Practical approaches for diagnosis and management of prurigo nodularis: United States expert panel consensus.

BACKGROUND: Prurigo nodularis (PN) is a chronic disease characterized by intensely pruritic, raised, nodular lesions. Because there are currently no United States Food and Drug Administration-approved therapies specifically for PN, management is highly variable, and no consensus exists on treatment regimens. OBJECTIVE: To provide practical guidance to help United States dermatologists diagnose and effectively treat patients with PN. METHODS: We participated in a roundtable discussion to develop consensus recommendations on diagnosis and treatment of PN from a United States perspective. RESULTS: The core findings in PN are the presence of firm, nodular lesions; pruritus lasting at least 6 weeks; and a history or signs, or both, of repeated scratching, picking, or rubbing. The diagnostic workup involves a complete review of systems, considering potential systemic diseases, and assessment of disease severity, including disease burden and pruritus intensity. Treatment should be selected based on a patient's clinical presentation, comorbidities, and response to prior treatments and should address both neural and immunologic components of pruritus. LIMITATIONS: Data on PN are from anecdotal or small clinical trials, and all treatments are currently used off-label. CONCLUSION: An effective treatment approach for patients with PN should be based on clinical judgment and tailored to the individual needs of the patient.

The Multifaceted Role of Curcumin in Advanced Nanocurcumin Form in the Treatment and Management of Chronic Disorders.

Curcumin is the primary polyphenol in turmeric's curcuminoid class. It has a wide range of therapeutic applications, such as anti-inflammatory, antioxidant, antidiabetic, hepatoprotective, antibacterial, and anticancer effects against various cancers, but has poor solubility and low bioavailability. Objective: To improve curcumin's bioavailability, plasma concentration, and cellular permeability processes. The nanocurcumin approach over curcumin has been proven appropriate for encapsulating or loading curcumin (nanocurcumin) to increase its therapeutic potential. Conclusion: Though incorporating curcumin into nanocurcumin form may be a viable method for overcoming its intrinsic limitations, and there are reasonable concerns regarding its toxicological safety once it enters biological pathways. This review article mainly highlights the therapeutic benefits of nanocurcumin over curcumin.

Opuntia ficus-indica (L.) Mill.: A Multi-Benefit Potential to Be Exploited.

Consumer interest in foods with enhanced nutritional quality has increased in recent years. The nutritional and bioactive characterization of fruits and their byproducts, as well as their use in the formulation of new food products, is advisable, contributing to decrease the global concerns related to food waste and food security. Moreover, the compounds present in these raw materials and the study of their biological properties can promote health and help to prevent some chronic diseases. Opuntia ficus-indica (L.) Mill. (prickly pear) is a plant that grows wild in the arid and semi-arid regions of the world, being a food source for ones and a potential for others, but not properly valued. This paper carries out an exhaustive review of the scientific literature on the nutritional composition and bioactive compounds of prickly pear and its constituents, as well as its main biological activities and applications. It is a good source of dietary fiber, vitamins and bioactive compounds. Many of its natural compounds have interesting biological activities such as anti-inflammatory, hypoglycemic and antimicrobial. The antioxidant power of prickly pear makes it a good candidate as an ingredient of new food products with fascinating properties for health promotion and/or to be used as natural extracts for food, pharmaceutic or cosmetic applications. In addition, it could be a key player in food security in many arid and semi-arid regions of the world, where there are often no more plants.

Evidence for deprescription in primary care through an umbrella review.

BACKGROUND: There is a high prevalence of potentially inappropriate prescriptions in primary care. This is associated with more frequent adverse events, lower quality of life and more frequent visits to hospital accident & emergency departments. The aim of the present study is to summarise available evidence on the effectiveness of deprescription interventions in primary care, and to describe the barriers and enablers of the process from the point of view of patients and healthcare professionals. METHODS: We designed an umbrella review which includes nine systematic reviews. More than 50% of included studies were performed with adults in primary care. Two reviewers independently performed data extraction and analysis. RESULTS: In considering studies of the effectiveness of interventions, it can be observed that the educational component of deprescription procedures is a key factor, whilst procedures tailored towards the patient's situation offer better results. With regards to studies involving healthcare professionals, the main explored areas were the balance between risks and benefits, and the need to improve communication with patients as well as other colleagues involved in patient care. Amongst the identified barriers we found lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. With regards to patients, it is clear that they have worries and doubts. In order to overcome these issues, a good relationship with healthcare professionals and receipt of their support is required during the process. CONCLUSIONS: Optimizing medication through targeted deprescribing is an important part of managing chronic conditions, avoiding adverse effects and improving outcomes. The majority of deprescription interventions in primary care are effective. Good communication between healthcare professionals is a key element for success in the deprescription process.

Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care.

Short-term systemic corticosteroids, also known as steroids, are frequently prescribed for adults in the outpatient setting by primary care physicians. There is a lack of supporting evidence for most diagnoses for which steroids are prescribed, and there is evidence against steroid use for patients with acute bronchitis, acute sinusitis, carpal tunnel, and allergic rhinitis. There is insufficient evidence supporting routine use of steroids for patients with acute pharyngitis, lumbar radiculopathy, carpal tunnel, and herpes zoster. There is evidence supporting use of short-term steroids for Bell palsy and acute gout. Physicians might assume that short-term steroids are harmless and free from the widely known long-term effects of steroids; however, even short courses of systemic corticosteroids are associated with many possible adverse effects, including hyperglycemia, elevated blood pressure, mood and sleep disturbance, sepsis, fracture, and venous thromboembolism. This review considers the evidence for short-term steroid use for common conditions seen by primary care physicians.

Citric acid treatment of oral ulcers refractory to conventional treatment: a case study.

OBJECTIVE: Oral ulcers are painful sores that appear in the mouth. Most of them are usually harmless and clear up on their own. Sometimes, they are non-responsive and difficult to manage. This report describes the case of an 80-year-old female patient with chronic oral ulcers of three years duration and which were refractory to conventional therapy. The ulcers were subsequently treated using 3% citric acid as a sole topical agent, applied three times a day that resulted in complete healing of oral ulcers by day 10 of treatment. The findings of this case report suggest that topical citric acid is a possible alternative treatment for chronic oral ulcers unresponsive to conventional treatment.

Non-Adherence to Prescribed Therapies: Pharmacare's Existential Challenge.

Pharmacare, a recently proposed addition to Canada's universal medicare program, has become a prominent topic in the public discourse, but funding and leadership have not been established. Repeated Health Care in Canada (HCIC) surveys of the adult public and a broad spectrum of health professionals reveal very strong support for a national system that is easy to access and covers all prescribed pharmaceuticals. Although the practical details of universal pharmacare remain to be established, there is strong support among the public and professionals as well as increasing federal government interest in moving forward and ultimately implementing pharmacare. At the same time, HCIC surveys indicate that a high percentage of patients do not take their medications as directed, both for acute and chronic illnesses. The data suggest that pharmacare's success will be severely challenged by this. Of the four major challenges preventing usual care from being the best care - suboptimal access, non-diagnosis, non-prescription and non-adherence - risk from some form of non-adherence is often ranked first by care professionals. The most commonly reported reasons for non-adherence in clinical settings are patients' forgetfulness and how they feel in the moment on any given day. Costs of therapy, lack of understanding or poor knowledge transfer between prescribers and patients regarding therapeutic risks and benefits are rarely cited causes for poor adherence. These findings from the 2018 HCIC survey are not new. They are very consistent with measurements in the 2016 and other previous HCIC surveys. They do, however, raise practical challenges for the creation and ongoing management of universal pharmacare. Specifically, a patient-centred care component designed to improve non-adherence to prescribed therapies is needed. Ideally, it should include a measurement and feedback component on adherence that shares data with and between patients, health professionals and payers. Things can be better.

Impact of a nurse-based intervention on medication outcomes in vulnerable older adults.

BACKGROUND: Medication-related problems are common in older adults with multiple chronic conditions. We evaluated the impact of a nurse-based primary care intervention, based on the Guided Care model of care, on patient-centered aspects of medication use. METHODS: Controlled clinical trial of the Comprehensive Care for Multimorbid Adults Project (CC-MAP), conducted among 1218 participants in 7 intervention clinics and 6 control (usual care) clinics. Inclusion criteria included age 45-94, presence of ≥3 chronic conditions, and Adjusted Clinical Groups (ACG) score > 0.19. The co-primary outcomes were number of changes to the medication regimen between baseline and 9 month followup, and number of changes to symptom-focused medications, markers of attentiveness to medication-related issues. RESULTS: Mean age in the intervention group was 72 years, 59% were women, and participants used a mean of 6.6 medications at baseline. The control group was slightly older (73 years) and used more medications (mean 7.1). Between baseline and 9 months, intervention subjects had more changes to their medication regimen than control subjects (mean 4.04 vs. 3.62 medication changes; adjusted difference 0.55, p = 0.001). Similarly, intervention subjects had more changes to their symptomatic medications (mean 1.38 vs. 1.26 changes, adjusted difference 0.20, p = 0.003). The total number of medications in use remained stable between baseline and follow-up in both groups (p > 0.18). CONCLUSION: This nurse-based, primary care intervention resulted in substantially more changes to patients' medication regimens than usual care, without increasing the total number of medications used. This enhanced rate of change likely reflects greater attentiveness to the medication-related needs of patients. TRIAL REGISTRATION: This trial is registered at https://clinicaltrials.gov , trial number NCT01811173 .

