Expert Commentary

Although bilateral salpingo-oophorectomy is known to prevent breast and ovarian cancer in BRCA mutation carriers,¹ published reports also have suggested that, among mutation carriers with breast cancer, oophorectomy improves survival. In this retrospective analysis, investigators focused on women with stage I or II breast cancer and a BRCA1 or BRCA2 mutation, observing them for as long as 20 years after diagnosis. Survival rates were compared between women who did and did not undergo oophorectomy.

Details of the trial
Metcalfe and colleagues followed women with a BRCA1 or BRCA2 mutation and intact ovaries who were diagnosed with breast cancer at age 65 or younger between 1975 and 2008, tracking them for a mean of 12.5 years. Of 676 women, 345 underwent oophorectomy, usually with the intent of preventing ovarian cancer.

Overall, oophorectomy was associated with a 56% reduction in the risk of breast cancer-specific mortality (P = .005). Among breast cancer survivors with a BRCA1 mutation, oophorectomy was associated with a significant 62% reduction in breast cancer mortality. Among BRCA2 carriers, the observed 43% reduction in breast cancer mortality did not achieve statistical significance (P = .23).

Full impact of oophorectomy may be difficult to tease out
As Metcalfe and colleagues point out, recent improvements in breast imaging that have led to earlier diagnosis, as well as improvements in the treatment of breast cancer, might attenuate the mortality benefits observed with oophorectomy.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
This important report underscores the importance of testing all women with early-stage breast cancer for BRCA mutations, and informs the management of known BRCA1 carriers with breast cancer.
—Andrew M. Kaunitz, MD

Although bilateral salpingo-oophorectomy is known to prevent breast and ovarian cancer in BRCA mutation carriers,¹ published reports also have suggested that, among mutation carriers with breast cancer, oophorectomy improves survival. In this retrospective analysis, investigators focused on women with stage I or II breast cancer and a BRCA1 or BRCA2 mutation, observing them for as long as 20 years after diagnosis. Survival rates were compared between women who did and did not undergo oophorectomy.

Details of the trial
Metcalfe and colleagues followed women with a BRCA1 or BRCA2 mutation and intact ovaries who were diagnosed with breast cancer at age 65 or younger between 1975 and 2008, tracking them for a mean of 12.5 years. Of 676 women, 345 underwent oophorectomy, usually with the intent of preventing ovarian cancer.

Overall, oophorectomy was associated with a 56% reduction in the risk of breast cancer-specific mortality (P = .005). Among breast cancer survivors with a BRCA1 mutation, oophorectomy was associated with a significant 62% reduction in breast cancer mortality. Among BRCA2 carriers, the observed 43% reduction in breast cancer mortality did not achieve statistical significance (P = .23).

Full impact of oophorectomy may be difficult to tease out
As Metcalfe and colleagues point out, recent improvements in breast imaging that have led to earlier diagnosis, as well as improvements in the treatment of breast cancer, might attenuate the mortality benefits observed with oophorectomy.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
This important report underscores the importance of testing all women with early-stage breast cancer for BRCA mutations, and informs the management of known BRCA1 carriers with breast cancer.
—Andrew M. Kaunitz, MD

Although bilateral salpingo-oophorectomy is known to prevent breast and ovarian cancer in BRCA mutation carriers,¹ published reports also have suggested that, among mutation carriers with breast cancer, oophorectomy improves survival. In this retrospective analysis, investigators focused on women with stage I or II breast cancer and a BRCA1 or BRCA2 mutation, observing them for as long as 20 years after diagnosis. Survival rates were compared between women who did and did not undergo oophorectomy.

Details of the trial
Metcalfe and colleagues followed women with a BRCA1 or BRCA2 mutation and intact ovaries who were diagnosed with breast cancer at age 65 or younger between 1975 and 2008, tracking them for a mean of 12.5 years. Of 676 women, 345 underwent oophorectomy, usually with the intent of preventing ovarian cancer.

Overall, oophorectomy was associated with a 56% reduction in the risk of breast cancer-specific mortality (P = .005). Among breast cancer survivors with a BRCA1 mutation, oophorectomy was associated with a significant 62% reduction in breast cancer mortality. Among BRCA2 carriers, the observed 43% reduction in breast cancer mortality did not achieve statistical significance (P = .23).

Full impact of oophorectomy may be difficult to tease out
As Metcalfe and colleagues point out, recent improvements in breast imaging that have led to earlier diagnosis, as well as improvements in the treatment of breast cancer, might attenuate the mortality benefits observed with oophorectomy.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
This important report underscores the importance of testing all women with early-stage breast cancer for BRCA mutations, and informs the management of known BRCA1 carriers with breast cancer.
—Andrew M. Kaunitz, MD

VALENCIA, SPAIN – Pediatric migraine often has a markedly adverse effect upon school performance and psychosocial adjustment, according to a landmark series of Brazilian studies.

“This is a series of articles that has certainly changed my own practice,” Dr. Kenneth J. Mack said at the International Headache Congress.

The Brazilian investigators are following a nationally representative sample of 5,671 Brazilian 5- to 12-year-olds. They found the prevalence of episodic migraine was 9%, while 17.6% of the youths were categorized as having probable migraine, 12.8% had periodic tensiontype headaches, and 0.6% had chronic migraine as defined by migraine headaches on at least 15 days per month, a rate Dr. Mack said was disturbingly high in such a young population.

In their most recent analysis, the Brazilian investigators reported that the children with episodic or chronic migraine had significantly higher rates of abnormal scores on various measures of psychosocial adjustment. They also had increased rates of attention-deficit/hyperactivity disorder, dyslexia, and other learning disabilities (Headache 2015;55 [suppl. 1]:39-50).

Previously, the investigators reported that the children with migraine were at significantly elevated risk of impaired school performance, as assessed by their teachers as well as on standardized tests of academic competencies. The more frequent, severe, and/or longer-lasting the migraines, the poorer the school performance (Neurology 2012;79:1881-8).

“I’ve always asked about school problems, but since these studies I’ve spent much more time delving into school problems in younger kids with chronic headaches. And I’m surprised by how often they really do have school problems – how often they need extra support and help at school,” said Dr. Mack, professor of neurology and pediatrics at the Mayo Clinic in Rochester, Minn.

Another recent research focus in the field of pediatric headache has been its seasonality, which appears to be strongly tied to the school year, he added at the meeting sponsored by the International Headache Society and the American Headache Society.

One good way to look at how severe headaches are and when they occur is by examining pediatric emergency department visits. In a single-center study of 2,731 visits to a Pittsburgh pediatric emergency department by children aged 4 years and older with a chief complaint of headache, there was a clear peak incidence in September and October – the start of the school year – and a nadir in May and June, when school lets out for the summer. This applied to headaches of all types and to patients of all ages and races and to both sexes (Pediatr. Emerg. Care 2014;30:174-6).

This report was soon followed by a nationwide study of ED visits recorded in the U.S. National Hospital Ambulatory Medical Care Survey. The investigators concluded that 5- to 18-year-olds in the United States collectively make an estimated 250,000 ED visits annually related to various types of primary headache. Indeed, headache accounted for 2.1% of all ED visits in this age group during the study years. Looking at rates on a month-by-month basis, the investigators found that ED visits for headache were highest in September (odds ratio, 1.64) and January (OR, 1.92), when children and adolescents start the academic year and return from winter break, respectively, and lowest in April (OR, 0.42) (Cephalalgia 2014;34:473-8).

In an effort to nail down the apparent link between seeking care for a headache and the school year, Dr. Mack and a coinvestigator, in a soon-to-be-published study, looked retrospectively at 103 pediatric patients diagnosed with new daily persistent headache. They focused on this particular type of headache because its onset can be traced to a particular day. Twenty-two percent of patients presented in September and another 18% in January, the school-start months. And just 1 of 103 patients presented in May or June, Dr. Mack reported.

He said he had no relevant financial conflicts.

[email protected]

VALENCIA, SPAIN – Pediatric migraine often has a markedly adverse effect upon school performance and psychosocial adjustment, according to a landmark series of Brazilian studies.

“This is a series of articles that has certainly changed my own practice,” Dr. Kenneth J. Mack said at the International Headache Congress.

The Brazilian investigators are following a nationally representative sample of 5,671 Brazilian 5- to 12-year-olds. They found the prevalence of episodic migraine was 9%, while 17.6% of the youths were categorized as having probable migraine, 12.8% had periodic tensiontype headaches, and 0.6% had chronic migraine as defined by migraine headaches on at least 15 days per month, a rate Dr. Mack said was disturbingly high in such a young population.

In their most recent analysis, the Brazilian investigators reported that the children with episodic or chronic migraine had significantly higher rates of abnormal scores on various measures of psychosocial adjustment. They also had increased rates of attention-deficit/hyperactivity disorder, dyslexia, and other learning disabilities (Headache 2015;55 [suppl. 1]:39-50).

