Current Trends in Clinical Practice for the Direct Anterior Approach Total Hip Arthroplasty.

BACKGROUND: Despite increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), current practice trends and specific driving factors leading to adoption are not well established. METHODS: We conducted an electronic e-mail survey of members of the American Association of Hip and Knee Surgeons inquiring into the choice of THA surgical approach, perceptions of clinical outcomes, and economic implications associated with the DAA. RESULTS: Of 996 total respondents (44.3% American Association of Hip and Knee Surgeons member response rate), 56.2% currently perform the DAA. DAA performers have been in practice for statistically less time than non-performers (17.0 years vs 20.9 years, P < .001). Similarly, high-volume DAA surgeons have been in practice for less time than low-volume surgeons. DAA performers felt that revision case status (79.3%), complex anatomy (65.0%), and body habitus (53.0%) were factors leading to preferential use of the posterior approach. We also provide comprehensive data for perceived outcomes comparing the DAA and posterior approach. For current non-performers, the top reasons for not utilizing the DAA were feelings of worse outcomes, no clinical benefit, and concern for the learning curve. Economically, 76.1% of DAA performers reported increased patient market share by performing the DAA while 65.8% of non-performers endorsed lost patient market share. Only 3.0% of current non-performers plan to adopt the DAA in the future. CONCLUSION: This is the first study of its kind to highlight current trends and clinical practices from a surgeon perspective regarding the DAA. Specifically, it provides comprehensive data regarding perceptions of clinical outcomes, practice economics, and driving factors for choice of surgical approach for surgeons who do and do not perform the DAA.

Retrospective assessment of patient characteristics and healthcare costs prior to a diagnosis of Alzheimer's disease in an administrative claims database.

BACKGROUND: The objective of this study was to examine patient characteristics and health care resource utilization (HCRU) in the 36 months prior to a confirmatory diagnosis of Alzheimer's disease (AD) compared to a matched cohort without dementia during the same time interval. METHODS: Patients newly diagnosed with AD (with ≥2 claims) were identified between January 1, 2013 to September 31, 2015, and the date of the second claim for AD was defined as the index date. Patients were enrolled for at least 36 months prior to index date. The AD cohort was matched to a cohort with no AD or dementia codes (1:3) on age, gender, race/ethnicity, and enrollment duration prior to the index date. Descriptive analyses were used to summarize patient characteristics, HCRU, and healthcare costs prior to the confirmatory AD diagnosis. The classification and regression tree analysis and logistic regression were used to identify factors associated with the AD diagnosis. RESULTS: The AD cohort (N = 16,494) had significantly higher comorbidity indices and greater odds of comorbid mental and behavioral diagnoses, including mild cognitive impairment, mood and anxiety disorders, behavioral disturbances, and cerebrovascular disease, heart disease, urinary tract infections, and pneumonia than the matched non-AD or dementia cohort (N = 49,482). During the six-month period before the confirmatory AD diagnosis, AD medication use and diagnosis of mild cognitive impairment, Parkinson's disease, or mood disorder were the strongest predictors of a subsequent confirmatory diagnosis of AD. Greater HCRU and healthcare costs were observed for the AD cohort primarily during the six-month period before the confirmatory AD diagnosis. CONCLUSION: The results of this study demonstrated a higher comorbidity burden and higher costs for patients prior to a diagnosis of AD in comparison to the matched cohort. Several comorbidities were associated with a subsequent diagnosis of AD.

The Achilles Tendon in Healthy Subjects: An Anthropometric and Ultrasound Mapping Study.

Ultrasonography is an inexpensive, fast, and reliable imaging technique widely used to assess the Achilles tendon. Although significant data exists regarding pathologic tendon changes, ultrasound data from healthy individuals are more limited. We aimed to better characterize ultrasound Achilles tendon measurements in healthy individuals and identify important correlating factors. The information collected included patient demographics, body habitus, activity level, foot dominance, and resting ankle angle. Ultrasound analysis was performed bilaterally on the Achilles tendons of 50 subjects using a high-frequency transducer to measure tendon width, thickness, cross-sectional area, and length. Males had a significantly larger mean tendon length, width, thickness, and cross-sectional area. No statistically significant difference was found in any tendon dimension between the white and black participants. Similarly, no difference was found in any tendon parameter when comparing right versus left leg dominance. Healthy subjects had a mean ankle resting angle of 45.1° ± 24° with no statistically significant difference between right and left ankles. Considering all individuals, each tendon parameter (tendon length, width, thickness, and cross-sectional area) correlated positively with subject height, weight, tibia length, and foot size. Only the Achilles cross-sectional area correlated significantly with the activity level. The resting angle of the ankle correlated positively with both tendon length and thickness. In conclusion, we found significant variations in Achilles tendon anatomy in the healthy adult population. We have thoroughly characterized significant correlations between healthy tendon dimensions and various body habitus, activity levels, and ankle parameters. Greater knowledge of the normal Achilles tendon anatomy and characterization of its variations in the healthy population will potentially allow for better pathologic diagnosis and surgical repair.

