the efficacy of various informational messages tailored to reduce misperceptions about vaccines and increase MMR vaccination rates (Pediatrics 2014;133:e835-42). Nearly 1,800 parents were randomly assigned to receive one of four interventions: information explaining the lack of evidence that MMR causes autism from the Centers for Disease Control and Prevention; information about the danger of the diseases prevented by MMR from the Vaccine Information Statement; photos of children with diseases prevented by the MMR vaccine; a dramatic narrative about an infant who almost died of measles from a CDC fact sheet. In addition there was a control group. None of the four interventions increased parents’ intention to vaccinate another child if they had one in the future. Although refuting claims of an MMR/autism link did reduce misperceptions that vaccines cause autism, it decreased intent to vaccinate among parents who had the least favorable attitudes toward vaccines. Also, photos of sick children increased belief in an association between vaccines and autism, and the dramatic narrative about an infant in danger increased belief in serious vaccine side effects. Attempts to rectify misperceptions about vaccines may be counterproductive in some populations, so public health communications about vaccines should be tested before being widely disseminated.

Silent reintroduction of wild-type poliovirus to Israel, 2013

Dr. E. Kaliner of the Israeli Ministry of Health, Jerusalem, and associates, reported that Israel has been certified as polio-free by the World Health Organization for decades and its routine immunization schedule, like the United States, consists of inactivated poliovirus vaccine only (Euro. Surveill. 2014;19:20703). At the end of May 2013, the Israeli Ministry of Health confirmed the reintroduction of wild-type poliovirus 1 into the country. Documented ongoing human-to-human transmission required a thorough risk assessment followed by a supplemental immunization campaign using oral polio vaccine.

Trends in otitis media–related health care use in the United States, 2001-2011

Dr. Tal Marom of the University of Texas, Galveston, and associates studied the trend in otitis media–related health care use in the United States during the pneumococcal conjugate vaccine (PCV) era in 2001-2011 (JAMA Pediatr. 2014;168:68-75). An analysis of an insurance claims database of a large, nationwide managed health care plan was conducted; 7.82 million children aged 6 years and under had 6.21 million primary otitis media (OM) visits. There was an overall downward trend in OM-related health care use across the 10-year study. Recurrent OM rates (defined as greater than or equal to three OM visits within 6 months) decreased at 0.003 per child-year in 2001-2009 and at 0.018 per child-year in 2010-2011. Prior to the pneumococcal conjugate vaccine (PCV-13), there was a stable rate ratio of 1.38 between OM visit rates. During the transition year 2010, the RR decreased significantly to 1.32, and in 2011 the RR decreased further to 1.01. Mastoiditis rates significantly decreased from 61 per 100,000 child-years in 2008 to 37 per 100,000 child-years in 2011. The ventilating tube insertion rate decreased by 19% from 2010 to 2011. Tympanic membrane perforation/otorrhea rates increased gradually and significantly from 3,721 per 100,000 OM child-years in 2001 to 4,542 per 100,000 OM child-years in 2011; the reasons for this are unclear.

 

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].

I recently attended the International Interscience Conference of Infectious Diseases and Vaccines, and I would like to share some of the presentations from the session entitled “Hot Topics in Vaccines.”

CNS complications of varicella-zoster virus infection

Dr. Michelle Science of the Hospital for Sick Children, Toronto, and her associates described the spectrum of CNS complications of varicella-zoster virus (VZV) in children admitted to the hospital during 1999-2012 (J. Pediatr. 2014;165:779-85). Clinical syndromes included 26 cases of acute cerebellar ataxia, 17 of encephalitis, 16 isolated seizures, 10 strokes, 10 cases of meningitis, 2 cases of Guillain-Barré syndrome, 2 cases of acute disseminated encephalomyelitis, and 1 case of Ramsay Hunt syndrome. In children with acute nonstroke complications, neurologic symptoms occurred a median 5 days after the onset of rash, but neurologic symptoms predated the onset of rash in five cases and in two cases there were no exanthems. Time between rash onset and stroke ranged from 2 to 26 weeks (median 16 weeks). There were three deaths among the 17 (18%) children with encephalitis. Among the 39 children with follow-up at 1 year, residual neurologic sequelae occurred in 9 (23%). Only four of the children had received a VZV vaccine. Although an effective vaccine exists, neurologic complications of VZV infection continue to occur.