Previously, the investigators reported that the children with migraine were at significantly elevated risk of impaired school performance, as assessed by their teachers as well as on standardized tests of academic competencies. The more frequent, severe, and/or longer-lasting the migraines, the poorer the school performance (Neurology 2012;79:1881-8).

“I’ve always asked about school problems, but since these studies I’ve spent much more time delving into school problems in younger kids with chronic headaches. And I’m surprised by how often they really do have school problems – how often they need extra support and help at school,” said Dr. Mack, professor of neurology and pediatrics at the Mayo Clinic in Rochester, Minn.

Another recent research focus in the field of pediatric headache has been its seasonality, which appears to be strongly tied to the school year, he added at the meeting sponsored by the International Headache Society and the American Headache Society.

One good way to look at how severe headaches are and when they occur is by examining pediatric emergency department visits. In a single-center study of 2,731 visits to a Pittsburgh pediatric emergency department by children aged 4 years and older with a chief complaint of headache, there was a clear peak incidence in September and October – the start of the school year – and a nadir in May and June, when school lets out for the summer. This applied to headaches of all types and to patients of all ages and races and to both sexes (Pediatr. Emerg. Care 2014;30:174-6).

This report was soon followed by a nationwide study of ED visits recorded in the U.S. National Hospital Ambulatory Medical Care Survey. The investigators concluded that 5- to 18-year-olds in the United States collectively make an estimated 250,000 ED visits annually related to various types of primary headache. Indeed, headache accounted for 2.1% of all ED visits in this age group during the study years. Looking at rates on a month-by-month basis, the investigators found that ED visits for headache were highest in September (odds ratio, 1.64) and January (OR, 1.92), when children and adolescents start the academic year and return from winter break, respectively, and lowest in April (OR, 0.42) (Cephalalgia 2014;34:473-8).

In an effort to nail down the apparent link between seeking care for a headache and the school year, Dr. Mack and a coinvestigator, in a soon-to-be-published study, looked retrospectively at 103 pediatric patients diagnosed with new daily persistent headache. They focused on this particular type of headache because its onset can be traced to a particular day. Twenty-two percent of patients presented in September and another 18% in January, the school-start months. And just 1 of 103 patients presented in May or June, Dr. Mack reported.

He said he had no relevant financial conflicts.

[email protected]

VALENCIA, SPAIN – Pediatric migraine often has a markedly adverse effect upon school performance and psychosocial adjustment, according to a landmark series of Brazilian studies.

“This is a series of articles that has certainly changed my own practice,” Dr. Kenneth J. Mack said at the International Headache Congress.

The Brazilian investigators are following a nationally representative sample of 5,671 Brazilian 5- to 12-year-olds. They found the prevalence of episodic migraine was 9%, while 17.6% of the youths were categorized as having probable migraine, 12.8% had periodic tensiontype headaches, and 0.6% had chronic migraine as defined by migraine headaches on at least 15 days per month, a rate Dr. Mack said was disturbingly high in such a young population.

In their most recent analysis, the Brazilian investigators reported that the children with episodic or chronic migraine had significantly higher rates of abnormal scores on various measures of psychosocial adjustment. They also had increased rates of attention-deficit/hyperactivity disorder, dyslexia, and other learning disabilities (Headache 2015;55 [suppl. 1]:39-50).

Previously, the investigators reported that the children with migraine were at significantly elevated risk of impaired school performance, as assessed by their teachers as well as on standardized tests of academic competencies. The more frequent, severe, and/or longer-lasting the migraines, the poorer the school performance (Neurology 2012;79:1881-8).

“I’ve always asked about school problems, but since these studies I’ve spent much more time delving into school problems in younger kids with chronic headaches. And I’m surprised by how often they really do have school problems – how often they need extra support and help at school,” said Dr. Mack, professor of neurology and pediatrics at the Mayo Clinic in Rochester, Minn.

Another recent research focus in the field of pediatric headache has been its seasonality, which appears to be strongly tied to the school year, he added at the meeting sponsored by the International Headache Society and the American Headache Society.

One good way to look at how severe headaches are and when they occur is by examining pediatric emergency department visits. In a single-center study of 2,731 visits to a Pittsburgh pediatric emergency department by children aged 4 years and older with a chief complaint of headache, there was a clear peak incidence in September and October – the start of the school year – and a nadir in May and June, when school lets out for the summer. This applied to headaches of all types and to patients of all ages and races and to both sexes (Pediatr. Emerg. Care 2014;30:174-6).

This report was soon followed by a nationwide study of ED visits recorded in the U.S. National Hospital Ambulatory Medical Care Survey. The investigators concluded that 5- to 18-year-olds in the United States collectively make an estimated 250,000 ED visits annually related to various types of primary headache. Indeed, headache accounted for 2.1% of all ED visits in this age group during the study years. Looking at rates on a month-by-month basis, the investigators found that ED visits for headache were highest in September (odds ratio, 1.64) and January (OR, 1.92), when children and adolescents start the academic year and return from winter break, respectively, and lowest in April (OR, 0.42) (Cephalalgia 2014;34:473-8).

In an effort to nail down the apparent link between seeking care for a headache and the school year, Dr. Mack and a coinvestigator, in a soon-to-be-published study, looked retrospectively at 103 pediatric patients diagnosed with new daily persistent headache. They focused on this particular type of headache because its onset can be traced to a particular day. Twenty-two percent of patients presented in September and another 18% in January, the school-start months. And just 1 of 103 patients presented in May or June, Dr. Mack reported.

He said he had no relevant financial conflicts.

[email protected]

ATLANTA – The potential utility of the medical emergency department as a key venue in which to conduct youth suicide screening is now well established, and a federally funded effort to develop and validate an optimal screening tool designed specifically for this purpose is underway.

Suicide is the second-leading cause of death among 12- to 17-year-olds in the United States. Routine screening for suicide risk in medical EDs would solve a major challenge in preventing these deaths: namely, that adolescents – especially older male teens, who are at highest suicide risk – seldom seek mental health care. Yet, roughly one-third of adolescents visit the ED per year, Cheryl A. King, Ph.D., explained at the annual conference of the American Association of Suicidology.

“They come in for exacerbation of common medical illnesses and sports injuries, but they’re also coming in for things like alcohol poisoning, car accidents, and fistfights,” noted Dr. King, professor of psychology and psychiatry at the University of Michigan, Ann Arbor.

These ED visits offer a particularly good opportunity to screen for suicide risk in adolescent males, who account for 80% of all youth suicides in the United States. Yet, because they are so much less likely than teen girls to share thoughts of suicide, males comprise only 25%-35% of teens hospitalized for suicide risk, she continued.

Dr. King has been a leader in the exploration of the medical ED as a venue for routine screening for high risk for suicidal behavior in adolescents. She and others have shown that such screening is productive. But there’s a problem: ED personnel already feel plenty busy and time crushed without taking on a huge new responsibility. And screening instruments designed to miss few teens at risk will have a high false-positive rate. “I don’t want to set the screen-positive threshold so low that 40% of all youth who come in with a broken thumb that was jammed in a car door screen positive, because then what will the ED physicians say to me? They may not even want to talk to me,” she said.

In an early proof-of-concept study, she and her colleagues developed and tested a high-bar screen, one in which a positive result required self-reported serious suicidal ideation within the past 2 weeks, a suicide attempt within the past month, or co-occurring depression plus alcohol/substance misuse. Applying the screen to 298 adolescents who presented to an ED, the investigators found a 16% screen-positive rate (Acad. Emerg. Med. 2009;16:1234-41).

The investigators went on to survey pools of adolescents and parents as to the acceptability of routine ED screening for suicide risk, and got a thumbs-up from both groups (Ped. Emerg. Care 2012;28:626-32).

Next, Dr. King and her colleagues established that their screening tool actually predicted a high near-term risk for suicidal behavior. In a separate study of 81 adolescents aged 14-19 who were screen positive, 15 (18.5%) engaged in some type of suicidal behavior in the 2 months following their ED visit (J. Child Adolesc. Psychopharmacol. 2015;25:100-8).

Another promising screening tool for use in youths presenting to EDs is the ASQ (Ask Suicide-Screening Questions), a four-question test developed at the National Institute of Mental Health (NIMH). It assesses current thoughts of wishing to die, being better off dead, suicidal ideation, and past attempts (Arch. Pediatr. Adolesc. Med. 2012;166:1170-16); however, the predictive validity of this scale in terms of future suicide attempts has yet to be validated, according to Dr. King.

The clinician-administered Columbia–Suicide Severity Rating Scale has demonstrated predictive validity, but it is likely to prove too comprehensive and time consuming for routine use as a screening tool in the ED. However, several specific items incorporated in the scale – namely, the duration element of the intensity scale score and a lifetime history of nonsuicidal self-injury – showed predictive validity as a streamlined screening tool in a study by Dr. King and her colleagues (Pediatr. Emerg. Care 2015;31:88-94).

