Caren Garber

A Nationwide Survey of Antimicrobial Stewardship Practices

OBJECTIVEnThe goal of this study was to characterize hospital antimicrobial stewardship practices nationwide and to identify factors associated with the presence of these programs.nnnMETHODSnThe first web-based survey was sent in 2009 to members of the Yankee Alliance and the Premier Healthcare Alliance, nationwide organizations of health-care providers. The second survey, a slightly modified version of the first, was sent in 2010 to a commercially purchased list of hospital pharmacy director e-mail addresses.nnnRESULTSnA total of 406 responses were received from ~5890 providers targeted, for an overall response rate of ~7%. More than one half (206 of 406) of the respondents reported having what they considered to be a formal antimicrobial stewardship program (ASP). Among all respondents regardless of presence or absence of an ASP, 96.4% (351 of 364) were using some form of antimicrobial stewardship technique. Of those respondents working in hospitals without an ASP, 63.3% (114 of 180) had considered implementing one. After controlling for all significant variables, those that remained which were significantly associated with having an ASP were survey (Premier vs commercial), having an infectious disease consultation service, and having an infectious disease pharmacist.nnnCONCLUSIONSnIn this survey of 406 respondents from across the country, we found that just more than one half of hospitals had what they considered to be formal ASPs; however, the vast majority were using stewardship techniques to optimize the use of antibiotics. Common barriers to implementation of ASPs included staffing constraints and insufficient funding.

Nutritional modulation of cataract

Lens opacification or cataract reduces vision in over 80 million people worldwide and blinds 18 million. These numbers will increase dramatically as both the size of the elderly demographic and the number of those with carbohydrate metabolism-related problems increase. Preventative measures for cataract are critical because the availability of cataract surgery in much of the world is insufficient. Epidemiologic literature suggests that the risk of cataract can be diminished by diets that are optimized for vitamin C, lutein/zeaxanthin, B vitamins, omega-3 fatty acids, multivitamins, and carbohydrates: recommended levels of micronutrients are salutary. The limited data from intervention trials provide some support for observational studies with regard to nuclear - but not other types of - cataracts. Presented here are the beneficial levels of nutrients in diets or blood and the total number of participants surveyed in epidemiologic studies since a previous review in 2007.

Diminishing Risk for Age-Related Macular Degeneration with Nutrition: A Current View

Age-related macular degeneration (AMD) is the leading cause of blindness in the elderly. Clinical hallmarks of AMD are observed in one third of the elderly in industrialized countries. Preventative interventions through dietary modification are attractive strategies, because they are more affordable than clinical therapies, do not require specialists for administration and many studies suggest a benefit of micro- and macro-nutrients with respect to AMD with few, if any, adverse effects. The goal of this review is to provide information from recent literature on the value of various nutrients, particularly omega-3 fatty acids, lower glycemic index diets and, perhaps, some carotenoids, with regard to diminishing risk for onset or progression of AMD. Results from the upcoming Age-Related Eye Disease Study (AREDS) II intervention trial should be particularly informative.

Use of spatial mapping technology to characterize geographic and socioeconomic reach of teledermatology service

Teledermatology has been shown to be cost saving from patient and societal perspectives, and can improve access to care. However, few studies have analysed the geographic and socioeconomic status distribution of patients utilizing a teledermatology versus dermatology clinic when both services are available. Such analysis can objectively assess whether teledermatology is preferentially utilized by the underserved and/or socioeconomically disadvantaged patients, and help institutions plan for the targeted expansion of teledermatology services to improve outreach efforts. The current study applied spatial or geo-mapping technology to assess the geographic and socioeconomic status distribution of patients receiving teledermatology versus dermatology clinic services at veterans affairs (VA) Boston Healthcare System. The same technology can be applied to other institutional or commercial teledermatology services, and scaled to analyse regional and national data. This single institution, retrospective, veterans affairs institutional review board (VA-IRB)-approved study analysed data from all teledermatology patients and a randomly selected subset of clinic patients in 2014. Patients who were referred to clinics as a direct result of teledermatology evaluation were excluded. Residential census tracts were determined using the federal financial institutions examination council (FFIEC) Geocoding/Mapping system, and mapped using the Arc-GIS software. Patient’s socioeconomic status was inferred from residential census tract’s poverty level; that is, percentage of households living below the federal poverty level (FPL), a validated measure for studies on health outcome disparities. Referral pattern, location of residence, driving distance to site of initial evaluation, and patients’ socioeconomic status as inferred from poverty level of residential neighbourhood were compared. There were 296 teledermatology patients and 532 clinic patients with over 95% of both cohorts residing in Massachusetts. Some 93.8% of teledermatology consults came from the five clinical sites with no or limited dermatology clinics. Teledermatology patients travelled significantly fewer miles to the site of initial evaluation compared to clinic patients (12.2 miles vs. 20.9 miles, p< 0.001). A smaller proportion of teledermatology patients had to travel >20 miles (17% vs. 45%, p< 0.001). Geographic distribution of teledermatology and clinic patients were similar: the majority resided along the coast, centring on the Boston metropolitan area. Few resided in the relatively underserved areas of Cape Cod and central Massachusetts (Figure 1). A smaller proportion of teledermatology patients lived within a 15-mile radius of VA Boston: 26.4% (171/269) versus 41.3% (198/479), p< 0.05. Over 90% of both teledermatology and clinic patients lived in urban census tracts, defined as areas with>2500 people. Most patients in both cohorts lived in fairly affluent neighbourhoods, with <10% of residents earning an income below the FPL (Figure 2). The average percentage of households with an income below the FPL was 9.0% versus 8.9% for teledermatology versus clinic patients. There was no significant difference between teledermatology and clinic cohorts in the proportion of patients living in poverty areas; that is, census tracts with 20% or more residents with an income below the FPL: 11.2% versus 8.4%, respectively (Figure 2). While our study suggests that teledermatology is not preferentially utilized in impoverished areas of Massachusetts, a recent analysis of California Medicaid patients with coverage for both teledermatology and dermatology clinic visits showed that nearly half of dermatology patients were evaluated by teledermatology, indicating that socioeconomically disadvantaged patients

Incidence of melanoma and keratinocytic carcinomas in patients evaluated by store-and-forward teledermatology vs. dermatology clinic

It is unclear whether incidence of detected skin cancer in patients evaluated by store‐and‐forward teledermatology (SAF) vs. face‐to‐face consultation (F2F) significantly differs, and whether such differences are because of variations in patient demographics, diagnostic accuracy, or both.