Timely versus delayed early childhood vaccination and seizures

Dr. Simon J. Hambidge of Denver Health, Colorado, and his associates studied a cohort of 323,247 U.S. children from the Vaccine Safety Datalink born during 2004-2008 for an association between the timing of childhood vaccination and the first occurrence of seizures (Pediatrics 2014;133(6):e1492-9). In the first year, there was no association between the timing of infant vaccination and postvaccination seizures. In the second year, the incidence rate ratio for seizures after receiving the first MMR dose at 12-15 months was 2.7, compared with a rate of 6.5 after an MMR dose at 16-23 months; thus there were more seizures when MMR was delayed. The incidence rate ratio for seizures after receiving the first measles-mumps-rubella-varicella vaccine (MMRV) dose at 12-15 months was 4.95, compared with 9.80 after an MMRV dose at 16-23 months. Again, there were more seizures when MMRV was delayed. These findings suggest that on-time vaccination is as safe with regard to seizures as delayed vaccination in year 1, and that delayed vaccination in year 2 is linked to more postvaccination seizures than on-time vaccination with MMR and that risk is doubled with MMRV.

Effective messages in vaccine promotion: a randomized trial

Brendan Nyhan, Ph.D., of Dartmouth College, Hanover, N.H., and his associates tested the efficacy of various informational messages tailored to reduce misperceptions about vaccines and increase MMR vaccination rates (Pediatrics 2014;133:e835-42). Nearly 1,800 parents were randomly assigned to receive one of four interventions: information explaining the lack of evidence that MMR causes autism from the Centers for Disease Control and Prevention; information about the danger of the diseases prevented by MMR from the Vaccine Information Statement; photos of children with diseases prevented by the MMR vaccine; a dramatic narrative about an infant who almost died of measles from a CDC fact sheet. In addition there was a control group. None of the four interventions increased parents’ intention to vaccinate another child if they had one in the future. Although refuting claims of an MMR/autism link did reduce misperceptions that vaccines cause autism, it decreased intent to vaccinate among parents who had the least favorable attitudes toward vaccines. Also, photos of sick children increased belief in an association between vaccines and autism, and the dramatic narrative about an infant in danger increased belief in serious vaccine side effects. Attempts to rectify misperceptions about vaccines may be counterproductive in some populations, so public health communications about vaccines should be tested before being widely disseminated.

Silent reintroduction of wild-type poliovirus to Israel, 2013

Dr. E. Kaliner of the Israeli Ministry of Health, Jerusalem, and associates, reported that Israel has been certified as polio-free by the World Health Organization for decades and its routine immunization schedule, like the United States, consists of inactivated poliovirus vaccine only (Euro. Surveill. 2014;19:20703). At the end of May 2013, the Israeli Ministry of Health confirmed the reintroduction of wild-type poliovirus 1 into the country. Documented ongoing human-to-human transmission required a thorough risk assessment followed by a supplemental immunization campaign using oral polio vaccine.

Trends in otitis media–related health care use in the United States, 2001-2011

Dr. Tal Marom of the University of Texas, Galveston, and associates studied the trend in otitis media–related health care use in the United States during the pneumococcal conjugate vaccine (PCV) era in 2001-2011 (JAMA Pediatr. 2014;168:68-75). An analysis of an insurance claims database of a large, nationwide managed health care plan was conducted; 7.82 million children aged 6 years and under had 6.21 million primary otitis media (OM) visits. There was an overall downward trend in OM-related health care use across the 10-year study. Recurrent OM rates (defined as greater than or equal to three OM visits within 6 months) decreased at 0.003 per child-year in 2001-2009 and at 0.018 per child-year in 2010-2011. Prior to the pneumococcal conjugate vaccine (PCV-13), there was a stable rate ratio of 1.38 between OM visit rates. During the transition year 2010, the RR decreased significantly to 1.32, and in 2011 the RR decreased further to 1.01. Mastoiditis rates significantly decreased from 61 per 100,000 child-years in 2008 to 37 per 100,000 child-years in 2011. The ventilating tube insertion rate decreased by 19% from 2010 to 2011. Tympanic membrane perforation/otorrhea rates increased gradually and significantly from 3,721 per 100,000 OM child-years in 2001 to 4,542 per 100,000 OM child-years in 2011; the reasons for this are unclear.