The most recent development in ED screening is the National Institute of Mental Health–funded ED-STARS (Emergency Department Screening for Teens at Risk for Suicide) project. Dr. King is a codirector of this multicenter effort to develop the optimal suicide risk screening tool for adolescents in the ED, along with a triage algorithm ED physicians can follow.

The tool being developed is a computerized adaptive screen. Rather than answering a fixed list of screening questions, patients will take a very brief, personalized test administered via computer. The adaptive aspect involves an algorithm in which the next question posed depends upon the individual’s response to the question before. This screening instrument is being paired with the Implicit Association Test developed by investigators at Harvard University, Cambridge, Mass.

ED-STARS is being carried out by the Pediatric Emergency Care Applied Research Network. If the project proves successful, the plan is to extend the screening tool into school settings.

Dr. King’s research efforts are funded by the NIMH. She reported having no relevant financial conflicts.

[email protected]

ATLANTA – The potential utility of the medical emergency department as a key venue in which to conduct youth suicide screening is now well established, and a federally funded effort to develop and validate an optimal screening tool designed specifically for this purpose is underway.

Suicide is the second-leading cause of death among 12- to 17-year-olds in the United States. Routine screening for suicide risk in medical EDs would solve a major challenge in preventing these deaths: namely, that adolescents – especially older male teens, who are at highest suicide risk – seldom seek mental health care. Yet, roughly one-third of adolescents visit the ED per year, Cheryl A. King, Ph.D., explained at the annual conference of the American Association of Suicidology.

“They come in for exacerbation of common medical illnesses and sports injuries, but they’re also coming in for things like alcohol poisoning, car accidents, and fistfights,” noted Dr. King, professor of psychology and psychiatry at the University of Michigan, Ann Arbor.

These ED visits offer a particularly good opportunity to screen for suicide risk in adolescent males, who account for 80% of all youth suicides in the United States. Yet, because they are so much less likely than teen girls to share thoughts of suicide, males comprise only 25%-35% of teens hospitalized for suicide risk, she continued.

Dr. King has been a leader in the exploration of the medical ED as a venue for routine screening for high risk for suicidal behavior in adolescents. She and others have shown that such screening is productive. But there’s a problem: ED personnel already feel plenty busy and time crushed without taking on a huge new responsibility. And screening instruments designed to miss few teens at risk will have a high false-positive rate. “I don’t want to set the screen-positive threshold so low that 40% of all youth who come in with a broken thumb that was jammed in a car door screen positive, because then what will the ED physicians say to me? They may not even want to talk to me,” she said.

In an early proof-of-concept study, she and her colleagues developed and tested a high-bar screen, one in which a positive result required self-reported serious suicidal ideation within the past 2 weeks, a suicide attempt within the past month, or co-occurring depression plus alcohol/substance misuse. Applying the screen to 298 adolescents who presented to an ED, the investigators found a 16% screen-positive rate (Acad. Emerg. Med. 2009;16:1234-41).

The investigators went on to survey pools of adolescents and parents as to the acceptability of routine ED screening for suicide risk, and got a thumbs-up from both groups (Ped. Emerg. Care 2012;28:626-32).

Next, Dr. King and her colleagues established that their screening tool actually predicted a high near-term risk for suicidal behavior. In a separate study of 81 adolescents aged 14-19 who were screen positive, 15 (18.5%) engaged in some type of suicidal behavior in the 2 months following their ED visit (J. Child Adolesc. Psychopharmacol. 2015;25:100-8).

Another promising screening tool for use in youths presenting to EDs is the ASQ (Ask Suicide-Screening Questions), a four-question test developed at the National Institute of Mental Health (NIMH). It assesses current thoughts of wishing to die, being better off dead, suicidal ideation, and past attempts (Arch. Pediatr. Adolesc. Med. 2012;166:1170-16); however, the predictive validity of this scale in terms of future suicide attempts has yet to be validated, according to Dr. King.

The clinician-administered Columbia–Suicide Severity Rating Scale has demonstrated predictive validity, but it is likely to prove too comprehensive and time consuming for routine use as a screening tool in the ED. However, several specific items incorporated in the scale – namely, the duration element of the intensity scale score and a lifetime history of nonsuicidal self-injury – showed predictive validity as a streamlined screening tool in a study by Dr. King and her colleagues (Pediatr. Emerg. Care 2015;31:88-94).

The most recent development in ED screening is the National Institute of Mental Health–funded ED-STARS (Emergency Department Screening for Teens at Risk for Suicide) project. Dr. King is a codirector of this multicenter effort to develop the optimal suicide risk screening tool for adolescents in the ED, along with a triage algorithm ED physicians can follow.

The tool being developed is a computerized adaptive screen. Rather than answering a fixed list of screening questions, patients will take a very brief, personalized test administered via computer. The adaptive aspect involves an algorithm in which the next question posed depends upon the individual’s response to the question before. This screening instrument is being paired with the Implicit Association Test developed by investigators at Harvard University, Cambridge, Mass.

ED-STARS is being carried out by the Pediatric Emergency Care Applied Research Network. If the project proves successful, the plan is to extend the screening tool into school settings.

Dr. King’s research efforts are funded by the NIMH. She reported having no relevant financial conflicts.

[email protected]

ATLANTA – The potential utility of the medical emergency department as a key venue in which to conduct youth suicide screening is now well established, and a federally funded effort to develop and validate an optimal screening tool designed specifically for this purpose is underway.

Suicide is the second-leading cause of death among 12- to 17-year-olds in the United States. Routine screening for suicide risk in medical EDs would solve a major challenge in preventing these deaths: namely, that adolescents – especially older male teens, who are at highest suicide risk – seldom seek mental health care. Yet, roughly one-third of adolescents visit the ED per year, Cheryl A. King, Ph.D., explained at the annual conference of the American Association of Suicidology.

“They come in for exacerbation of common medical illnesses and sports injuries, but they’re also coming in for things like alcohol poisoning, car accidents, and fistfights,” noted Dr. King, professor of psychology and psychiatry at the University of Michigan, Ann Arbor.

These ED visits offer a particularly good opportunity to screen for suicide risk in adolescent males, who account for 80% of all youth suicides in the United States. Yet, because they are so much less likely than teen girls to share thoughts of suicide, males comprise only 25%-35% of teens hospitalized for suicide risk, she continued.

Dr. King has been a leader in the exploration of the medical ED as a venue for routine screening for high risk for suicidal behavior in adolescents. She and others have shown that such screening is productive. But there’s a problem: ED personnel already feel plenty busy and time crushed without taking on a huge new responsibility. And screening instruments designed to miss few teens at risk will have a high false-positive rate. “I don’t want to set the screen-positive threshold so low that 40% of all youth who come in with a broken thumb that was jammed in a car door screen positive, because then what will the ED physicians say to me? They may not even want to talk to me,” she said.

In an early proof-of-concept study, she and her colleagues developed and tested a high-bar screen, one in which a positive result required self-reported serious suicidal ideation within the past 2 weeks, a suicide attempt within the past month, or co-occurring depression plus alcohol/substance misuse. Applying the screen to 298 adolescents who presented to an ED, the investigators found a 16% screen-positive rate (Acad. Emerg. Med. 2009;16:1234-41).

The investigators went on to survey pools of adolescents and parents as to the acceptability of routine ED screening for suicide risk, and got a thumbs-up from both groups (Ped. Emerg. Care 2012;28:626-32).

Next, Dr. King and her colleagues established that their screening tool actually predicted a high near-term risk for suicidal behavior. In a separate study of 81 adolescents aged 14-19 who were screen positive, 15 (18.5%) engaged in some type of suicidal behavior in the 2 months following their ED visit (J. Child Adolesc. Psychopharmacol. 2015;25:100-8).

Another promising screening tool for use in youths presenting to EDs is the ASQ (Ask Suicide-Screening Questions), a four-question test developed at the National Institute of Mental Health (NIMH). It assesses current thoughts of wishing to die, being better off dead, suicidal ideation, and past attempts (Arch. Pediatr. Adolesc. Med. 2012;166:1170-16); however, the predictive validity of this scale in terms of future suicide attempts has yet to be validated, according to Dr. King.

The clinician-administered Columbia–Suicide Severity Rating Scale has demonstrated predictive validity, but it is likely to prove too comprehensive and time consuming for routine use as a screening tool in the ED. However, several specific items incorporated in the scale – namely, the duration element of the intensity scale score and a lifetime history of nonsuicidal self-injury – showed predictive validity as a streamlined screening tool in a study by Dr. King and her colleagues (Pediatr. Emerg. Care 2015;31:88-94).