Effect of Pregnancy on Psoriasis and Psoriatic Arthritis

Psoriasis and psoriatic arthritis are chronic illnesses that are prevalent in women of childbearing age. The aim of this review is to bring to light data regarding the effect of pregnancy and the postpartum period on psoriasis and psoriatic arthritis and to discuss the major theories underlying these changes. To date, evidence indicates a tendency toward improvement of psoriasis and psoriatic arthritis during pregnancy and a flare in the postpartum period. This is likely a consequence of physiologic adaptations during pregnancy and the subsequent loss of these protective factors in the postpartum period. Most prominent among these adaptations are hormonally induced changes in helper T cell (Th1, Th2, and Th17) cytokines. However, alterations in proteins and cell surface molecules also have been implicated. The relatively high prevalence of psoriasis and psoriatic arthritis in women of childbearing age mandates that patients, dermatologists, and obstetricians alike be knowledgeable of the gestational and postpartum changes that occur in these diseases.

Analysis of Gender Differences in the Efficacy of Psoriasis Treatment Modalities Resulting in Clearance

Background/Objective Characterize gender differences in efficacy of psoriasis treatments, as this has not been well studied. Methods In this retrospective cohort study, data were collected on patients with psoriasis seen at Tufts Medical Center between 2008 and 2014. Treatment courses lasting ≥ 4 weeks in patients with baseline moderate to severe psoriasis were included. Clearance was defined as an S-MAPA (simple measure for assessing psoriasis activity, the product of body surface area and physician global assessment) ≤ 3. Results Of the 172 biologic treatment courses, 81 (47%) resulted in clearance, 56% of females and 39% of males (RR=1.43, p=0.032). Women were more likely to clear on infliximab (88% compared to 27% of males, RR=3.21, p=0.02) despite a significantly higher baseline S-MAPA in females in this subgroup (166.63 versus 94.86 in men, p=0.05). There was no statistically significant gender difference in clinical outcomes for patients on conventional systemics or combination treatment courses. Conclusion Clinical outcomes are better for biologics, especially infliximab, in females compared to males with moderate to severe psoriasis. Further investigation of possible biologic or pharmacokinetic explanations for this finding is warranted.

The Comparative Efficacy of Traditional Systemic, Biologic, and Combination Therapies in the Treatment of Psoriasis: An Expansion Study:

Background There is a lack of comparative effectiveness research, particularly in the clinical setting, guiding psoriasis therapy. Objective To compare the efficacies of the traditional systemic, biologic, and combination therapies. Methods This retrospective cohort study analyzed psoriasis patient visits to the Tufts Medical Center Department of Dermatology. The outcome measure used was the validated simple measure for assessing psoriasis activity (S-MAPA). Results Patients treated with biologic or combination therapies had a significantly larger improvement in S-MAPA than patients treated with a traditional systemic medication at 24 weeks (biologic: 62.69% vs. 36.20%, p=0.021; combination: 83.28% vs. 36.20%, p=0.011). Multivariate analysis demonstrated the superiority of biologics to traditional systemic therapy was independent of patient demographics and comorbidities. Conclusions In the clinical setting, the biologic and combination therapies are superior to the traditional systemic therapies in the treatment of psoriasis. Emphasis should be placed on future trials that compare current active therapies.

Assessment of the Use of Adrenocorticotropic Hormone in Psoriatic Arthritis

Background A 39-amino-acid peptide of the natural form of adrenocorticotropic hormone (ACTH) was designed to provide a prolonged release after administration by intramuscular or subcutaneous injection. It is FDA-approved as adjunctive therapy for psoriatic arthritis for short-term administration. Clinical data on the safety of ACTH in psoriatic arthritis is limited. Objective To assess the safety data for the use of ACTH in psoriatic arthritis and compare it with the safety data for corticosteroids. Methods We conducted a systematic review of the literature pertaining to the safety of ACTH versus corticosteroids in psoriatic arthritis. We queried the PubMed database for studies evaluating (i) ACTH and Acthar in psoriatic arthritis using the search terms “psoriatic arthritis” and “ACTH” or “acthar” or “adrenocorticotropic hormone” and (ii) ACTH and Acthar in RA or psoriatic arthritis using the terms “rheumatoid arthritis” or “psoriatic arthritis” and “ACTH” or “acthar” or “adrenocorticotropic hormone.” We placed no time limits on either search. From the search results, we selected studies that emphasize safety data. Due to limited psoriatic arthritis-related data, we included data related to rheumatoid arthritis (RA). Results The current body of knowledge surrounding the safety of ACTH in psoriatic arthritis is limited. Twenty studies met our inclusion criteria, 14 of which directly compared ACTH to corticosteroids in either psoriatic arthritis or RA. Of these, five studies reported comparable safety between the two, four studies reported more adverse events with ACTH, two studies reported more adverse events with corticosteroids, and three studies were inconclusive. Conclusion There is no clear evidence that ACTH is safer than corticosteroids for psoriatic arthritis.