Impact of a pregabalin step therapy policy among medicare advantage beneficiaries.

BACKGROUND: Managed healthcare organizations often utilize formulary management strategies such as prior authorization and step therapy to guide appropriate medication use and to control medication expenditures. The objective of this study was to examine clinical and economic outcomes associated with implementation of a pregabalin step therapy (ST) policy among Medicare Advantage Prescription Drug (MAPD) members. METHODS: Pharmacy and medical claims data from Humana (restricted cohort; ST policy implemented 01/01/2009) and Thomson Reuters MarketScan(®) (unrestricted cohort) were analyzed for MAPD members aged 65 to 89 years receiving treatment for painful diabetic peripheral neuropathy (pDPN), postherpetic neuralgia (PHN) or fibromyalgia (FM). Difference-in-differences (DID) was used to examine year-over-year changes in disease-related and all-cause utilization and costs. Regression analyses examined medication utilization and healthcare expenditures after controlling for between-group compositional differences. RESULTS: We identified 13,911 members in the restricted cohort and matched to members from unrestricted health plans. FM (51.0%) and pDPN (41.8%) were the most common diagnoses. Members in the unrestricted cohort were older and had a greater level of comorbidity than members in the restricted cohort. The restricted cohort demonstrated greater year-over-year decrease in pregabalin utilization and increase in year-over-year gabapentin utilization compared with the unrestricted cohort. ST restriction was associated with an increase in disease-related pharmacy costs and a decrease in total medical costs for the restricted cohort compared with the unrestricted cohort. There was no difference between cohorts in total healthcare cost. CONCLUSION: After controlling for differences in age and comorbidity burden between the groups, implementation of a pregabalin ST restriction was associated with increased disease-related pharmacy costs and decreased total medical costs; however, there was no net difference in total healthcare cost or total pharmacy cost.

Pain conditions ranked by healthcare costs for members of a national health plan.

Healthcare resource utilization (HCRU) and associated costs specific to pain are a growing concern, as increasing dollar amounts are spent on pain-related conditions. Understanding which pain conditions drive the highest utilization and cost burden to the healthcare system would enable providers and payers to better target conditions to manage pain adequately and efficiently. The current study focused on 36 noncancer chronic and 14 noncancer acute pain conditions and measured the HCRU and costs per member over 365 days. These conditions were ranked by per-member costs and total adjusted healthcare costs to determine the most expensive conditions to a national health plan. The top 5 conditions for the commercial line of business were back pain, osteoarthritis (OA), childbirth, injuries, and non-hip, non-spine fractures (adjusted annual total costs for the commercial members were $119 million, $98 million, $69 million, $61 million, and $48 million, respectively). The top 5 conditions for Medicare members were OA, back pain, hip fractures, injuries, and non-hip, non-spine fractures (adjusted annual costs for the Medicare members were $327 million, $218 million, $117 million, $82 million, and $67 million, respectively). The conditions ranked highest for both per-member and total healthcare costs were hip fractures, childbirth, and non-hip, non-spine fractures. Among these, hip fractures in the Medicare member population had the highest mean cost per member (adjusted per-member cost was $21,058). Further examination specific to how pain is managed in these high-cost conditions will enable providers and payers to develop strategies to improve patient outcomes through appropriate pain management.

Cost drivers of prescription opioid abuse in commercial and Medicare populations.