Information about management of chronic drug therapies prescribed at hospital discharge: does it affect patients' knowledge and self-confidence?

BACKGROUND: Hospital stay represents the opportunity for a change of therapy, about which patients may not know indications, contraindications, and mode of administration, which may lead to dosing errors, drug interactions, side effects, etc. It is therefore vital to communicate appropriate information to the discharged patient with a new prescription drug. The purpose of the study was to evaluate: 1) how communication about new chronic therapies is managed at hospital discharge and what kind of information is provided to patients; 2) to what extent patients are aware and confident in the management of these medications; 3) whether the way communication is provided affects patients' awareness and self-confidence in the management of these therapies. METHODS: Participants were adult patients who were prescribed at least one new chronic medication at hospital discharge. A telephone interview after hospital discharge was performed to assess whether or not hospital healthcare personnel had given information about prescribed therapies and which aspects of therapies had been object of information. RESULTS: Five hundred thirty patients were interviewed. 67.7% reported having received counseling by the hospital physician, while 32.3% by discharge form. Basic information on treatment was provided to the great majority of patients, whereas only few patients reported to have been informed about eventual side effects and related behavior in case of side effects. CONCLUSIONS: Several aspects of patients' knowledge and self-confidence on long term medications prescribed at hospital discharge need to be improved and the way communication is provided has a crucial role in the empowerment of patients in the management of these medications.

Updating the research on the chemopreventive and therapeutic role of the peptide lunasin.

Chronic diseases have become the medical challenge of the 21st century because of their high incidence and mortality rates. Modulation of diet and lifestyle habits is considered as the best strategy for the prevention of these disorders. Health promoting benefits beyond their nutritional effects have been described for multiple dietary compounds. Among these compounds, the peptide lunasin is considered as one of the most promising. Naturally present in soybean, lunasin has been extensively studied in the last two decades because of its potential against chronic diseases such as cancer, cardiovascular and immunological disorders. The purpose of this article is to summarise the evidence on the presence of lunasin in soybean and derived foods, and its bioavailability once it is orally ingested. The protective and therapeutic effects of this peptide against cancer, oxidative stress, inflammation, and high cholesterol levels as well as the molecular mechanisms of action involved in these effects are also described in this review. © 2017 Society of Chemical Industry.

Relationship Between Traditional Chinese Medicine(TCM)Constitution and TCM Syndrome in the Diagnosis and Treatment of Chronic Diseases.

Chronic diseases are global threats to human health. By applying the traditional Chinese medicine (TCM) theory of body constitution to the treatment of chronic diseases, and comprehensively identifying and differentiating the syndrome, disease, and constitution, TCM can be fully used in the diagnosis and treatment of chronic diseases. In this manner, population-based and evidence-based modern medicine can organically align with the individual-focused and speculation-based TCM, with subsequent benefits for the control of chronic diseases, reducing their burden on human health.

CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management - Innovations and Opportunities.

Adherence to prescribed medications is associated with improved clinical outcomes for chronic disease management and reduced mortality from chronic conditions (1). Conversely, nonadherence is associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs (2). In the United States, 3.8 billion prescriptions are written annually (3). Approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency, and duration (4). Whereas rates of nonadherence across the United States have remained relatively stable, direct health care costs associated with nonadherence have grown to approximately $100-$300 billion of U.S. health care dollars spent annually (5,6). Improving medication adherence is a public health priority and could reduce the economic and health burdens of many diseases and chronic conditions (7).

The efficacy of topical hyaluronan in rhinosinusitis: a systematic review.

