Variation in Specialist Palliative Care Reach and Associated Factors Among People With Advanced Heart Failure in the Department of Veterans Affairs

CONTEXT

Clinical practice guidelines recommend palliative care for people with advanced heart failure (aHF), yet it remains underutilized.

OBJECTIVES

We examined medical center variation in specialist palliative care (SPC) and identified factors associated with variation among people with aHF.

METHODS

We conducted a retrospective cohort study of 21,654 people with aHF who received healthcare in 83 Veterans Affairs Medical Centers (VAMCs) from 2018-2020. We defined aHF with ICD-9/10 codes and hospitalizations. We used random intercept multilevel logistic regression to derive SPC reach (i.e., predicted probability) for each VAMC adjusting for demographic and clinical characteristics. We then examined VAMC-level SPC delivery characteristics associated with predicted SPC reach including the availability of outpatient SPC (proportion of outpatient consultations), cardiology involvement (number of outpatient cardiology-initiated referrals), and earlier SPC (days from aHF identification to consultation).

RESULTS

Of the sample the mean age = 72.9+/-10.9 years, 97.9% were male, 61.6% were White, and 32.2% were Black. The predicted SPC reach varied substantially across VAMCs from 9% to 57% (mean: 28% [95% Confidence Interval: 25%-30%]). Only the availability of outpatient SPC was independently associated with higher SPC reach. VAMCs, in which outpatient delivery made up the greatest share of SPC consultations (9% or higher) had 11% higher rates of SPC reach relative to VAMCs with a lower proportion of outpatient SPC.

CONCLUSION

SPC reach varies widely across VAMCs for people with aHF. Outpatient palliative is common among high-reach VAMCs but its role in reach warrants further investigation. Strategies used by high-reach VAMCs may be potential targets to test for implementation and dissemination.

Clinical documentation of patient identities in the electronic health record: Ethical principles to consider

The American Psychological Association's multicultural guidelines encourage psychologists to use language sensitive to the lived experiences of the individuals they serve. In organized care settings, psychologists have important decisions to make about the language they use in the electronic health record (EHR), which may be accessible to both the patient and other health care providers. Language about patient identities (including but not limited to race, ethnicity, gender, and sexual orientation) is especially important, but little guidance exists for psychologists on how and when to document these identities in the EHR. Moreover, organizational mandates, patient preferences, fluid identities, and shifting language may suggest different documentation approaches, posing ethical dilemmas for psychologists to navigate. In this article, we review the purposes of documentation in organized care settings, review how each of the five American Psychological Association Code of Ethics' General Principles relates to identity language in EHR documentation, and propose a set of questions for psychologists to ask themselves and their patients when making choices about documenting identity variables in the EHR. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Validation of Electronic Health Record-Based Algorithms to Identify Specialist Palliative Care Within the Department of Veterans Affairs

BACKGROUND

The measurement of specialist palliative care (SPC) across Department of Veterans Affairs (VA) facilities relies on algorithms applied to administrative databases. However, the validity of these algorithms has not been systematically assessed.

MEASURES

In a cohort of people with heart failure identified by ICD 9/10 codes, we validated the performance of algorithms to identify SPC consultation in administrative data and differentiate outpatient from inpatient encounters.

INTERVENTION

We derived separate samples of people by receipt of SPC using combinations of stop codes signifying specific clinics, current procedural terminology (CPT), a variable representing encounter location, and ICD-9/ICD-10 codes for SPC. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for each algorithm using chart review as the reference standard.

OUTCOMES

Among 200 people who did and did not receive SPC (mean age = 73.9 years (standard deviation [SD] = 11.5), 98% male, 73% White), the validity of the stop code plus CPT algorithm to identify any SPC consultation was: Sensitivity = 0.89 (95% Confidence Interval [CI] 0.82-0.94), Specificity = 1.0 [0.96-1.0], PPV = 1.0 [0.96-1.0], NPV = 0.93 [0.86-0.97]. The addition of ICD codes increased sensitivity but decreased specificity. Among 200 people who received SPC (mean age = 74.2 years [SD = 11.8], 99% male, 71% White), algorithm performance in differentiating outpatient from inpatient encounters was: Sensitivity = 0.95 (0.88-0.99), Specificity = 0.81 (0.72-0.87), PPV = 0.38 (0.29-0.49), and NPV = 0.99 (0.95-1.0). Adding encounter location improved the sensitivity and specificity of this algorithm.