OBJECTIVE: Growth in the number of patients with pain conditions, and the subsequent rise in prescription opioid use for treatment, has been accompanied by an increase in diagnosed opioid abuse. Understanding what drives the incremental healthcare costs of members diagnosed with prescription opioid abuse may assist in developing better screening techniques for abuse. DESIGN: This retrospective analysis examined costs, resource use, and comorbidities 365 days pre- and postdiagnosis in prescription opioid users diagnosed with abuse (cases) vs. their matched nondiagnosed controls. Inclusion criteria for cases were diagnosis of opioid abuse (ICD-9-CM: 304.0x, 304.7x, 305.5x, 965.0x). Multivariate analysis used generalized linear modeling with log-transformed cost as dependent variable, controlling for comorbidities. RESULTS: Final sample sizes were 8,390 cases and 16,780 matched controls. Postindex abuse-related costs were $2,099 for commercial members, $539 for Medicare members aged < 65, and $170 for Medicare members aged ≥ 65. A higher percentage of cases had pain conditions (82.0% vs. 57.4% commercial, 95.9% vs. 87.5% Medicare members aged < 65, 92.9% vs. 82.4% Medicare members aged ≥ 65, P < 0.0001), and a higher numbers of cases had multiple opioid prescribers (3.7 vs. 1.4 commercial, 3.3 vs. 2.2 Medicare < 65, 2.2 vs. 1.6 Medicare ≥ 65, P < 0.0001) than controls preindex. Cases had higher rates of substance abuse and psychiatric diagnoses pre- and postindex (P < 0.0001, all comparisons). Adjusted costs were 28% higher for cases than for controls (P < 0.0001). CONCLUSION: Costs of members diagnosed with prescription opioid abuse are driven by higher pain and psychiatric comorbidities relative to nonabuse controls.

The prevalence of diagnosed opioid abuse in commercial and Medicare managed care populations.

PURPOSE: To measure the prevalence of diagnosed opioid abuse and prescription opioid use in a multistate managed care organization. METHODS: This retrospective claims data analysis reviewed the prevalence of diagnosed opioid abuse and the parallel prevalence of prescription opioid use in half-year intervals for commercial and Medicare members enrolled with Humana Inc., from January 1, 2008 to June 30, 2010. Diagnosis of opioid abuse was defined by ≥ 1 medical claim with any of the following ICD-9-CM codes: 304.0 ×, 304.7 ×, 305.5 ×, 965.0 ×, excluding 965.01, and opioid use was defined by ≥ 1 filled prescription for an opioid. The prevalence of opioid abuse was defined by the number of members with an opioid abuse diagnosis, divided by the number of members enrolled in each 6-month interval. RESULTS: The 6-month prevalence of diagnosed opioid abuse increased from 0.84 to 1.15 among commercial and from 3.17 to 6.35 among Medicare members, per 1,000. In contrast, there was no marked increase in prescription opioid use during the same time period (118.0 to 114.8 for commercial members, 240.6 to 256.9 for Medicare members, per 1,000). The prevalence of diagnosed opioid abuse was highest among members younger than 65 years for both genders in commercial (18- to 34-year-olds) and Medicare (35- to 54-year-olds) populations. CONCLUSIONS: Despite a stable rate of prescription opioid use among the observed population, the prevalence of diagnosed opioid abuse is increasing, particularly in the Medicare population.

Manifestations of pulmonary disease in adults with congenital heart disease.

Children with congenital heart disease (CHD) are more frequently living into adulthood as their survival has improved due to availability of better medical and surgical management in recent times. Management of adults with CHD is emerging as new challenge in the field of medical science. Adults surviving with CHD for longer duration have been observed to develop more complications as compared to children. It is important to recognise and treat these complications early to reduce the morbidity. Pulmonary diseases are the most common systemic complications associated with adults having CHD. These individuals are presenting to clinics or emergency for pulmonary complaints, hence, pulmonologist must be aware about the pulmonary manifestations of CHD and their management.

Telehealth Clinical Appropriateness and Quality.

Contrary to common perception, telehealth is not simply a substitute for in-person care. With an array of modalities-live audio-video, asynchronous patient communication, and remote patient monitoring, to name a few-telehealth creates entirely new avenues of care delivery (Table 1). Although our current care model is reactive-relying on episodic visits to an office or hospital-telehealth allows us to be proactive, filling in the gaps to provide a continuum of care. Widespread uptake of telehealth has created fertile ground for long-overdue health system reform. In this study, we describe essential next steps: redefine telehealth clinical appropriateness, evolve payment models, provide necessary training, and reimagine the patient-physician interaction.

Diagnostic accuracy of the repeatable battery of the assessment of neuropsychological status update, Spanish version, in predicting Alzheimer's disease among Hispanic older adults in the United States reporting memory problems.