The most recent development in ED screening is the National Institute of Mental Health–funded ED-STARS (Emergency Department Screening for Teens at Risk for Suicide) project. Dr. King is a codirector of this multicenter effort to develop the optimal suicide risk screening tool for adolescents in the ED, along with a triage algorithm ED physicians can follow.

The tool being developed is a computerized adaptive screen. Rather than answering a fixed list of screening questions, patients will take a very brief, personalized test administered via computer. The adaptive aspect involves an algorithm in which the next question posed depends upon the individual’s response to the question before. This screening instrument is being paired with the Implicit Association Test developed by investigators at Harvard University, Cambridge, Mass.

ED-STARS is being carried out by the Pediatric Emergency Care Applied Research Network. If the project proves successful, the plan is to extend the screening tool into school settings.

Dr. King’s research efforts are funded by the NIMH. She reported having no relevant financial conflicts.

[email protected]

ATLANTA – Among all deaths by suicide, 15%-20% are attributable to a previously undescribed entity that now has a name: acute suicidal affective disturbance, Thomas Joiner, Ph.D., said at the annual conference of the American Association of Suicidology.

“It’s real, it’s fairly common, and it’s extremely dangerous. We think it ranks up there among the most serious of conditions – more likely to result in death than the manic phase of bipolar disorder or schizophrenia, for example,” said Dr. Joiner, who first identified and characterized the condition, named it, plays a pivotal role in ongoing multicenter collaborative research efforts targeting it, and vows to see acute suicidal affective disturbance, or ASAD, included in the DSM-6.

Bruce Jancin/Frontline Medical News

ASAD is a concept compatible with Dr. Joiner’s “Interpersonal Theory of Suicide,” which has taken the field of suicidology by storm. But ASAD , he stressed, is not a theoretical construct.

“ASAD exists as an entity, as a true object in nature that I worry over because it kills people and we can’t diagnose it currently because there’s a gap in the nomenclature. We’re proposing this condition to fill that gap,” explained Dr. Joiner, professor of psychology at Florida State University, Tallahassee.

Roughly 80% of all deaths by suicide can be attributed to a recognized mental health disorder, such as major depressive disorder, the depressive phase of bipolar disorder, anorexia nervosa, schizophrenia, or borderline personality disorder. Dr. Joiner presented highlights of three separate studies now in press – one conducted in Veterans Affairs outpatients, another in high-risk university undergraduates, and a third involving nearly 7,700 Mayo Clinic psychiatric inpatients and more than 3,400 U.S. Army high-risk patients – all of which support the construct validity of ASAD as a distinct entity that correlates negatively with impulsivity and is unrelated to alcohol use disorders or mood disorders.

In addition, Dr. Joiner continued, three different research teams – his own; the Military Suicide Research Consortium, which he codirects; and the U.S. Army STARRS group – have identified subgroups of patients at very high suicide risk who are characterized by ASAD symptoms that are discernible from those of established clinical entities (see list for proposed ASAD criteria).

“We intend to put ASAD into DSM-6. We know that’s going to be a battle, and we’re ready for it. We’re determined to fight it,” the psychologist said.

If ASAD were to eventually become a diagnosable condition, the clinical implications would be far-reaching, he observed. It would be a billable entity. Also, its existence in the formal psychiatric nomenclature would alert clinicians to be vigilant regarding ASAD; that’s crucial because recurrences can be lethal, and recognition of the prodromal overarousal symptoms may head off a full-blown crisis.

“If we’re right about ASAD, it would imply that mood disorders and ASAD are distinct, that their onset and remission patterns are different, thus supporting the rationale of suicide-specific treatments like CAMS [collaborative assessment and management of suicidality] and DBT [dialectical behavior therapy]. It would suggest the need for intensive and long-lasting therapies, because a recurrence can cost people their lives,” he continued.

Should ASAD become legitimized as a diagnosis, it would shore up the public health argument in favor of suicide-means restriction as a strategy for forestalling suicidal action.

“ASAD is a time-limited arousal state. You can’t sustain it for more than an hour or a few hours. It’ll abate with the passage of time,” according to Dr. Joiner.

In response to an audience question, he said it’s his clinical impression – not yet supported by data – that the most common comorbid conditions in patients with ASAD are anxiety disorders and personality disorders. Also, ASAD doesn’t appear to be age dependent: “We think it can emerge at any point in the lifespan.”

Dr. Joiner emphasized that many questions regarding ASAD remain unanswered.

“We have a long way to go,” he conceded. “And I’m not talking about years here, I’m talking about decades. The effort is going to be primarily research oriented. It’s a scientific effort. We’ve got to clear the hurdle scientifically, and we haven’t done that yet, although we’ve gotten a start.”

He reported having no financial conflicts regarding his presentation.

Proposed criteria for ASAD

1. A sudden surge in suicidal intent occurring over the course of minutes, hours, or days rather than weeks or months.

2. One or both of two alienation criteria: a) severe social withdrawal defined by extreme disgust with others or perceived liability to others; b) marked self-alienation manifested as self-disgust or the view that one’s selfhood is an onerous burden.

3. The perception that numbers 1 and 2 are hopelessly intractable.

4. At least two of the following manifestations of overarousal: insomnia, nightmares, irritability, agitation.

5. Exclusion criteria: The above is not due to exacerbation of a mood disorder or ingestion of alcohol or another substance.

Source: Dr. Joiner

[email protected]

ATLANTA – Among all deaths by suicide, 15%-20% are attributable to a previously undescribed entity that now has a name: acute suicidal affective disturbance, Thomas Joiner, Ph.D., said at the annual conference of the American Association of Suicidology.

“It’s real, it’s fairly common, and it’s extremely dangerous. We think it ranks up there among the most serious of conditions – more likely to result in death than the manic phase of bipolar disorder or schizophrenia, for example,” said Dr. Joiner, who first identified and characterized the condition, named it, plays a pivotal role in ongoing multicenter collaborative research efforts targeting it, and vows to see acute suicidal affective disturbance, or ASAD, included in the DSM-6.

Bruce Jancin/Frontline Medical News

ASAD is a concept compatible with Dr. Joiner’s “Interpersonal Theory of Suicide,” which has taken the field of suicidology by storm. But ASAD , he stressed, is not a theoretical construct.

“ASAD exists as an entity, as a true object in nature that I worry over because it kills people and we can’t diagnose it currently because there’s a gap in the nomenclature. We’re proposing this condition to fill that gap,” explained Dr. Joiner, professor of psychology at Florida State University, Tallahassee.

Roughly 80% of all deaths by suicide can be attributed to a recognized mental health disorder, such as major depressive disorder, the depressive phase of bipolar disorder, anorexia nervosa, schizophrenia, or borderline personality disorder. Dr. Joiner presented highlights of three separate studies now in press – one conducted in Veterans Affairs outpatients, another in high-risk university undergraduates, and a third involving nearly 7,700 Mayo Clinic psychiatric inpatients and more than 3,400 U.S. Army high-risk patients – all of which support the construct validity of ASAD as a distinct entity that correlates negatively with impulsivity and is unrelated to alcohol use disorders or mood disorders.

In addition, Dr. Joiner continued, three different research teams – his own; the Military Suicide Research Consortium, which he codirects; and the U.S. Army STARRS group – have identified subgroups of patients at very high suicide risk who are characterized by ASAD symptoms that are discernible from those of established clinical entities (see list for proposed ASAD criteria).

“We intend to put ASAD into DSM-6. We know that’s going to be a battle, and we’re ready for it. We’re determined to fight it,” the psychologist said.

If ASAD were to eventually become a diagnosable condition, the clinical implications would be far-reaching, he observed. It would be a billable entity. Also, its existence in the formal psychiatric nomenclature would alert clinicians to be vigilant regarding ASAD; that’s crucial because recurrences can be lethal, and recognition of the prodromal overarousal symptoms may head off a full-blown crisis.

“If we’re right about ASAD, it would imply that mood disorders and ASAD are distinct, that their onset and remission patterns are different, thus supporting the rationale of suicide-specific treatments like CAMS [collaborative assessment and management of suicidality] and DBT [dialectical behavior therapy]. It would suggest the need for intensive and long-lasting therapies, because a recurrence can cost people their lives,” he continued.

Should ASAD become legitimized as a diagnosis, it would shore up the public health argument in favor of suicide-means restriction as a strategy for forestalling suicidal action.

“ASAD is a time-limited arousal state. You can’t sustain it for more than an hour or a few hours. It’ll abate with the passage of time,” according to Dr. Joiner.

In response to an audience question, he said it’s his clinical impression – not yet supported by data – that the most common comorbid conditions in patients with ASAD are anxiety disorders and personality disorders. Also, ASAD doesn’t appear to be age dependent: “We think it can emerge at any point in the lifespan.”

Dr. Joiner emphasized that many questions regarding ASAD remain unanswered.