CONCLUSIONS

VA algorithms are highly sensitive and specific in identifying SPC and in differentiating outpatient from inpatient encounters. These algorithms can be used with confidence to measure SPC in quality improvement and research across the VA.

Long-term opioid therapy trajectories and overdose in patients with and without cancer

Objective

Pain is experienced by most patients with cancer and opioids are a cornerstone of management. Our objectives were (1) to identify patterns or trajectories of long-term opioid therapy (LTOT) and their correlates among patients with and without cancer and (2) to assess the association between trajectories and risk for opioid overdose, considering the potential moderating role of cancer.

Methods and Analysis

We conducted a retrospective cohort study among individuals in the US Veterans Health Administration (VHA) database with incident LTOT with and without cancer (N=44,351; N=285,772, respectively) between 2010-2017. We investigated the relationship between LTOT trajectory and all International Classification of Diseases-9 and 10-defined accidental and intentional opioid-related overdoses.

Results

Trajectories of opioid receipt observed in patients without cancer and replicated in patients with cancer were: low-dose/stable trend, low-dose/de-escalating trend, moderate-dose/stable trend, moderate-dose/escalating with quadratic downturn trend, and high-dose/escalating with quadratic downturn trend. Time to first overdose was significantly predicted by higher-dose and escalating trajectories; the two low-dose trajectories conferred similar, lower risk. Conditional hazard ratios (99% CI) for the moderate-dose, moderate-dose/escalating with quadratic downturn and high-dose/escalating with quadratic downturn trends were 1·84 (1·18, 2·85), 2·56 (1·54, 4·25), and 2·41 (1·37, 4·26), respectively. Effects of trajectories on time to overdose did not differ by presence of cancer; inferences were replicated when restricting to patients with stage 3/4 cancer.

Conclusion

Patients with cancer face opioid overdose risks like patients without cancer. Future studies should seek to expand and address our knowledge about opioid risk in cancer patients.

Trial registration

None.

Association between early nonpharmacological management and follow-up for low back pain in the veterans health administration

Background

Low back pain (LBP) is a common reason individuals seek healthcare. Nonpharmacologic management (NPM) is often recommended as a primary intervention, and earlier use of NPM for LBP shows positive clinical outcomes. Our purpose was to evaluate how timing of engagement in NPM for LBP affects downstream LBP visits during the first year.

Methods

This study was a secondary analysis of an observational cohort study of national electronic health record data. Patients entering the Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort with LBP from October 1, 2016 to September 30, 2017 were included. Exclusive patient groups were defined by engagement in NPM within 30 days of entry ("very early NPM"), between 31 and 90 days ("early NPM"), or not within the first 90 days ("no NPM"). The outcome was time, in days, to the final LBP follow-up after 90 days and within the first year. Cox proportional hazards regression was used to model time to final follow up, controlling for additional demographic and clinical covariables.

Results

The study population included 44,175 patients, with 16.7% engaging in very early NPM and 13.1% in early NPM. Patients with very early NPM (5.2 visits, SD=4.5) or early NPM (5.7 visits, SD=4.6) had a higher mean number of LBP visits within the first year than those not receiving NPM in the first 90 days (3.2 visits, SD = 2.5). The very early NPM (HR=1.50, 95% CI: 1.46-1.54; median=48 days, IQR=97) and early NPM (HR=1.27, 95% CI: 1.23-1.30; median=88 days, IQR=92) had a significantly shorter time to final follow-up than the no NPM group (median=109 days, IQR=150).

Conclusions

Veterans Health Administration patients receiving NPM for LBP within the first 90 days after initially seeking care demonstrate a significantly faster time to final follow-up visit within the first year compared to those who do not.