OBJECTIVES: There are few standardized, Spanish-language diagnostic tools to help identify Hispanic persons at early stages of Alzheimer's disease (AD). This study evaluated the accuracy of the Spanish version of the Repeatable Battery for the Assessment of Neuropsychological Status-Update (RBANS) in predicting AD in older Hispanic adults in the United States reporting memory problems. METHODS: We analyzed data from age, sex, and education level propensity score-matched Hispanic memory clinic patients with (n = 38) and without (n = 38) a clinical diagnosis of AD. Estimates of diagnostic accuracy included sensitivity, specificity, predictive value, and receiver operating characteristic analysis. RESULTS: After controlling for sex and matched pairs, the Total Scale score [area under curve (AUC) = 0.7417] and the Immediate (AUC = 0.7258) and Delayed (AUC = 0.7735) Memory index scores provided better estimates of diagnostic accuracy than Language, Attention, and Visuospatial/Constructional index scores. A minus 2-standard deviation (SD) cut point enhanced the predictive probability of the Delayed Memory index score. A cut point of -1.5 SD optimized the predictive probability of the Total Scale score. CONCLUSIONS: These results suggest that optimal cutoff values for the RBANS Delayed Memory index and Total Scale scores that may help identify Hispanic patients with AD as part of a comprehensive diagnostic AD assessment.

Remote Care Management for Older Adult Populations With Elevated Prevalence of Depression or Anxiety and Comorbid Chronic Medical Illness: A Systematic Review.

BACKGROUND: Comorbidity of psychiatric and medical illnesses among older adult populations is highly prevalent and associated with adverse outcomes. Care management is a common form of outpatient support for both psychiatric and medical conditions in which assessment, care planning, and care coordination are provided. Although care management is often remote and delivered by telephone, the evidence supporting this model of care is uncertain. OBJECTIVE: To perform a systematic review of the literature on remote care management programs for older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness. METHODS: A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A multidatabase search was performed. Articles were included for review if they studied fully remote care management for older adult populations with elevated prevalence of depression or anxiety and chronic medical illness or poor physical health. A narrative synthesis was performed. RESULTS: A total of 6 articles representing 6 unique studies met inclusion criteria. The 6 studies included 4 randomized controlled trials, 1 case-matched retrospective cohort study, and 1 pre-post analysis. Two studies focused on specific medical conditions. All interventions were entirely telephonic. Five of 6 studies involved an intervention that was 3 to 6 months in duration. Across the 6 studies, care management demonstrated mixed results in terms of impact on psychiatric outcomes and limited impact on medical outcomes. No studies demonstrated a statistically significant impact on health care utilization or cost. CONCLUSIONS: Among older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness, remote care management may have favorable impact on psychiatric symptoms, but impact on physical health and health care utilization is uncertain. Future research should focus on identifying effective models and elements of remote care management for this population, with a particular focus on optimizing medical outcomes.

Assessment of Unmet Health-Related Social Needs Among Patients With Mental Illness Enrolled in Medicare Advantage.

Importance: A large body of literature has found associations between unmet health-related social needs (HRSNs) and adverse mental health outcomes. A comparative analysis of the risks associated with HRSNs among patients with varying severity of mental illness and an assessment of how these risks compare with those of individuals without mental illness are needed. Objective: To examine the prevalence and risks of HRSNs among patients with serious and persistent mental illness (SPMI), patients with mental health diagnoses but no serious and persistent mental illness (non-SPMI), and patients with both SPMI and non-SPMI compared with individuals without mental illness. Design, Setting, and Participants: This retrospective cohort study used data from the Accountable Health Communities HRSN Screening Tool surveys, which target a nationally representative sample of Medicare Advantage members of a large payer (Humana Inc). The surveys were conducted between October 16, 2019, and February 29, 2020. Of the initial 329 008 eligible Medicare Advantage enrollees, 70 273 responded to the survey (21.4% response rate). Of those, 56 081 respondents (79.8%) had complete survey responses and were included in the final analytic sample. Main Outcomes and Measures: Outcomes of interest included 7 HRSNs (financial strain, food insecurity, housing instability, housing quality, severe loneliness, transportation problems, and utility affordability) based on responses to the survey. The major independent variable was the presence of mental illness up to 12 months preceding the date of survey completion. Codes indicating mental illness listed as the primary, principal, or secondary diagnoses of a patient's inpatient or outpatient medical claims data were identified, and participants were grouped into 4 cohorts: SPMI, non-SPMI, SPMI plus non-SPMI, and no mental illness. Results: Among 56 081 older adults, the mean (SD) age was 71.31 (8.59) years; 32 717 participants (58.3%) were female, and 43 498 (77.6%) were White. A total of 21 644 participants (38.6%) had at least 1 mental illness diagnosis in the past year, 30 262 (54.0%) had an HRSN, and 14 163 (25.3%) had both mental illness and an HRSN. Across all specific HRSNs, the odds of experiencing the respective HRSN was most substantial for those with SPMI plus non-SPMI vs those with only non-SPMI or SPMI. The HRSN with the largest risk differences among the study cohorts was severe loneliness; compared with the cohort without mental illness, the non-SPMI cohort had 2.07 times higher odds (95% CI, 1.84-2.32; P < .001), the SPMI cohort had 3.35 times higher odds (95% CI, 3.03-3.71; P < .001), and the SPMI plus non-SPMI cohort had 5.13 times higher odds (95% CI, 4.68-5.61; P < .001) of severe loneliness. Conclusions and Relevance: In this study, the increased risk of having HRSNs associated with SPMI, alone or in combination with non-SPMI, emphasizes the need for more targeted interventions to address social needs in this vulnerable population.