“We have a long way to go,” he conceded. “And I’m not talking about years here, I’m talking about decades. The effort is going to be primarily research oriented. It’s a scientific effort. We’ve got to clear the hurdle scientifically, and we haven’t done that yet, although we’ve gotten a start.”

He reported having no financial conflicts regarding his presentation.

Proposed criteria for ASAD

1. A sudden surge in suicidal intent occurring over the course of minutes, hours, or days rather than weeks or months.

2. One or both of two alienation criteria: a) severe social withdrawal defined by extreme disgust with others or perceived liability to others; b) marked self-alienation manifested as self-disgust or the view that one’s selfhood is an onerous burden.

3. The perception that numbers 1 and 2 are hopelessly intractable.

4. At least two of the following manifestations of overarousal: insomnia, nightmares, irritability, agitation.

5. Exclusion criteria: The above is not due to exacerbation of a mood disorder or ingestion of alcohol or another substance.

Source: Dr. Joiner

[email protected]

ATLANTA – Among all deaths by suicide, 15%-20% are attributable to a previously undescribed entity that now has a name: acute suicidal affective disturbance, Thomas Joiner, Ph.D., said at the annual conference of the American Association of Suicidology.

“It’s real, it’s fairly common, and it’s extremely dangerous. We think it ranks up there among the most serious of conditions – more likely to result in death than the manic phase of bipolar disorder or schizophrenia, for example,” said Dr. Joiner, who first identified and characterized the condition, named it, plays a pivotal role in ongoing multicenter collaborative research efforts targeting it, and vows to see acute suicidal affective disturbance, or ASAD, included in the DSM-6.

Bruce Jancin/Frontline Medical News

ASAD is a concept compatible with Dr. Joiner’s “Interpersonal Theory of Suicide,” which has taken the field of suicidology by storm. But ASAD , he stressed, is not a theoretical construct.

“ASAD exists as an entity, as a true object in nature that I worry over because it kills people and we can’t diagnose it currently because there’s a gap in the nomenclature. We’re proposing this condition to fill that gap,” explained Dr. Joiner, professor of psychology at Florida State University, Tallahassee.

Roughly 80% of all deaths by suicide can be attributed to a recognized mental health disorder, such as major depressive disorder, the depressive phase of bipolar disorder, anorexia nervosa, schizophrenia, or borderline personality disorder. Dr. Joiner presented highlights of three separate studies now in press – one conducted in Veterans Affairs outpatients, another in high-risk university undergraduates, and a third involving nearly 7,700 Mayo Clinic psychiatric inpatients and more than 3,400 U.S. Army high-risk patients – all of which support the construct validity of ASAD as a distinct entity that correlates negatively with impulsivity and is unrelated to alcohol use disorders or mood disorders.

In addition, Dr. Joiner continued, three different research teams – his own; the Military Suicide Research Consortium, which he codirects; and the U.S. Army STARRS group – have identified subgroups of patients at very high suicide risk who are characterized by ASAD symptoms that are discernible from those of established clinical entities (see list for proposed ASAD criteria).

“We intend to put ASAD into DSM-6. We know that’s going to be a battle, and we’re ready for it. We’re determined to fight it,” the psychologist said.

If ASAD were to eventually become a diagnosable condition, the clinical implications would be far-reaching, he observed. It would be a billable entity. Also, its existence in the formal psychiatric nomenclature would alert clinicians to be vigilant regarding ASAD; that’s crucial because recurrences can be lethal, and recognition of the prodromal overarousal symptoms may head off a full-blown crisis.

“If we’re right about ASAD, it would imply that mood disorders and ASAD are distinct, that their onset and remission patterns are different, thus supporting the rationale of suicide-specific treatments like CAMS [collaborative assessment and management of suicidality] and DBT [dialectical behavior therapy]. It would suggest the need for intensive and long-lasting therapies, because a recurrence can cost people their lives,” he continued.

Should ASAD become legitimized as a diagnosis, it would shore up the public health argument in favor of suicide-means restriction as a strategy for forestalling suicidal action.

“ASAD is a time-limited arousal state. You can’t sustain it for more than an hour or a few hours. It’ll abate with the passage of time,” according to Dr. Joiner.

In response to an audience question, he said it’s his clinical impression – not yet supported by data – that the most common comorbid conditions in patients with ASAD are anxiety disorders and personality disorders. Also, ASAD doesn’t appear to be age dependent: “We think it can emerge at any point in the lifespan.”

Dr. Joiner emphasized that many questions regarding ASAD remain unanswered.

“We have a long way to go,” he conceded. “And I’m not talking about years here, I’m talking about decades. The effort is going to be primarily research oriented. It’s a scientific effort. We’ve got to clear the hurdle scientifically, and we haven’t done that yet, although we’ve gotten a start.”

He reported having no financial conflicts regarding his presentation.

Proposed criteria for ASAD

1. A sudden surge in suicidal intent occurring over the course of minutes, hours, or days rather than weeks or months.

2. One or both of two alienation criteria: a) severe social withdrawal defined by extreme disgust with others or perceived liability to others; b) marked self-alienation manifested as self-disgust or the view that one’s selfhood is an onerous burden.

3. The perception that numbers 1 and 2 are hopelessly intractable.

4. At least two of the following manifestations of overarousal: insomnia, nightmares, irritability, agitation.

5. Exclusion criteria: The above is not due to exacerbation of a mood disorder or ingestion of alcohol or another substance.

Source: Dr. Joiner

[email protected]

In this prospective cohort study of women undergoing induction of labor of a singleton fetus at term (≥37 weeks), Clark and colleagues examined each patient chart for adherence to 6 clinical practices:

Defined requirements for fetal heart rate included at least 1 acceleration of 15 bpm x 15 seconds in 30 minutes, or adequate variability for 10 of the previous 30 minutes. There should have been no more than 1 late deceleration in the previous 30 minutes. And there should have been no more than 2 variable decelerations exceeding 60 seconds and decreasing more than 60 bpm from baseline in the previous 30 minutes.

Defined requirements for uterine activity included no more than 5 contractions in 10 minutes for any 20-minute interval. There should have been no 2 contractions longer than 120 seconds in duration. In addition, the uterus should have been soft upon palpation between contractions. If an intrauterine pressure catheter was in place, measurement in Montevideo units should have been less than 300 mm Hg, with baseline resting tone of less than 25 mm Hg.

Outcome measures included admission to a neonatal intensive care unit (NICU), 1- and 5-minute Apgar scores of less than 7, and primary cesarean delivery.

Study findings underscore value of a checklist
The study found that completion of a safety checklist every 30 minutes during labor was associated with a significantly reduced rate of NICU admission and cesarean delivery. When the clinician stopped or reduced oxytocin for failure to meet specific uterine activity requirements, the rate of NICU admission also was reduced, but there were no differences in other outcomes. When the clinician stopped or reduced oxytocin for a failure to meet specific fetal heart-rate requirements, the rate of NICU admission was significantly reduced, as was the rate of low Apgar scores at birth, but there was a significantly higher rate of cesarean delivery (26.6% vs 17.5%).

Strengths include size of the study
This is a large study in a population with demographics that likely reflect those of the general US population. The study size permitted detection of relatively small differences in outcome.

The data clearly support the conclusions that “electronic fetal heart-rate monitoring improves neonatal outcomes when unambiguous definitions of abnormal fetal heart rate and tachysystole are coupled with specific interventions” and that “utilization of a checklist for oxytocin monitoring is associated with improved neonatal outcomes.” However, data were conflicting regarding the impact of a standard oxytocin checklist on the rate of cesarean delivery.

What this evidence means for practice
Implementation of a conservative intrapartum checklist has been shown to improve specific measures of newborn outcome. Further study is needed to define the impact on the rate of cesarean delivery.
—David A. Miller, MD

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

In this prospective cohort study of women undergoing induction of labor of a singleton fetus at term (≥37 weeks), Clark and colleagues examined each patient chart for adherence to 6 clinical practices:

Defined requirements for fetal heart rate included at least 1 acceleration of 15 bpm x 15 seconds in 30 minutes, or adequate variability for 10 of the previous 30 minutes. There should have been no more than 1 late deceleration in the previous 30 minutes. And there should have been no more than 2 variable decelerations exceeding 60 seconds and decreasing more than 60 bpm from baseline in the previous 30 minutes.

Defined requirements for uterine activity included no more than 5 contractions in 10 minutes for any 20-minute interval. There should have been no 2 contractions longer than 120 seconds in duration. In addition, the uterus should have been soft upon palpation between contractions. If an intrauterine pressure catheter was in place, measurement in Montevideo units should have been less than 300 mm Hg, with baseline resting tone of less than 25 mm Hg.

Outcome measures included admission to a neonatal intensive care unit (NICU), 1- and 5-minute Apgar scores of less than 7, and primary cesarean delivery.