Research and policy recommendations from the SOTA XVI: State of the Art Conference on VA Emergency Medicine

To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED. For Veterans with mental health needs, priorities included enhancing the reach of effective, multicomponent suicide prevention interventions; development and evaluation of interventions to manage substance use disorders; and identifying and examining safety and effective acute psychosis practices. Community (non-VA) emergency care priorities included examining changes in patterns of use and costs in VA and the community care settings as a result of recent policy and coverage changes (with an emphasis on modifiable factors); understanding quality, safety, and Veteran experience differences between VA and community settings; and better understanding follow-up needs among Veterans who received emergency care (or urgent care) and how well those needs are being coordinated, communicated, and met. Beyond these three groups, cross-cutting themes included the use of telehealth and implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. Findings from this conference will be disseminated through multiple mechanisms and contribute to future funding applications focused on improving Veteran health.

Continuing the transformation: charting the path for the future delivery of Veteran emergency care

Important changes in the delivery of Veteran emergency care in the early 2000s in the Department of Veteran Affairs (VA) emergency departments and urgent care clinics substantially elevated the role of emergency medicine (EM) in Veteran health care. Focused on enhancing the quality of care, emergency care visits in both VA and non-VA (community) care locations have nearly doubled from the 1980s to more than 3 million visits in Fiscal Year 2022. Recognizing the need to plan for continued growth and the opportunity to address key research priorities, the VA Office of Emergency Medicine, together with the VA Health Services Research and Development Service, collaborated to convene a State of the Art Conference on Veteran Emergency Medicine (SAVE) in the winter of 2022. The goal of this conference was to identify research gaps and priorities for implementation of policies for three priority groups: geriatric Veterans, Veterans with mental health and substance use complaints, and Veterans presenting to non-VA (community) emergency care sites. In this article we discuss the rationale for the SAVE conference including a brief history of VA EM and the planning process and conclude with next steps for findings from the conference.

Incidence and Trends in the Use of Palliative Care among Patients with Reduced, Middle-Range, and Preserved Ejection Fraction Heart Failure

Background: Clinical practice guidelines recommend integrating palliative care (PC) into the care of patients with heart failure (HF) to address their many palliative needs. However, the incidence rates of PC use among HF subtypes are unknown. Methods: We conducted a retrospective cohort study of patients with the following HF subtypes in the Department of Veterans Affairs: reduced ejection fraction (HFrEF), mid-range ejection fraction (HFmEF), and preserved ejection fraction (HFpEF). Patients were included at the time of HF diagnosis from 2011 to 2015 and followed until a minimum of five years or death. Incidence rates of receipt of PC (primary outcome) were calculated using generalized estimating equations. We evaluated the time to incident PC by HF subtype with Kaplan-Meier analyses and with adjusted restricted mean survival time. Results: Of the 113,555 patients, 69% were ≥65 years, 98% were male, 73% White, and 18% Black; 58% had HFrEF, 7% HFmEF, and 34% HFpEF. Twenty percent received PC during follow-up, and 66% died. Adjusted PC incidence rates were higher among patients with HFrEF (47 per 1000 person-years, confidence interval [95% CI] 43-52) than for HFmEF and HFpEF (42 per 1000 person-years, CI 38-47 for both). Restricting follow-up to five years, patients with HFrEF received PC six weeks earlier than patients with HFpEF. There was no significant difference in time to PC between patients with HFmEF versus HFpEF. Conclusion: About 1 in 20 patients with HFrEF and 1 in 25 patients with HFmEF and HFpEF receive PC annually. Patients with HFrEF receive PC sooner than patients with HFmEF and HFpEF.

Sex Differences in Use of a Clinical Complexity Measure to Predict Primary Care Utilization