Characteristics of Parkinson's Disease in Patients with and without Cognitive Impairment.

BACKGROUND: Characterizing patients with Parkinson's disease (PD) and cognitive impairment is important toward understanding their natural history. OBJECTIVE: Understand clinical, treatment, and cost characteristics of patients with PD pre- and post-cognitive impairment (memory loss/mild cognitive impairment/dementia or dementia treatment) recognition. METHODS: 2,711 patients with PD newly diagnosed with cognitive impairment (index) were identified using administrative claims data. They were matched (1:1) on age and gender to patients with PD and no cognitive impairment (controls). These two cohorts were compared on patient characteristics, healthcare resource utilization, and total median costs for 3 years pre- and post-index using Chi-square tests, t-tests, and Wilcoxon rank-sum tests. Logistic regression was used to identify factors predicting cognitive impairment. RESULTS: Comorbidity indices for patients with cognitive impairment increased during the 6-year study period, especially after the index. Enrollment in Medicare Advantage Prescription Drug plans vs. commercial (OR = 1.60), dual Medicare/Medicaid eligibility (OR = 1.36), cerebrovascular disease (OR = 1.24), and PD medication use (OR = 1.46) were associated with a new cognitive impairment diagnosis (all p < 0.05). A greater proportion of patients with cognitive impairment had hospitalizations and emergency department visits and higher median total healthcare costs than controls for each year pre- and post-index. CONCLUSION: In patients with PD newly diagnosed with cognitive impairment, comorbidity burden, hospitalizations, emergency department visits, and total costs peaked 1-year pre- and post-identification. These data coupled with recommendations for annual screening for cognitive impairment in PD support the early diagnosis and management of cognitive impairment in order to optimize care for patients and their caregivers.

Spontaneous Spinal Epidural Hematoma: An Atypical Clinical Presentation and Discussion of Management.

INTRODUCTION: Spontaneous spinal epidural hematoma (SSEH) is a rare but potentially devastating condition if not appropriately identified and managed. A few case series exist regarding SSEH and certain risk factors have been described; however, much continues to be unknown regarding the pathophysiology and optimal management. CASE PRESENTATION: We present the case of SSEH in a healthy 33-year-old African American woman with no identifiable risk factors who initially presented with significant neurologic compromise. This case reports discusses pertinent clinical presentation, imaging findings, and surgical management. The patient demonstrated near-complete neurologic recovery, highlighting the need for prompt identification and intervention. CONCLUSIONS: We believe this case adds to the limited literature surrounding the topic, particularly in regard to diagnosis and surgical management. It is essential for clinicians to be cognizant of SSEH for timely diagnosis and treatment, even in patients without obvious risk factors.

Metabolic Monitoring Rates of Youth Treated with Second-Generation Antipsychotics in Usual Care: Results of a Large US National Commercial Health Plan.