Study findings underscore value of a checklist
The study found that completion of a safety checklist every 30 minutes during labor was associated with a significantly reduced rate of NICU admission and cesarean delivery. When the clinician stopped or reduced oxytocin for failure to meet specific uterine activity requirements, the rate of NICU admission also was reduced, but there were no differences in other outcomes. When the clinician stopped or reduced oxytocin for a failure to meet specific fetal heart-rate requirements, the rate of NICU admission was significantly reduced, as was the rate of low Apgar scores at birth, but there was a significantly higher rate of cesarean delivery (26.6% vs 17.5%).

Strengths include size of the study
This is a large study in a population with demographics that likely reflect those of the general US population. The study size permitted detection of relatively small differences in outcome.

The data clearly support the conclusions that “electronic fetal heart-rate monitoring improves neonatal outcomes when unambiguous definitions of abnormal fetal heart rate and tachysystole are coupled with specific interventions” and that “utilization of a checklist for oxytocin monitoring is associated with improved neonatal outcomes.” However, data were conflicting regarding the impact of a standard oxytocin checklist on the rate of cesarean delivery.

What this evidence means for practice
Implementation of a conservative intrapartum checklist has been shown to improve specific measures of newborn outcome. Further study is needed to define the impact on the rate of cesarean delivery.
—David A. Miller, MD

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

In this prospective cohort study of women undergoing induction of labor of a singleton fetus at term (≥37 weeks), Clark and colleagues examined each patient chart for adherence to 6 clinical practices:

Defined requirements for fetal heart rate included at least 1 acceleration of 15 bpm x 15 seconds in 30 minutes, or adequate variability for 10 of the previous 30 minutes. There should have been no more than 1 late deceleration in the previous 30 minutes. And there should have been no more than 2 variable decelerations exceeding 60 seconds and decreasing more than 60 bpm from baseline in the previous 30 minutes.

Defined requirements for uterine activity included no more than 5 contractions in 10 minutes for any 20-minute interval. There should have been no 2 contractions longer than 120 seconds in duration. In addition, the uterus should have been soft upon palpation between contractions. If an intrauterine pressure catheter was in place, measurement in Montevideo units should have been less than 300 mm Hg, with baseline resting tone of less than 25 mm Hg.

Outcome measures included admission to a neonatal intensive care unit (NICU), 1- and 5-minute Apgar scores of less than 7, and primary cesarean delivery.

Study findings underscore value of a checklist
The study found that completion of a safety checklist every 30 minutes during labor was associated with a significantly reduced rate of NICU admission and cesarean delivery. When the clinician stopped or reduced oxytocin for failure to meet specific uterine activity requirements, the rate of NICU admission also was reduced, but there were no differences in other outcomes. When the clinician stopped or reduced oxytocin for a failure to meet specific fetal heart-rate requirements, the rate of NICU admission was significantly reduced, as was the rate of low Apgar scores at birth, but there was a significantly higher rate of cesarean delivery (26.6% vs 17.5%).

Strengths include size of the study
This is a large study in a population with demographics that likely reflect those of the general US population. The study size permitted detection of relatively small differences in outcome.

The data clearly support the conclusions that “electronic fetal heart-rate monitoring improves neonatal outcomes when unambiguous definitions of abnormal fetal heart rate and tachysystole are coupled with specific interventions” and that “utilization of a checklist for oxytocin monitoring is associated with improved neonatal outcomes.” However, data were conflicting regarding the impact of a standard oxytocin checklist on the rate of cesarean delivery.

What this evidence means for practice
Implementation of a conservative intrapartum checklist has been shown to improve specific measures of newborn outcome. Further study is needed to define the impact on the rate of cesarean delivery.
—David A. Miller, MD

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

On October 1, 2014, the Centers for Medicare and Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) implemented a number of new coding pair edits that significantly restricted the types of surgical procedures that could be billed at the same time as vaginal hysterectomy. Most importantly, the new edits did not allow for combined anterior and posterior (AP) vaginal repair (57260) and apical vaginal suspensions (57282, 57283) to be separately billed and reimbursed when performed by the same surgeon and done in the same surgical session as a vaginal or laparoscopic hysterectomy. I initially reported on these changes in the January 2015 issue of OBG Management (“Recent NCCI edits have significantly impacted billing and reimbursement for vaginal hysterectomy”).

AUGS, ACOG, and others responded, and were heard
As a result of an intensive effort, the American Urogynecologic Society (AUGS), in conjunction with the American College of Obstetricians and Gynecologists (ACOG), the Society of Gynecologic Surgeons (SGS), and other professional societies, NCCI has agreed to change or modify a significant number of these pair edits.

As described in my earlier article, NCCI periodically reviews multiple surgical procedures performed in the same setting by a single surgeon to determine whether there is a significant overlap in services and therefore, in their opinion, redundant payment. Most significantly, CMS agreed with the argument made by the AUGS task force that it was inappropriate to bundle combined colporrhaphy with the various vaginal hysterectomy codes. These pair edits will no longer exist, and it is possible to bill separately for an AP repair performed in the same session as a vaginal hysterectomy—and expect additional payment for this procedure (subject to the multiple procedure reduction modifier -51).

Don’t miss out on reimbursement for your prior surgeries
It is important to recognize that this decision will be retroactive to October 1, 2014, which means that surgeons can resubmit charges for procedures performed between October 1, 2014, and March 31, 2015.

An exception to this rule is when the surgeon performs, and bills for, a vaginal hysterectomy code that includes enterocele repair, such as 58263. In these circumstances, the combined colporrhaphy remains bundled with the vaginal hysterectomy, unless a special modifier is used.

When can a modifier be used?
With regard to the majority of the other pair edits, CMS still contends that the edits are appropriate; however, they have modified the edits to allow for these procedures to be billed separately when the surgeon feels that substantial additional work has been performed. For example, CMS holds the position that all vaginal hysterectomies include some type of apical fixation to the surrounding tissues—such as fixation of the vaginal cuff at the time of closure to the distal uterosacral ligaments. However, it will allow for the additional billing for a more extensive vaginal apical suspension (such as a high uterosacral suspension or sacrospinous ligament suspension) as long as the surgeon documents the additional work performed and submits the claim using one of the NCCI-approved surgical modifiers. In this particular circumstance, the -59 modifier is the appropriate choice.

The AUGS task force also had objected to the bundling of a group of codes that, in the society’s opinion, were distinctly unrelated, such as a laparoscopic hysterectomy or vaginal hysterectomy combined with a sacral colpopexy performed through an open abdominal incision. CMS recognizes that these codes are used infrequently together and has therefore assumed that they may be billed in error. AUGS, however, has pointed out that, on occasion, a laparoscopic hysterectomy with an intended laparoscopic colpopexy may be converted to an open procedure due to a complication or technical difficulty, in which case the use of both codes would be appropriate.

The NCCI response was to keep the code pairs bundled but allow for billing with the -59 modifier.

We have cause for cheer, but bundling edits continue
Overall, these changes in pair edits represent a significant improvement in reimbursement for gynecologic surgeons, relative to the changes that went into effect on October 1. A more detailed explanation and list of the codes affected can be found on the AUGS Web site (http://www.augs.org). I emphasize again that these changes not only are in effect as of April 1, 2015, but also are retroactive to October 1, 2014.

Unfortunately, while AUGS and ACOG were advocating for these changes on behalf of gynecologists, NCCI recently has approved 6 additional pair edits that will go into effect on July 1. These changes specifically involve related procedures done at the time of vaginal hysterectomy with enterocele repair (58263, 58270 and 58294, 58292) and posterior vaginal repair (57250).

While these codes will be considered bundled on that date, NCCI will allow the use of the -59 modifier to override the bundle in clinically appropriate cases. The other code pairs affected are the 2 vaginal hysterectomy codes with colpourethropexy (58267, 58293) with anterior repair (57240). Again, these code pairs will be bundled, and it will require the use of a modifier to override this bundle.

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

On October 1, 2014, the Centers for Medicare and Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) implemented a number of new coding pair edits that significantly restricted the types of surgical procedures that could be billed at the same time as vaginal hysterectomy. Most importantly, the new edits did not allow for combined anterior and posterior (AP) vaginal repair (57260) and apical vaginal suspensions (57282, 57283) to be separately billed and reimbursed when performed by the same surgeon and done in the same surgical session as a vaginal or laparoscopic hysterectomy. I initially reported on these changes in the January 2015 issue of OBG Management (“Recent NCCI edits have significantly impacted billing and reimbursement for vaginal hysterectomy”).

AUGS, ACOG, and others responded, and were heard
As a result of an intensive effort, the American Urogynecologic Society (AUGS), in conjunction with the American College of Obstetricians and Gynecologists (ACOG), the Society of Gynecologic Surgeons (SGS), and other professional societies, NCCI has agreed to change or modify a significant number of these pair edits.