Rhinosinusitis is one of the most common inflammatory conditions of the nasal cavity and paranasal sinuses and is one of the most common causes of absence from work and for visits to the family doctor. The treatment strategy in both acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) is to reduce the severity of the symptoms, minimize the duration of the disease and prevent complications. Topical therapy has become an important tool in otolaryngologists’ armamentarium for rhinosinusitis treatment. Recently, topical hyaluronic acid (HA), the major component of many extracellular matrices that promotes tissue healing, including activation and moderation of the inflammatory responses, cell proliferation, migration and angiogenesis, has been proposed for ARS and CRS adjuvant tool. The aim of the study is to systematically review the published literature regarding all the therapeutic effects of HA on the ARS and CRS. Relevant published studies were found in PubMed, Google Scholar and Ovid, using a combined keyword search or medical subject headings. At the end of our study selection process, 5 relevant publications were included: 2 of them investigated the potential role of HA in reducing symptoms and preventing exacerbations of CRS in adult population, two of them in paediatric patients affected by upper respiratory tract infections and one of them in cystic fibrosis patients with bacterial rhinopharyngitis. Data deriving from the present review of 5 clinical studies showed that the use of topical HA represents a relevant therapeutic advance in rhinosinusitis to minimize symptoms and prevent reacutization with a significant improvement of their quality of life, as it avoids systemic side effects and increases local drug activity. Further studies on larger populations and with new specific nebulization devices for upper airway are needed to confirm these encouraging results.

Lower fragmentation of coordination in primary care is associated with lower prescribing drug costs-lessons from chronic illness care in Hungary.

Improving patient care coordination is critical for achieving better health outcome measures at reduced cost. However, assessing the results of patient care coordination at system level is lacking. In this report, based on administrative healthcare data, a provider-level care coordination measure is developed to assess the function of primary care at system level. In a sample of 31 070 patients with diabetes we find that the type of collaborative relationship general practitioners build up with specialists is associated with prescription drug costs. Regulating access to secondary care might result in cost savings through improved care coordination.

[Patient-oriented medicine in the elderly]. / Patientenorientierte Medizin im höheren Lebensalter.

A higher age is usually associated with multimorbidity due to chronic illnesses intermittently aggravated by acute disease and exarcerbation of pre-existing chronic illnesses. Physical and psychological diseases often coexist. Cure in the classical sense should not be the priority of diagnostic and therapeutic decision making, but more a prioritization of patient-oriented care. This includes polypharmacy which most often accompanies multimorbidity. Therapeutic actions and designated endpoints are therefore different from those in younger persons because preservation of functionality and independence is priority, not survival. Rehabilitative treatments are important in all settings that care for old and very old persons. Older adults and their care-givers also often express different time and treatment goals.

Reducing excess mortality due to chronic disease in people with severe mental illness: meta-review of health interventions.

BACKGROUND: People with severe mental illness (SMI) have high rates of chronic disease and premature death. AIMS: To explore the strength of evidence for interventions to reduce risk of mortality in people with SMI. METHOD: In a meta-review of 16 systematic reviews of controlled studies, mortality was the primary outcome (8 reviews). Physiological health measures (body mass index, weight, glucose levels, lipid profiles and blood pressure) were secondary outcomes (14 reviews). RESULTS: Antipsychotic and antidepressant medications had some protective effect on mortality, subject to treatment adherence. Integrative community care programmes may reduce physical morbidity and excess deaths, but the effective ingredients are unknown. Interventions to improve unhealthy lifestyles and risky behaviours can improve risk factor profiles, but longer follow-up is needed. Preventive interventions and improved medical care for comorbid chronic disease may reduce excess mortality, but data are lacking. CONCLUSIONS: Improved adherence to pharmacological and physical health management guidelines is indicated.

Impact of the introduction of mandatory generic substitution in South Africa: private sector sales of generic and originator medicines for chronic diseases.

OBJECTIVE: To assess the impact of mandatory offer of generic substitution, introduced in South Africa in May 2003, on private sector sales of generic and originator medicines for chronic diseases. METHODS: Private sector sales data (June 2001 to May 2005) were obtained from IMS Health for proton pump inhibitors (PPIs; ATC code A02BC), HMG-CoA reductase inhibitors (statins; C10AA), dihydropyridine calcium antagonists (C08CA), angiotensin-converting enzyme inhibitors (ACE-I; C09AA) and selective serotonin reuptake inhibitors (SSRIs; N06AB). Monthly sales were expressed as defined daily doses per 1000 insured population per month (DDD/TIM). Interrupted time-series models were used to estimate the changes in slope and level of medicines use after the policy change. ARIMA models were used to correct for autocorrelation and stationarity. RESULTS: Only the SSRIs saw a significant rise in level of generic utilisation (0.2 DDD/TIM; P < 0.001) and a fall in originator usage (-0.1 DDD/TIM; P < 0.001) after the policy change. Utilisation of generic PPIs fell (level 0.06 DDD/TIM, P = 0.048; slope 0.01 DDD/TIM, P = 0.043), but utilisation of originator products also grew (level 0.05 DDD/TIM, P < 0.001; slope 0.003, P = 0.001). Generic calcium antagonists and ACE-I showed an increase in slope (0.01 DDD/TIM, P = 0.016; 0.02 DDD/TIM, P < 0.001), while the originators showed a decrease in slope (-0.003 DDD/TIM, P = 0.046; -0.01 DDD/TIM, P < 0.001). There were insufficient data on generic statin use before the policy change to allow for analysis. CONCLUSION: The mandatory offer of generic substitution appeared to have had a quantifiable effect on utilisation patterns in the 2 years after May 2003. Managed care interventions that were already in place before the intervention may have blunted the extent of the changes seen in this period. Generic policies are an important enabling provision for cost-containment efforts. However, decisions taken outside of official policy may anticipate or differ from that policy, with important consequences.