Objectives: To examine metabolic monitoring rates in commercially insured children and adolescents treated with a second-generation antipsychotic (SGA) during calendar years (CYs) 2016 and 2017. Methods: In this retrospective study, data were collected from a large national commercial health plan for the period covering January 1, 2016 to December 31, 2017. Commercially insured children and adolescents, aged 8-19 years with ≥2 SGA prescription claims during the CY, were identified for the CY2016 and CY2017 cohorts. The primary outcome of interest was the percentage of subjects with any glucose or lipid metabolism parameter monitoring. Other calculated metabolic testing rates included glucose, hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), other cholesterol (including triglycerides), and combined glucose and lipid metabolism testing (≥1 test for blood glucose or HbA1c and ≥1 test for LDL-C or other cholesterol). Results: In CY2016 and CY2017, 1502 and 1239 subjects, respectively, were identified for this study. The most common psychiatric diagnoses in CY2016 and CY2017 were major depressive disorder (57.1%, 56.5%, respectively), anxiety disorders (42.9%, 47.5%), attention-deficit/hyperactivity disorder (41.6%, 45.8%), and bipolar disorder (24.1%, 25.9%). The rate of any metabolic testing was 53.5% in CY2016 and 51.3% in CY2017. Glucose testing (50.3%, 46.9%, respectively) was most common in both CYs, followed by LDL-C testing (31.2%, 28.5%). Rates of combined glucose and lipid metabolism testing were 30.7% in CY2016 and 26.9% in CY2017. Conclusions: Given the known potential for adverse cardiometabolic effects, rates of metabolic monitoring associated with SGA use in children and adolescents urgently need to be improved. There is a critical need for understanding barriers to routine monitoring, particularly of lipids, and developing interventions to enhance metabolic monitoring.

Hemorrhagic stroke associated with antidepressant use in patients with depression: does degree of serotonin reuptake inhibition matter?

OBJECTIVE: This study aimed to determine whether the degree of serotonin (5-HT) reuptake inhibition affects risk of hemorrhagic stroke associated with antidepressant use in patients with depression. METHOD: A population-based, nested case-control study was performed using a managed care medical claims database. Ninety two depressed patients with a diagnosis of hemorrhagic stroke were identified and matched with 552 controls by age, sex, and year of index date of depression (IDD). Diagnoses of depression, hemorrhagic stroke, and other medical comorbidities were identified using ICD-9 codes. Antidepressants were classified as high, medium, or low reuptake inhibition based on their affinities for the 5-HT reuptake transporter, determined using their respective equilibrium dissociation constants (K(D); high: K(D) < 1 nM; medium: 1 or= 10 nM). Conditional logistic regression analysis was performed to estimate the crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of the risk of hemorrhagic stroke. RESULTS: Compared to non-users of antidepressants, risk of hemorrhagic stroke did not significantly differ between patients who had ever used antidepressants with high (OR = 0.82; 95% CI = 0.44-1.55), medium (OR = 0.93; 95% CI = 0.37-2.31), or low (OR = 0.38; 95% CI = 0.11-1.41) 5-HTT inhibition. CONCLUSION: Risk of hemorrhagic stroke associated with antidepressant use may not be related to an antidepressant's degree of 5-HT reuptake inhibition. Given the limitations of this study, additional studies are needed to confirm these findings.

Pulmonary manifestations of primary Sjögren's syndrome.

Sjögren's syndrome (SS) is a complex autoimmune exocrinopathy with multifactorial pathogenesis and multisystem manifestation. It is called primary Sjögren's syndrome (PSS) when the manifestations are seen without any other co-existent rheumatic diseases. The incidence of respiratory system involvement varies widely in the reported medical literature, partly due to lack of a universal agreement over the diagnostic criteria of the disease and the type of study methods employed. Respiratory system manifestations are protean; upper airway symptoms are very common and so is the complaint of dry cough. The PSS patients may develop interstitial lung diseases (ILDs) such as usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP), lymphocytic interstitial pneumonia (LIP), bronchiolitis obliterans and organising pneumonia (BOOP), etc. They may also develop the whole spectrum of lymphoproliferative disorders of the lung ranging from LIP to follicular bronchiolitis, nodular lymphoid hyperplasia and low-grade lymphomas. Therapeutic options include symptomatic and supportive measures and corticosteroids as the mainstay of the treatment for ILDs occurring in these patients. In recent years, rituximab (anti-CD20) has emerged as a promising treatment for this disease, though data from controlled trials are still lacking. Pulmonary involvement may be a source of significant morbidity in these patients, though only rarely, it is the cause of death.

Clonidine for attention-deficit/hyperactivity disorder: II. ECG changes and adverse events analysis.