 

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].

I recently attended the International Interscience Conference of Infectious Diseases and Vaccines, and I would like to share some of the presentations from the session entitled “Hot Topics in Vaccines.”

CNS complications of varicella-zoster virus infection

Dr. Michelle Science of the Hospital for Sick Children, Toronto, and her associates described the spectrum of CNS complications of varicella-zoster virus (VZV) in children admitted to the hospital during 1999-2012 (J. Pediatr. 2014;165:779-85). Clinical syndromes included 26 cases of acute cerebellar ataxia, 17 of encephalitis, 16 isolated seizures, 10 strokes, 10 cases of meningitis, 2 cases of Guillain-Barré syndrome, 2 cases of acute disseminated encephalomyelitis, and 1 case of Ramsay Hunt syndrome. In children with acute nonstroke complications, neurologic symptoms occurred a median 5 days after the onset of rash, but neurologic symptoms predated the onset of rash in five cases and in two cases there were no exanthems. Time between rash onset and stroke ranged from 2 to 26 weeks (median 16 weeks). There were three deaths among the 17 (18%) children with encephalitis. Among the 39 children with follow-up at 1 year, residual neurologic sequelae occurred in 9 (23%). Only four of the children had received a VZV vaccine. Although an effective vaccine exists, neurologic complications of VZV infection continue to occur.

Timely versus delayed early childhood vaccination and seizures

Dr. Simon J. Hambidge of Denver Health, Colorado, and his associates studied a cohort of 323,247 U.S. children from the Vaccine Safety Datalink born during 2004-2008 for an association between the timing of childhood vaccination and the first occurrence of seizures (Pediatrics 2014;133(6):e1492-9). In the first year, there was no association between the timing of infant vaccination and postvaccination seizures. In the second year, the incidence rate ratio for seizures after receiving the first MMR dose at 12-15 months was 2.7, compared with a rate of 6.5 after an MMR dose at 16-23 months; thus there were more seizures when MMR was delayed. The incidence rate ratio for seizures after receiving the first measles-mumps-rubella-varicella vaccine (MMRV) dose at 12-15 months was 4.95, compared with 9.80 after an MMRV dose at 16-23 months. Again, there were more seizures when MMRV was delayed. These findings suggest that on-time vaccination is as safe with regard to seizures as delayed vaccination in year 1, and that delayed vaccination in year 2 is linked to more postvaccination seizures than on-time vaccination with MMR and that risk is doubled with MMRV.

Effective messages in vaccine promotion: a randomized trial

Brendan Nyhan, Ph.D., of Dartmouth College, Hanover, N.H., and his associates tested the efficacy of various informational messages tailored to reduce misperceptions about vaccines and increase MMR vaccination rates (Pediatrics 2014;133:e835-42). Nearly 1,800 parents were randomly assigned to receive one of four interventions: information explaining the lack of evidence that MMR causes autism from the Centers for Disease Control and Prevention; information about the danger of the diseases prevented by MMR from the Vaccine Information Statement; photos of children with diseases prevented by the MMR vaccine; a dramatic narrative about an infant who almost died of measles from a CDC fact sheet. In addition there was a control group. None of the four interventions increased parents’ intention to vaccinate another child if they had one in the future. Although refuting claims of an MMR/autism link did reduce misperceptions that vaccines cause autism, it decreased intent to vaccinate among parents who had the least favorable attitudes toward vaccines. Also, photos of sick children increased belief in an association between vaccines and autism, and the dramatic narrative about an infant in danger increased belief in serious vaccine side effects. Attempts to rectify misperceptions about vaccines may be counterproductive in some populations, so public health communications about vaccines should be tested before being widely disseminated.

Silent reintroduction of wild-type poliovirus to Israel, 2013

Dr. E. Kaliner of the Israeli Ministry of Health, Jerusalem, and associates, reported that Israel has been certified as polio-free by the World Health Organization for decades and its routine immunization schedule, like the United States, consists of inactivated poliovirus vaccine only (Euro. Surveill. 2014;19:20703). At the end of May 2013, the Israeli Ministry of Health confirmed the reintroduction of wild-type poliovirus 1 into the country. Documented ongoing human-to-human transmission required a thorough risk assessment followed by a supplemental immunization campaign using oral polio vaccine.