Background: The Veterans Affairs (VA)-developed Care Assessment Need (CAN) score, a risk-stratification tool used to identify complex high-risk patients and guide VA care coordination, was designed to predict hospitalization or death. Little is known about its utility in predicting primary care utilization or if gender differences in this metric are detectable. Our objective was to determine association of CAN score quintiles with high primary care visit (PCV) utilization among Veterans, the impact of adding reproductive health and psychosocial variables to the model and the difference between men and women Veterans. Methods: The sample included men and women from the post-9/11 cohort receiving VA care for at least 1 year, 2010-2017 (N = 665,379). PCV data for each year were collected from national Corporate Data Warehouse. A cumulative count ≥6 visits in a year was used as an indication for high PCV utilization in the analyses. Results: After accounting for potential confounding factors, women were associated with 42% higher odds of heavy PCV utilization (adjusted odds ratio: 1.42, 95% confidence interval: 1.37-1.46) than men. However, there was a significant interaction between sex and CAN quintiles (p < 0.001). After adjusting for all the covariates, CAN score quintiles appeared to have stronger associations and better predictive accuracy on the risk of 1-year heavy PCV utilization for men than for women. Conclusion: Further research is needed to understand sex differences in Veterans Health Administration clinical complexity measures and whether they can be successfully used to identify high-risk, high-utilizing women Veterans.

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study

INTRODUCTION

Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics.

METHODS

The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access.

RESULTS

The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women).

CONCLUSION

Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.

Relationships between chronic pain and mood symptoms among veterans with bipolar disorder

BACKGROUND

Chronic pain is highly prevalent among individuals with mood disorders. While much is known about the relationship between pain and unipolar depression, little is known about pain experiences among people with bipolar disorder. This pilot study addresses this gap by examining pain and its relationship to mood and functioning in a sample of US military veterans with bipolar disorder.

METHODS

Qualitative interviews were conducted with 15 veterans with bipolar disorder and chronic pain who were recruited from outpatient services within a Veterans Affairs medical center.

RESULTS

Veterans reported a bidirectional relationship between pain and bipolar depression. When discussing manic episodes, individuals' experiences varied between notable reductions in pain (usually in euphoric states), increases in pain (usually in angry/irritable states), and feeling disconnected from pain. Many reported that increased activity when manic contributed to worse pain after an episode. Veterans clearly articulated how these connections negatively affected their functioning and quality of life.

LIMITATIONS

This was a small, retrospective study that included a non-random sample of veteran participants from one VA medical center. All veterans were engaged in outpatient mental health care, so the majority reported that their mood has been well-stabilized through medications and/or psychotherapy.

CONCLUSIONS

Chronic pain experiences appear to be related to depressive and manic mood states and significantly affects functioning and quality of life in Veterans with bipolar disorder. This study highlights the need to assess chronic pain among veterans with bipolar disorder, as changes in mood could have significant implications for functioning and pain management.

Gender Differences in Suicide and Self-Directed Violence Risk Among Veterans With Post-traumatic Stress and Substance Use Disorders

BACKGROUND

Veterans have a high prevalence of both post-traumatic stress disorder (PTSD) and substance use disorders (SUDs), which are related to suicide risk. Exploring gender-related differences in suicidal behavior risk among this subgroup of veterans is important to improve prevention and treatment strategies. To date, few studies have explored these differences.

METHODS

The sample included 352,476 men and women veterans from the Women Veterans Cohort Study with a diagnosis of PTSD. First, we conducted analyses to assess gender-related differences in sociodemographic and clinical variables at baseline, as well as by suicidal behavior. Then, we conducted a series of Cox proportional hazards regression models to estimate the hazard ratios of engaging in self-directed violence (SDV) and dying by suicide by SUD status and gender, controlling for potential confounders.

RESULTS

Adjusted analyses showed that, among veterans with PTSD, the presence of a SUD significantly increased the risk of SDV and death by suicide. Women with PTSD had a decreased risk of dying by suicide compared with men. No gender-related difference was observed for SDV. SUD increased the risk of SDV behavior in both women and men but increased the risk of dying by suicide only among men.

CONCLUSIONS

Our findings revealed gender-related differences in SDV and suicide among veterans with a PTSD diagnosis with or without a SUD. Our study, along with the increasing numbers of women serving in the military, stresses the need to conduct gender-based analyses to help improve prevention and treatment strategies.

Dual Use of a Patient Portal and Clinical Video Telehealth by Veterans with Mental Health Diagnoses: Retrospective, Cross-Sectional Analysis

Background

Access to mental health care is challenging. The Veterans Health Administration (VHA) has been addressing these challenges through technological innovations including the implementation of Clinical Video Telehealth, two-way interactive and synchronous videoconferencing between a provider and a patient, and an electronic patient portal and personal health record, My HealtheVet.