OBJECTIVE: To examine the safety and tolerability of clonidine used alone or with methylphenidate in children with attention-deficit/hyperactivity disorder (ADHD). METHOD: In a 16-week multicenter, double-blind trial, 122 children with ADHD were randomly assigned to clonidine (n = 31), methylphenidate (n = 29), clonidine and methylphenidate (n = 32), or placebo (n = 30). Doses were flexibly titrated up to 0.6 mg/day for clonidine and 60 mg/day for methylphenidate (both with divided dosing). Groups were compared regarding adverse events and changes from baseline to week 16 in electrocardiograms and vital signs. RESULTS: There were more incidents of bradycardia in subjects treated with clonidine compared with those not treated with clonidine (17.5% versus 3.4%; p =.02), but no other significant group differences regarding electrocardiogram and other cardiovascular outcomes. There were no suggestions of interactions between clonidine and methylphenidate regarding cardiovascular outcomes. Moderate or severe adverse events were more common in subjects on clonidine (79.4% versus 49.2%; p =.0006) but not associated with higher rates of early study withdrawal. Drowsiness was common on clonidine, but generally resolved by 6 to 8 weeks. CONCLUSIONS: Clonidine, used alone or with methylphenidate, appears safe and well tolerated in childhood ADHD. Physicians prescribing clonidine should monitor for bradycardia and advise patients about the high likelihood of initial drowsiness.

Atypical neuroleptic malignant syndrome: diagnostic controversies and considerations.

Neuroleptic malignant syndrome (NMS) is a serious and potentially fatal adverse effect of antipsychotic drugs. The diagnosis of NMS commonly requires core symptoms of hyperthermia and muscle rigidity. Although diagnostic criteria for NMS have been established and are widely accepted and used, it should be recognized that atypical presentations pose a diagnostic dilemma, as hyperthermia and/or muscle rigidity may be absent or develop slowly over several days, leading to impairment or a significant delay in diagnosis and treatment. Evidence from case reports and retrospective evaluations supports a concept of atypical NMS, particularly with regard to treatment with atypical antipsychotics. However, it remains unclear whether these atypical presentations represent early or impending NMS. Furthermore, it is unclear whether dysfunction in other neurotransmitter systems, in addition to dopamine, may be involved in the pathogenesis of NMS induced by atypical antipsychotics. In patients receiving any antipsychotic, clinicians should carefully evaluate any features of NMS and should not prematurely exclude a diagnosis of NMS in cases where severe rigidity or hyperthermia is not initially apparent.

Risk of cerebrovascular events associated with antidepressant use in patients with depression: a population-based, nested case-control study.

BACKGROUND: Given the widespread use of antidepressants and the negative consequence of cerebrovascular events (CVEs), an evaluation of the risk of CVEs associated with antidepressants is warranted. OBJECTIVE: To examine the association between the use of an antidepressant and risk of CVEs among patients diagnosed with depression. METHODS: A case-control study was performed using a managed care medical claims database from 1998 through 2002. A total of 1086 cases with CVEs were identified and matched with 6515 controls by age, sex, and the year of the index date of depression. Case patients were categorized by stroke type: hemorrhagic stroke, ischemic stroke, and other CVEs. Diagnoses of depression, CVEs, and other medical comorbidities were identified based on International Classification of Diseases, Ninth Revision, codes. Patients were defined as current users (antidepressant ended < or =30 days before CVE), recent users (31-60 days before CVE), past users (61-90 days before CVE), and remote/nonusers (> or =91 days before CVE or nonuse). Cox proportional hazards regression analysis was conducted to estimate the risk of CVEs associated with antidepressant use. RESULTS: A 24% increased risk of a CVE was noted in patients with current exposure to selective serotonin-reuptake inhibitors (SSRIs; adjusted hazard ratio [HR] 1.24; 95% CI 1.07 to 1.44), 34% increased risk for current exposure to tricyclic antidepressants (HR 1.34; 95% CI 1.10 to 1.62), and 43% increased risk for current exposure to other antidepressants (HR 1.43; 95% CI 1.21 to 1.69). The risk of ischemic stroke in current SSRI users was significantly higher (HR 1.55; 95% CI 1.00 to 2.39) compared with remote/nonusers. CONCLUSIONS: Current users of antidepressants may be at increased risk of a CVE. Clinicians should consider the relationship of antidepressants with the occurrence of CVEs when determining the risk-benefit profile of pharmacologic treatment in patients with depression, particularly those with existing risk factors for a CVE.