Trends in otitis media–related health care use in the United States, 2001-2011

Dr. Tal Marom of the University of Texas, Galveston, and associates studied the trend in otitis media–related health care use in the United States during the pneumococcal conjugate vaccine (PCV) era in 2001-2011 (JAMA Pediatr. 2014;168:68-75). An analysis of an insurance claims database of a large, nationwide managed health care plan was conducted; 7.82 million children aged 6 years and under had 6.21 million primary otitis media (OM) visits. There was an overall downward trend in OM-related health care use across the 10-year study. Recurrent OM rates (defined as greater than or equal to three OM visits within 6 months) decreased at 0.003 per child-year in 2001-2009 and at 0.018 per child-year in 2010-2011. Prior to the pneumococcal conjugate vaccine (PCV-13), there was a stable rate ratio of 1.38 between OM visit rates. During the transition year 2010, the RR decreased significantly to 1.32, and in 2011 the RR decreased further to 1.01. Mastoiditis rates significantly decreased from 61 per 100,000 child-years in 2008 to 37 per 100,000 child-years in 2011. The ventilating tube insertion rate decreased by 19% from 2010 to 2011. Tympanic membrane perforation/otorrhea rates increased gradually and significantly from 3,721 per 100,000 OM child-years in 2001 to 4,542 per 100,000 OM child-years in 2011; the reasons for this are unclear.

 

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].

In a casual conversation I was having with a marriage counselor, he mentioned that a growing number of young couples are struggling with impotence. The main cause is watching too much pornography.

Now, it is no surprise that adolescents would watch pornography. Since the dawn of time young men have been seeking arousal from pornographic images. With the advent of the Internet, the availability and variety of images is endless. Teens are able to access pornography on their phones, tablets, computers, and cable. It’s next to impossible for parents to block all access because every adolescent has one form of technology or another; if he doesn’t have access at home, it surely can be seen at a friend’s house.

The physiologic effect of pornography is an excessive release of dopamine that binds to dopamine receptors and causes a maximal state of arousal. These receptors over time become less and less sensitive, so when these young men engage in intercourse, the stimulation is much less, and they are unable to have an erection. Many men do not make the connection between the pornography and their erectile dysfunction, so they may go years without seeking help.

There is a growing trend among younger men to use Viagra and Cialis, according to statistics (Int. J. Impot. Res. 2004;16:313-8). Most are using them for sexual enhancement, but others are seeking them for performance anxiety which may be related to their dysfunction associated with pornography. The problem is, pornography-induced erectile dysfunction is not an issue of blood flow, so these drugs are not helpful in most cases. Since the issue is the sensitivity of the dopamine receptors, the only treatment is to reduce or stop watching pornography, thus allowing the dopamine receptors to become more sensitive.

Now, as a physician, this clearly is an awkward topic to bring up during a routine health physical. But if left unsaid, this behavior could clearly lead to years of dysfunction. What I have found to be a simple solution to the “not so popular topics” is to present a handout with a topic simply stated and easy to read. This allows you to give patients the information without the embarrassment. The purpose is just to identify what is normal and what is not so normal so a patient knows to seek help if the problem occurs. Quick fixes also should be listed if known, especially if the quick fix is just to stop the behavior.

Other topics – such as bacterial vaginosis, the morning after pill, acne, and gynecomastia – can be addressed similarly because teens don’t know what they don’t know, so they may not even consider asking. Many women don’t realize that bacterial vaginosis requires a prescription medication and so may remain symptomatic for long periods of time.

Education is key. As pediatricians, arming our patients with knowledge allows them to at least ask the appropriate questions, which hopefully will get them the right answer.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

In a casual conversation I was having with a marriage counselor, he mentioned that a growing number of young couples are struggling with impotence. The main cause is watching too much pornography.