As described in my earlier article, NCCI periodically reviews multiple surgical procedures performed in the same setting by a single surgeon to determine whether there is a significant overlap in services and therefore, in their opinion, redundant payment. Most significantly, CMS agreed with the argument made by the AUGS task force that it was inappropriate to bundle combined colporrhaphy with the various vaginal hysterectomy codes. These pair edits will no longer exist, and it is possible to bill separately for an AP repair performed in the same session as a vaginal hysterectomy—and expect additional payment for this procedure (subject to the multiple procedure reduction modifier -51).

Don’t miss out on reimbursement for your prior surgeries
It is important to recognize that this decision will be retroactive to October 1, 2014, which means that surgeons can resubmit charges for procedures performed between October 1, 2014, and March 31, 2015.

An exception to this rule is when the surgeon performs, and bills for, a vaginal hysterectomy code that includes enterocele repair, such as 58263. In these circumstances, the combined colporrhaphy remains bundled with the vaginal hysterectomy, unless a special modifier is used.

When can a modifier be used?
With regard to the majority of the other pair edits, CMS still contends that the edits are appropriate; however, they have modified the edits to allow for these procedures to be billed separately when the surgeon feels that substantial additional work has been performed. For example, CMS holds the position that all vaginal hysterectomies include some type of apical fixation to the surrounding tissues—such as fixation of the vaginal cuff at the time of closure to the distal uterosacral ligaments. However, it will allow for the additional billing for a more extensive vaginal apical suspension (such as a high uterosacral suspension or sacrospinous ligament suspension) as long as the surgeon documents the additional work performed and submits the claim using one of the NCCI-approved surgical modifiers. In this particular circumstance, the -59 modifier is the appropriate choice.

The AUGS task force also had objected to the bundling of a group of codes that, in the society’s opinion, were distinctly unrelated, such as a laparoscopic hysterectomy or vaginal hysterectomy combined with a sacral colpopexy performed through an open abdominal incision. CMS recognizes that these codes are used infrequently together and has therefore assumed that they may be billed in error. AUGS, however, has pointed out that, on occasion, a laparoscopic hysterectomy with an intended laparoscopic colpopexy may be converted to an open procedure due to a complication or technical difficulty, in which case the use of both codes would be appropriate.

The NCCI response was to keep the code pairs bundled but allow for billing with the -59 modifier.

We have cause for cheer, but bundling edits continue
Overall, these changes in pair edits represent a significant improvement in reimbursement for gynecologic surgeons, relative to the changes that went into effect on October 1. A more detailed explanation and list of the codes affected can be found on the AUGS Web site (http://www.augs.org). I emphasize again that these changes not only are in effect as of April 1, 2015, but also are retroactive to October 1, 2014.

Unfortunately, while AUGS and ACOG were advocating for these changes on behalf of gynecologists, NCCI recently has approved 6 additional pair edits that will go into effect on July 1. These changes specifically involve related procedures done at the time of vaginal hysterectomy with enterocele repair (58263, 58270 and 58294, 58292) and posterior vaginal repair (57250).

While these codes will be considered bundled on that date, NCCI will allow the use of the -59 modifier to override the bundle in clinically appropriate cases. The other code pairs affected are the 2 vaginal hysterectomy codes with colpourethropexy (58267, 58293) with anterior repair (57240). Again, these code pairs will be bundled, and it will require the use of a modifier to override this bundle.

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

On October 1, 2014, the Centers for Medicare and Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) implemented a number of new coding pair edits that significantly restricted the types of surgical procedures that could be billed at the same time as vaginal hysterectomy. Most importantly, the new edits did not allow for combined anterior and posterior (AP) vaginal repair (57260) and apical vaginal suspensions (57282, 57283) to be separately billed and reimbursed when performed by the same surgeon and done in the same surgical session as a vaginal or laparoscopic hysterectomy. I initially reported on these changes in the January 2015 issue of OBG Management (“Recent NCCI edits have significantly impacted billing and reimbursement for vaginal hysterectomy”).

AUGS, ACOG, and others responded, and were heard
As a result of an intensive effort, the American Urogynecologic Society (AUGS), in conjunction with the American College of Obstetricians and Gynecologists (ACOG), the Society of Gynecologic Surgeons (SGS), and other professional societies, NCCI has agreed to change or modify a significant number of these pair edits.

As described in my earlier article, NCCI periodically reviews multiple surgical procedures performed in the same setting by a single surgeon to determine whether there is a significant overlap in services and therefore, in their opinion, redundant payment. Most significantly, CMS agreed with the argument made by the AUGS task force that it was inappropriate to bundle combined colporrhaphy with the various vaginal hysterectomy codes. These pair edits will no longer exist, and it is possible to bill separately for an AP repair performed in the same session as a vaginal hysterectomy—and expect additional payment for this procedure (subject to the multiple procedure reduction modifier -51).

Don’t miss out on reimbursement for your prior surgeries
It is important to recognize that this decision will be retroactive to October 1, 2014, which means that surgeons can resubmit charges for procedures performed between October 1, 2014, and March 31, 2015.

An exception to this rule is when the surgeon performs, and bills for, a vaginal hysterectomy code that includes enterocele repair, such as 58263. In these circumstances, the combined colporrhaphy remains bundled with the vaginal hysterectomy, unless a special modifier is used.

When can a modifier be used?
With regard to the majority of the other pair edits, CMS still contends that the edits are appropriate; however, they have modified the edits to allow for these procedures to be billed separately when the surgeon feels that substantial additional work has been performed. For example, CMS holds the position that all vaginal hysterectomies include some type of apical fixation to the surrounding tissues—such as fixation of the vaginal cuff at the time of closure to the distal uterosacral ligaments. However, it will allow for the additional billing for a more extensive vaginal apical suspension (such as a high uterosacral suspension or sacrospinous ligament suspension) as long as the surgeon documents the additional work performed and submits the claim using one of the NCCI-approved surgical modifiers. In this particular circumstance, the -59 modifier is the appropriate choice.

The AUGS task force also had objected to the bundling of a group of codes that, in the society’s opinion, were distinctly unrelated, such as a laparoscopic hysterectomy or vaginal hysterectomy combined with a sacral colpopexy performed through an open abdominal incision. CMS recognizes that these codes are used infrequently together and has therefore assumed that they may be billed in error. AUGS, however, has pointed out that, on occasion, a laparoscopic hysterectomy with an intended laparoscopic colpopexy may be converted to an open procedure due to a complication or technical difficulty, in which case the use of both codes would be appropriate.

The NCCI response was to keep the code pairs bundled but allow for billing with the -59 modifier.

We have cause for cheer, but bundling edits continue
Overall, these changes in pair edits represent a significant improvement in reimbursement for gynecologic surgeons, relative to the changes that went into effect on October 1. A more detailed explanation and list of the codes affected can be found on the AUGS Web site (http://www.augs.org). I emphasize again that these changes not only are in effect as of April 1, 2015, but also are retroactive to October 1, 2014.

Unfortunately, while AUGS and ACOG were advocating for these changes on behalf of gynecologists, NCCI recently has approved 6 additional pair edits that will go into effect on July 1. These changes specifically involve related procedures done at the time of vaginal hysterectomy with enterocele repair (58263, 58270 and 58294, 58292) and posterior vaginal repair (57250).

While these codes will be considered bundled on that date, NCCI will allow the use of the -59 modifier to override the bundle in clinically appropriate cases. The other code pairs affected are the 2 vaginal hysterectomy codes with colpourethropexy (58267, 58293) with anterior repair (57240). Again, these code pairs will be bundled, and it will require the use of a modifier to override this bundle.

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

ATLANTA – Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm, Dr. Keith Hawton urged at the annual conference of the American Association of Suicidology.

He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current U.K. NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the U.K.’s National Health Service, are famously evidence based and concerned with cost-effectiveness.

The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”

“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr. Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

“In our country, hospitals have become obsessed with risk assessment. And usually it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.

Dr. Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.

The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.

Dr. Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg. Med. J. 2014;31:796-8).

And yet, a 32-hospital U.K. national study conducted by Dr. Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014 May 2;4:e004732 [doi:10.1136/bmjopen-2013-004732]).

“It’s a very crude tool,” Dr. Hawton said. “How it found its way into common use in clinical practice is beyond me.”

[email protected]

ATLANTA – Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm, Dr. Keith Hawton urged at the annual conference of the American Association of Suicidology.

He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current U.K. NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the U.K.’s National Health Service, are famously evidence based and concerned with cost-effectiveness.

The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”

“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr. Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

“In our country, hospitals have become obsessed with risk assessment. And usually it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.

Dr. Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.

The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.

Dr. Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg. Med. J. 2014;31:796-8).

And yet, a 32-hospital U.K. national study conducted by Dr. Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014 May 2;4:e004732 [doi:10.1136/bmjopen-2013-004732]).