The prescription pickup lag, an automatic prescription refill program, and community pharmacy operations.

OBJECTIVES: To determine the effect of an automatic prescription refill program on the prescription pickup lag in community pharmacy. DESIGN: A post-only quasi-experimental design comparing automatic and manual refill prescription cohorts for each of the 3 Centers for Medicare and Medicaid medication adherence metrics. SETTING: A 29-store community pharmacy chain in the Midwest. PARTICIPANTS: Community-dwelling patients over the age of 65 years receiving prescription medications included in the statin, renin-angiotensin-aldosterone system antagonist, or non-insulin diabetes adherence metrics. INTERVENTION: An automatic prescription refill program that initiated prescription refills on a standardized, recurrent basis, eliminating the need for patients to phone in or drop off prescription refills. MAIN OUTCOME MEASURES: The prescription pickup lag, defined as the number of days between a prescription being adjudicated in the pharmacy and the prescription being picked up by the patient. RESULTS: A total of 37,207 prescription fills were examined. There were 20.5%, 22.4%, and 23.3% of patients enrolled in the automatic prescription refill program for the statin, renin-angiotensin-aldosterone system antagonist, and diabetes adherence metrics, respectively. Prescriptions in the automatic prescription refill cohorts experienced a median pickup lag of 7 days compared with 1 day for the manual refill prescriptions. 35.2% of all manual refill prescriptions had a pickup lag of 0 days compared with 13% for automatic refills. However, 15.4% of automatic prescription refills had a pickup lag of greater than 14 days, compared with 4.8% of manual refills. CONCLUSION: Prescriptions in the automatic prescription refill programs were associated with a significantly longer amount of time in the pharmacy before being picked up by the patient. This increased pickup lag may contribute positively by smoothing out workload demands of pharmacy staff, but may contribute negatively owing to an increased amount of rework and greater inventory requirements.

Revised response criteria for myelofibrosis: International Working Group-Myeloproliferative Neoplasms Research and Treatment (IWG-MRT) and European LeukemiaNet (ELN) consensus report.

The current document is a revision of the International Working Group-Myeloproliferative Neoplasms Research and Treatment (IWG-MRT) criteria for treatment response in myelofibrosis (MF) and represents a collaborative effort by the IWG-MRT and the European LeukemiaNet to objectively assess the value of new drugs in inducing morphologic remission or improvement in MF-associated symptomatic burden (MF-SB). Some of the changes in the current revision include stricter definitions of red cell transfusion dependency and independency and consideration of the Myeloproliferative Neoplasm Symptom Assessment Form as a tool to quantify meaningful changes in disease-related symptoms. Six response categories are listed: complete remission (CR) and partial remission signify treatment effects that are consistent with disease modification, whereas drug-induced improvements in MF-SB were annotated as clinical improvement, anemia response, spleen response, or symptoms response. Additional criteria are provided for progressive disease, stable disease, and relapse. The document also includes recommendations for assessing cytogenetic and molecular remissions, without mandating their inclusion for CR assignment.

Obsessive-Compulsive Disorder: Diagnosis and Management.

Obsessive-compulsive disorder (OCD) is a chronic illness that can cause marked distress and disability. It is a complex disorder with a variety of manifestations and symptom dimensions, some of which are underrecognized. Early recognition and treatment with OCD-specific therapies may improve outcomes, but there is often a delay in diagnosis. Patients can experience significant improvement with treatment, and some may achieve remission. Recommended first-line therapies are cognitive behavior therapy, specifically exposure and response prevention, and/or a selective serotonin reuptake inhibitor (SSRI). Patients with OCD require higher SSRI dosages than for other indications, and the treatment response time is typically longer. When effective, long-term treatment with an SSRI is a reasonable option to prevent relapse. Patients with severe symptoms or lack of response to first-line therapies should be referred to a psychiatrist. There are a variety of options for treatment-resistant OCD, including clomipramine or augmenting an SSRI with an atypical antipsychotic. Patients with OCD should be closely monitored for psychiatric comorbidities and suicidal ideation.