Objective

This study aimed to describe early adoption and use of My HealtheVet and Clinical Video Telehealth among VHA users with mental health diagnoses.

Methods

We conducted a retrospective, cross-sectional analysis of early My HealtheVet adoption and Clinical Video Telehealth engagement among veterans with one or more mental health diagnoses who were VHA users from 2007 to 2012. We categorized veterans into four electronic health (eHealth) technology use groups: My HealtheVet only, Clinical Video Telehealth only, dual users who used both, and nonusers of either. We examined demographic characteristics and mental health diagnoses by group. We explored My HealtheVet feature use among My HealtheVet adopters. We then explored predictors of My HealtheVet adoption, Clinical Video Telehealth engagement, and dual use using multivariate logistic regression.

Results

Among 2.17 million veterans with one or more mental health diagnoses, 1.51% (32,723/2,171,325) were dual users, and 71.72% (1,557,218/2,171,325) were nonusers of both My HealtheVet and Clinical Video Telehealth. African American and Latino patients were significantly less likely to engage in Clinical Video Telehealth or use My HealtheVet compared with white patients. Low-income patients who met the criteria for free care were significantly less likely to be My HealtheVet or dual users than those who did not. The odds of Clinical Video Telehealth engagement and dual use decreased with increasing age. Women were more likely than men to be My HealtheVet or dual users but less likely than men to be Clinical Video Telehealth users. Patients with schizophrenia or schizoaffective disorder were significantly less likely to be My HealtheVet or dual users than those with other mental health diagnoses (odds ratio, OR 0.50, CI 0.47-0.53 and OR 0.75, CI 0.69-0.80, respectively). Dual users were younger (53.08 years, SD 13.7, vs 60.11 years, SD 15.83), more likely to be white, and less likely to be low-income than the overall cohort. Although rural patients had 17% lower odds of My HealtheVet adoption compared with urban patients (OR 0.83, 95% CI 0.80-0.87), they were substantially more likely than their urban counterparts to engage in Clinical Video Telehealth and dual use (OR 2.45, 95% CI 1.95-3.09 for Clinical Video Telehealth and OR 2.11, 95% CI 1.81-2.47 for dual use).

Conclusions

During this study (2007-2012), use of these technologies was low, leaving much potential for growth. There were sociodemographic disparities in access to My HealtheVet and Clinical Video Telehealth and in dual use of these technologies. There was also variation based on types of mental health diagnosis. More research is needed to ensure that these and other patient-facing eHealth technologies are accessible and effectively used by all vulnerable patients.

Pain research using Veterans Health Administration electronic and administrative data sources

Health services researchers are using Veterans Health Administration (VHA) electronic health record (EHR) data sources to examine the prevalence, treatment, and outcomes of pain among Veterans in VHA care. Little guidance currently exists on using these data; thus, findings may vary depending on the methods, data sources, and definitions used. We sought to identify current practices in order to provide guidance to future pain researchers. We conducted an anonymous survey of VHA-affiliated researchers participating in a monthly national pain research teleconference. Thirty-two researchers (89%) responded: 75% conducted pain-focused research, 78% used pain intensity numeric rating screening scale (NRS) scores to identify pain, 41% used International Classification of Diseases-9th Revision codes, and 57% distinguished between chronic and acute pain using either NRS scores or pharmacy data. The NRS and pharmacy data were rated as the most valid pain data sources. Of respondents, 48% reported the EHR data sources were adequate for pain research, while 45% had published peer-reviewed articles based on the data. Despite limitations, VHA researchers are increasingly using EHR data for pain research, and several common methods were identified. More information on the performance characteristics of these data sources and definitions is needed.

Estimating healthcare mobility in the Veterans Affairs Healthcare System

BACKGROUND

Healthcare mobility, defined as healthcare utilization in more than one distinct healthcare system, may have detrimental effects on outcomes of care. We characterized healthcare mobility and associated characteristics among a national sample of Veterans.

METHODS

Using the Veterans Health Administration Electronic Health Record, we conducted a retrospective cohort study to quantify healthcare mobility within a four year period. We examined the association between sociodemographic and clinical characteristics and healthcare mobility, and characterized possible temporal and geographic patterns of healthcare mobility.