“It’s a very crude tool,” Dr. Hawton said. “How it found its way into common use in clinical practice is beyond me.”

[email protected]

ATLANTA – Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm, Dr. Keith Hawton urged at the annual conference of the American Association of Suicidology.

He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current U.K. NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the U.K.’s National Health Service, are famously evidence based and concerned with cost-effectiveness.

The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”

“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr. Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

“In our country, hospitals have become obsessed with risk assessment. And usually it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.

Dr. Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.

The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.

Dr. Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg. Med. J. 2014;31:796-8).

And yet, a 32-hospital U.K. national study conducted by Dr. Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014 May 2;4:e004732 [doi:10.1136/bmjopen-2013-004732]).

“It’s a very crude tool,” Dr. Hawton said. “How it found its way into common use in clinical practice is beyond me.”

[email protected]

The objective of this investigation by Pierson and colleagues was to determine if there was any significant difference between erythyromycin and azithromycin, used in combination with ampicillin, for prophylaxis in women with PPROM.

Details of the study
The authors conducted a retrospective study of 168 women at 24 to 34 weeks’ gestation. At the discretion of the attending physician, patients received either ampicillin plus erythromycin or ampicillin plus azithromycin as their prophylactic antibiotic regimen. Patients were excluded from the study if they had a cerclage, a multiple gestation, a history of amniocentesis or fetal surgery, a history of abdominal trauma, or if they had a fetus with a lethal anomaly.

The primary study end point was the duration of the latency period between rupture of membranes and onset of labor. The secondary outcomes were gestational age at delivery, adverse drug effects, neonatal birth weight, Apgar scores, and rates of neonatal death, respiratory distress syndrome, and sepsis.

The mean (SD) duration of the latent period was 9.4 (10.4) days in the azithromycin group and 9.6 (13.2) days in the erythromycin group (P = .4). There also were no significant differences in any of the secondary outcome measures. Accordingly, the authors concluded that azithromycin was an acceptable alternative to erythromycin in the prophylactic antibiotic regimen for patients with PPROM.

Several factors make azithromycin the favored PPROM prophylactic option
In the original Maternal-Fetal Medicine Network trial of prophylactic antibiotics for PPROM, Mercer and colleagues¹ used the combination regimen of ampicillin plus erythromycin. In this regimen, ampicillin primarily targets group B streptococci and Escherichia coli. Erythromycin specifically targets mycoplasma organisms, which can be part of the polymicrobial flora that causes chorioamnionitis. The drug also is effective against chlamydia.

However, erythromycin may cause troublesome gastrointestinal adverse effects, notably diarrhea, in some patients. Therefore, in recent years, several investigators have advocated use of azithromycin in lieu of erythromycin. Azithromycin has a similar spectrum of activity as erythromycin, but it has a more favorable pharmacokinetic profile. When given in a single oral dose of 1,000 mg, it has a half-life of 68 hours, compared with erythromycin’s half-life of 1.6 hours. Thus, it is much easier to administer. Moreover, it is usually much better tolerated than erythromycin and, now that generic versions of the drug are available, it is relatively inexpensive.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Although this study is retrospective (Level II evidence), it is the first to demonstrate that, from the perspective of clinical effectiveness, azithromycin is comparable to erythromycin when used in combination with ampicillin for prophylaxis in patients with PPROM. For the reasons outlined above, I strongly favor azithromycin in lieu of erythromycin.
At our center we administer the drug in a single 1,000-mg oral dose. If the patient cannot tolerate oral medication at the time of admission, the drug can be administered intravenously.

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

The objective of this investigation by Pierson and colleagues was to determine if there was any significant difference between erythyromycin and azithromycin, used in combination with ampicillin, for prophylaxis in women with PPROM.

Details of the study
The authors conducted a retrospective study of 168 women at 24 to 34 weeks’ gestation. At the discretion of the attending physician, patients received either ampicillin plus erythromycin or ampicillin plus azithromycin as their prophylactic antibiotic regimen. Patients were excluded from the study if they had a cerclage, a multiple gestation, a history of amniocentesis or fetal surgery, a history of abdominal trauma, or if they had a fetus with a lethal anomaly.

The primary study end point was the duration of the latency period between rupture of membranes and onset of labor. The secondary outcomes were gestational age at delivery, adverse drug effects, neonatal birth weight, Apgar scores, and rates of neonatal death, respiratory distress syndrome, and sepsis.

The mean (SD) duration of the latent period was 9.4 (10.4) days in the azithromycin group and 9.6 (13.2) days in the erythromycin group (P = .4). There also were no significant differences in any of the secondary outcome measures. Accordingly, the authors concluded that azithromycin was an acceptable alternative to erythromycin in the prophylactic antibiotic regimen for patients with PPROM.

Several factors make azithromycin the favored PPROM prophylactic option
In the original Maternal-Fetal Medicine Network trial of prophylactic antibiotics for PPROM, Mercer and colleagues¹ used the combination regimen of ampicillin plus erythromycin. In this regimen, ampicillin primarily targets group B streptococci and Escherichia coli. Erythromycin specifically targets mycoplasma organisms, which can be part of the polymicrobial flora that causes chorioamnionitis. The drug also is effective against chlamydia.

However, erythromycin may cause troublesome gastrointestinal adverse effects, notably diarrhea, in some patients. Therefore, in recent years, several investigators have advocated use of azithromycin in lieu of erythromycin. Azithromycin has a similar spectrum of activity as erythromycin, but it has a more favorable pharmacokinetic profile. When given in a single oral dose of 1,000 mg, it has a half-life of 68 hours, compared with erythromycin’s half-life of 1.6 hours. Thus, it is much easier to administer. Moreover, it is usually much better tolerated than erythromycin and, now that generic versions of the drug are available, it is relatively inexpensive.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Although this study is retrospective (Level II evidence), it is the first to demonstrate that, from the perspective of clinical effectiveness, azithromycin is comparable to erythromycin when used in combination with ampicillin for prophylaxis in patients with PPROM. For the reasons outlined above, I strongly favor azithromycin in lieu of erythromycin.
At our center we administer the drug in a single 1,000-mg oral dose. If the patient cannot tolerate oral medication at the time of admission, the drug can be administered intravenously.

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

The objective of this investigation by Pierson and colleagues was to determine if there was any significant difference between erythyromycin and azithromycin, used in combination with ampicillin, for prophylaxis in women with PPROM.

Details of the study
The authors conducted a retrospective study of 168 women at 24 to 34 weeks’ gestation. At the discretion of the attending physician, patients received either ampicillin plus erythromycin or ampicillin plus azithromycin as their prophylactic antibiotic regimen. Patients were excluded from the study if they had a cerclage, a multiple gestation, a history of amniocentesis or fetal surgery, a history of abdominal trauma, or if they had a fetus with a lethal anomaly.

The primary study end point was the duration of the latency period between rupture of membranes and onset of labor. The secondary outcomes were gestational age at delivery, adverse drug effects, neonatal birth weight, Apgar scores, and rates of neonatal death, respiratory distress syndrome, and sepsis.

The mean (SD) duration of the latent period was 9.4 (10.4) days in the azithromycin group and 9.6 (13.2) days in the erythromycin group (P = .4). There also were no significant differences in any of the secondary outcome measures. Accordingly, the authors concluded that azithromycin was an acceptable alternative to erythromycin in the prophylactic antibiotic regimen for patients with PPROM.

Several factors make azithromycin the favored PPROM prophylactic option
In the original Maternal-Fetal Medicine Network trial of prophylactic antibiotics for PPROM, Mercer and colleagues¹ used the combination regimen of ampicillin plus erythromycin. In this regimen, ampicillin primarily targets group B streptococci and Escherichia coli. Erythromycin specifically targets mycoplasma organisms, which can be part of the polymicrobial flora that causes chorioamnionitis. The drug also is effective against chlamydia.

However, erythromycin may cause troublesome gastrointestinal adverse effects, notably diarrhea, in some patients. Therefore, in recent years, several investigators have advocated use of azithromycin in lieu of erythromycin. Azithromycin has a similar spectrum of activity as erythromycin, but it has a more favorable pharmacokinetic profile. When given in a single oral dose of 1,000 mg, it has a half-life of 68 hours, compared with erythromycin’s half-life of 1.6 hours. Thus, it is much easier to administer. Moreover, it is usually much better tolerated than erythromycin and, now that generic versions of the drug are available, it is relatively inexpensive.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Although this study is retrospective (Level II evidence), it is the first to demonstrate that, from the perspective of clinical effectiveness, azithromycin is comparable to erythromycin when used in combination with ampicillin for prophylaxis in patients with PPROM. For the reasons outlined above, I strongly favor azithromycin in lieu of erythromycin.
At our center we administer the drug in a single 1,000-mg oral dose. If the patient cannot tolerate oral medication at the time of admission, the drug can be administered intravenously.

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