Beyond Confirmed Mast Cell Activation Syndrome: Approaching Patients With Dysautonomia and Related Conditions.

Allergist-immunologists face significant challenges as experts in an ever-evolving field of neuroimmunology. Among these challenges is the increasingly frequent need to counsel patients with suspected mast cell activation disorders about perceived comorbidities, which may include hypermobile Ehlers-Danlos syndrome, amplified pain syndrome, fibromyalgia, burning sensation syndromes, migraines, irritable bowel syndrome, and postural orthostatic tachycardia syndrome. Patients may experience comorbid anxiety, panic disorder, and depression associated with disturbed sleep, fatigue, and cognitive impairment that often worsen when their physical symptoms increase in severity. These conditions may mimic mast cell activation disorders and are emotionally taxing for patients and clinicians because they are often accompanied by vague diagnostic courses, perceived unmanageability, social stigma, and significant impairment in quality of life. Combined with relatively poorly researched therapies, it is no surprise that clinicians may feel overwhelmed or find it difficult to provide consistently compassionate care for this population. In this article, we review available therapies for these conditions, which run the gamut from physical therapy to antidepressants to multimodal pain control. We highlight the benefit of multidisciplinary care within the primary care home, which includes an important role by the allergist-immunologist. By outlining simple approaches to initial treatment, we hope to empower clinicians with the tools needed to curb emotional burnout and embrace this patient population with compassion.

What happens after the kidney biopsy? The findings nephrologists should know.

BACKGROUND: Percutaneous kidney biopsies are important tools for the diagnosis of kidney diseases. Nephrologists must be familiar with the expected complications of the procedure to provide an adequate informed consent. Here, we present a quality improvement analysis that reviews the complication rate of percutaneous kidney biopsies performed over a 2-year period by nephrologists at a single center, and that tabulates the nature and timing of these events. METHODS: From a single center cohort, pre- and post-biopsy anthropomorphic and clinical measurements were collected. Post-biopsy complications were tracked and sorted into either major or minor complications. Statistical tests were used to analyze complication incidence across the pre- and post-biopsy measurements obtained. RESULTS: Of the 154 nephrologist-performed percutaneous native kidney biopsies, 2 biopsies (1.3%) were found to result in a major complication. Both major complications were detected within 4 hours of the biopsy. Analysis of the pre-biopsy and post-biopsy measurements found that the proportion of complications was higher in patients with hematuria prior to biopsy. It was also found that patients with complications were statistically younger and had fewer comorbidities. Under univariable analysis, older age was associated with a lower incidence rate ratio for complications. However, no pre-or-post biopsy measurement or characteristic had a statistically significant change in incidence rate ratio under multivariable analysis. CONCLUSIONS: Percutaneous kidney biopsies were found to be low risk when performed by nephrologists in this single center cohort. Consistent with past literature, life threatening major complications rarely occurred and were reliably identified within 4 hours of biopsy, suggesting that centers can consider reduced observation times without compromising patient safety. Minor complications, such as pain, were more likely to occur in younger, healthier patients, and in those with hematuria prior to biopsy. This extensive tabulation of all biopsy adverse events is the first of its kind and will be beneficial for nephrologists to inform discussions with patients about expectations and risk-benefit of this procedure.

Insurance Plan Adherence to Mandate for Long-Acting Reversible Contraceptives in a Large Pediatric Hospital Network.

STUDY OBJECTIVE: Long-acting reversible contraceptives (LARCs) are the most effective form of pregnancy prevention for sexually active adolescents, yet usage rates are low. The Affordable Care Act (ACA) mandated insurers cover LARCs without cost-sharing. Compliance with this policy is not well documented. This study assessed LARC coverage by insurers in a large pediatric health system. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS: Between June and August 2016, LARC coverage was assessed through content reviews of insurance Web sites, formularies, and summaries of benefits for all Pennsylvania Medicaid plans and the top 20 commercial insurers for a large pediatric health system. MAIN OUTCOME MEASURES: The primary outcome was adherence to the ACA mandate for LARC coverage without cost-sharing. RESULTS: Among the 37 plans (17 public, 20 private), 21 (56.8%) were adherent and 16 (43.2%) were nonadherent. Among nonadherent plans, 3 plans covered LARC services but required cost-sharing, whereas 13 did not cover LARC services at all. There was not a statistically significant difference in LARC coverage between public and private plans. CONCLUSION: Despite the landmark ACA mandate, insurance coverage of LARCs in pediatric hospitals is low for young women among private and public insurers. Insurer failure to adhere to the ACA among pediatric patients represents a barrier to LARC access for those at high risk of unintended pregnancy.