RESULTS

Approximately nine percent of the sample were healthcare mobile. Younger Veterans, divorced or separated Veterans, and those with hepatitis C virus and psychiatric disorders were more likely to be healthcare mobile. We demonstrated two possible patterns of healthcare mobility, related to specialty care and lifestyle, in which Veterans repeatedly utilized two different healthcare systems.

CONCLUSIONS

Healthcare mobility is associated with young age, marital status changes, and also diseases requiring intensive management. This type of mobility may affect disease prevention and management and has implications for healthcare systems that seek to improve population health.

Personal health record reach in the Veterans Health Administration: a cross-sectional analysis

BACKGROUND

My HealtheVet (MHV) is the personal health record and patient portal developed by the United States Veterans Health Administration (VA). While millions of American veterans have registered for MHV, little is known about how a patient's health status may affect adoption and use of the personal health record.

OBJECTIVE

Our aim was to characterize the reach of the VA personal health record by clinical condition.

METHODS

This was a cross-sectional analysis of all veterans nationwide with at least one inpatient admission or two outpatient visits between April 2010 and March 2012. We compared adoption (registration, authentication, opt-in to use secure messaging) and use (prescription refill and secure messaging) of MHV in April 2012 across 18 specific clinical conditions prevalent in and of high priority to the VA. We calculated predicted probabilities of adoption by condition using multivariable logistic regression models adjusting for sociodemographics, comorbidities, and clustering of patients within facilities.

RESULTS

Among 6,012,875 veterans, 6.20% were women, 61.45% were Caucasian, and 26.31% resided in rural areas. The mean age was 63.3 years. Nationwide, 18.64% had registered for MHV, 11.06% refilled prescriptions via MHV, and 1.91% used secure messaging with their clinical providers. Results from the multivariable regression suggest that patients with HIV, hyperlipidemia, and spinal cord injury had the highest predicted probabilities of adoption, whereas those with schizophrenia/schizoaffective disorder, alcohol or drug abuse, and stroke had the lowest. Variation was observed across diagnoses in actual (unadjusted) adoption and use, with registration rates ranging from 29.19% of patients with traumatic brain injury to 14.18% of those with schizophrenia/schizoaffective disorder. Some of the variation in actual reach can be explained by facility-level differences in MHV adoption and by differences in patients' sociodemographic characteristics (eg, age, race, income) by diagnosis.

CONCLUSIONS

In this phase of early adoption, opportunities are being missed for those with specific medical conditions that require intensive treatment and self-management, which could be greatly supported by functions of a tethered personal health record.

Phototherapy: UVB and PUVA

The following paper is a review of the benefits of natural and artificial ultraviolet light in psoriasis. Phototherapy has been administered alone or in combination with topical corticosteroids, tars, anthralin, calcipotriene, and tazarotene, and with systemic therapies, such as methotrexate, acitretin, and cyclosporine. The choice of treatment with ultraviolet light B or psoralen plus ultraviolet light A is based on a history of previous response to treatment, skin type, severity of psoriasis, and patient considerations, including compliance and responsibility for observing the precautions to avoid potential side effects.

Phototherapy

This review illustrates that UVB phototherapy is not only a time-honored treatment, but also highly effective for widespread psoriasis. Treatment parameters include the frequency of irradiation, initial dose based on skin type or MED, increments of UV exposure, and maintenance schedule, according to defined protocols. UVB can be combined with adjunctive topical or systemic therapies either concomitantly or sequentially for additive effect. The use of various therapeutic modalities, including UVB phototherapy on a rotational basis, has been advocated for long-term control with reduced toxicity. UVB with emollients in an erythemogenic dosage schedule is as effective as PUVA for clearing of psoriasis in selected fair-skinned patients. Unlike PUVA, it does not involve a systemic photosensitizing drug and is relatively convenient and simple to use. UVB is the most commonly used therapy by dermatologists for widespread psoriasis that does not respond to topical therapies; it has been shown to be one of the most cost-effective therapies for widespread psoriasis.