Now, it is no surprise that adolescents would watch pornography. Since the dawn of time young men have been seeking arousal from pornographic images. With the advent of the Internet, the availability and variety of images is endless. Teens are able to access pornography on their phones, tablets, computers, and cable. It’s next to impossible for parents to block all access because every adolescent has one form of technology or another; if he doesn’t have access at home, it surely can be seen at a friend’s house.

The physiologic effect of pornography is an excessive release of dopamine that binds to dopamine receptors and causes a maximal state of arousal. These receptors over time become less and less sensitive, so when these young men engage in intercourse, the stimulation is much less, and they are unable to have an erection. Many men do not make the connection between the pornography and their erectile dysfunction, so they may go years without seeking help.

There is a growing trend among younger men to use Viagra and Cialis, according to statistics (Int. J. Impot. Res. 2004;16:313-8). Most are using them for sexual enhancement, but others are seeking them for performance anxiety which may be related to their dysfunction associated with pornography. The problem is, pornography-induced erectile dysfunction is not an issue of blood flow, so these drugs are not helpful in most cases. Since the issue is the sensitivity of the dopamine receptors, the only treatment is to reduce or stop watching pornography, thus allowing the dopamine receptors to become more sensitive.

Now, as a physician, this clearly is an awkward topic to bring up during a routine health physical. But if left unsaid, this behavior could clearly lead to years of dysfunction. What I have found to be a simple solution to the “not so popular topics” is to present a handout with a topic simply stated and easy to read. This allows you to give patients the information without the embarrassment. The purpose is just to identify what is normal and what is not so normal so a patient knows to seek help if the problem occurs. Quick fixes also should be listed if known, especially if the quick fix is just to stop the behavior.

Other topics – such as bacterial vaginosis, the morning after pill, acne, and gynecomastia – can be addressed similarly because teens don’t know what they don’t know, so they may not even consider asking. Many women don’t realize that bacterial vaginosis requires a prescription medication and so may remain symptomatic for long periods of time.

Education is key. As pediatricians, arming our patients with knowledge allows them to at least ask the appropriate questions, which hopefully will get them the right answer.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].

In a casual conversation I was having with a marriage counselor, he mentioned that a growing number of young couples are struggling with impotence. The main cause is watching too much pornography.

Now, it is no surprise that adolescents would watch pornography. Since the dawn of time young men have been seeking arousal from pornographic images. With the advent of the Internet, the availability and variety of images is endless. Teens are able to access pornography on their phones, tablets, computers, and cable. It’s next to impossible for parents to block all access because every adolescent has one form of technology or another; if he doesn’t have access at home, it surely can be seen at a friend’s house.

The physiologic effect of pornography is an excessive release of dopamine that binds to dopamine receptors and causes a maximal state of arousal. These receptors over time become less and less sensitive, so when these young men engage in intercourse, the stimulation is much less, and they are unable to have an erection. Many men do not make the connection between the pornography and their erectile dysfunction, so they may go years without seeking help.

There is a growing trend among younger men to use Viagra and Cialis, according to statistics (Int. J. Impot. Res. 2004;16:313-8). Most are using them for sexual enhancement, but others are seeking them for performance anxiety which may be related to their dysfunction associated with pornography. The problem is, pornography-induced erectile dysfunction is not an issue of blood flow, so these drugs are not helpful in most cases. Since the issue is the sensitivity of the dopamine receptors, the only treatment is to reduce or stop watching pornography, thus allowing the dopamine receptors to become more sensitive.

Now, as a physician, this clearly is an awkward topic to bring up during a routine health physical. But if left unsaid, this behavior could clearly lead to years of dysfunction. What I have found to be a simple solution to the “not so popular topics” is to present a handout with a topic simply stated and easy to read. This allows you to give patients the information without the embarrassment. The purpose is just to identify what is normal and what is not so normal so a patient knows to seek help if the problem occurs. Quick fixes also should be listed if known, especially if the quick fix is just to stop the behavior.

Other topics – such as bacterial vaginosis, the morning after pill, acne, and gynecomastia – can be addressed similarly because teens don’t know what they don’t know, so they may not even consider asking. Many women don’t realize that bacterial vaginosis requires a prescription medication and so may remain symptomatic for long periods of time.

Education is key. As pediatricians, arming our patients with knowledge allows them to at least ask the appropriate questions, which hopefully will get them the right answer.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].