Diagnosis of drug-induced psoriasis

Certain drugs have been reported to precipitate or to exacerbate psoriasis. These cases occur mostly in patients with a history of psoriasis, although occasionally the new onset of psoriasis has followed treatment with certain drugs. The suspect drugs include lithium, beta adrenergic antagonists, antimalarials, and non-steroidal anti-inflammatory drugs (NSAID), in addition to various miscellaneous agents, including tetracycline. Evidence for these reports must be critically examined based on clinical and histological data, time course between drug intake and psoriasis exacerbation or resistance to psoriasis therapy, and response to drug rechallenge when available. The clinical context must be taken into consideration, including effects of concomitant antipsoriatic therapy, and the possible role of other triggering factors, such as infection. Controlled, prospective studies of the use of NSAID in patients with psoriasis may help to clarify their varied cutaneous effects. Further knowledge of the mechanisms involved in drug exacerbation of psoriasis may help to elucidate the etiopathogenesis of this chronic skin disorder.

Most CD8+ cells in skin lesions of CD3+ CD4+ mycosis fungoides are CD3+ T cells that lack CD11b, CD16, CD56, CD57, and human Hanukah factor mRNA

To define further the characteristics of CD8+ cells in skin lesions of CD3+ CD4+ mycosis fungoides (MF), the authors used single- and double-label immunohistologic techniques and in situ hybridization to detect antigens and transcripts associated with certain types of cytotoxic or suppressor function. The cytotoxic markers included CD16, CD56, CD57, and an anti-sense probe for human Hanukah factor (HuHf) mRNA. Analysis of 23 cases demonstrated that lesional CD8+ cells were CD3+ T cells that generally lacked expression of any of the cytotoxic markers studied. Analysis of another 10 cases confirmed the CD3+ T-cell lineage of lesional CD8+ cells and demonstrated that these cells also lacked expression of the suppressor-associated marker, CD11b. In aggregate, these results indicate that most CD8+ cells in CD3+ CD4+ MF skin lesions are of T-cell rather than NK-cell differentiation. Their overall phenotype suggests that they may be major histocompatibility complex (MHC)-restricted cytotoxic T cells lacking appreciable levels of HuHF serine protease. Because the induction of CD8+ suppressor T cells is mediated by CD4+ T cells expressing the CD45RA+ RO- phenotype, CD45 epitope expression was studied in 15 MF cases. The vast majority (13/15) contained CD3+ CD4+ tumor cells that were CD45+ RA- RB+ RO+ 2B11+. This phenotype is consistent with memory T cells rather than suppressor-inducer T cells, and correlates with the paucity of phenotypically defined suppressor T cells in CD3+ CD4+ MF skin lesions.

Observations on the effect of chimeric anti-CD4 monoclonal antibody in patients with mycosis fungoides

Chimeric (murine/human) anti-CD4 monoclonal antibody was infused into seven patients with mycosis fungoides. Successive patients received doses of 10, 20, 40, and 80 mg of antibody twice a week for 3 consecutive weeks. All patients had some clinical improvement, but responses were of relatively short duration. Serum levels of chimeric antibody varied as a function of dose. At the 80-mg dose level, antibody was readily observed in biopsied skin lesions. Although there was coating by antibody of most CD4 positive cells in the blood, there was no significant depletion of CD4 positive cells. Low-level antibody responses against the mouse Ig variable region and human Ig allotypic constant region determinants were observed in several patients, but none were of clinical significance. All but two patients made primary antibody and T-cell proliferative responses to a simultaneously administered foreign protein test antigen. However, there was marked suppression of the mixed lymphocyte reaction. We conclude that at the dose levels studied, a chimeric anti-CD4 monoclonal antibody (1) had some clinical efficacy against mycosis fungoides; (2) was well tolerated; (3) had a low level of immunogenicity; (4) had immediate immunosuppressive effects; and (5) did not induce tolerance to a co-injected antigen.

Discordant expression of antigens between intraepidermal and intradermal T cells in mycosis fungoides

Using immunohistochemical methods, the authors studied the expression of pan-T- and majority-T-cell antigens (CD5, CD2, CD3, TCR-beta, CD7) and T-cell subset antigens (CD4, CD8) in cutaneous T cells in mycosis fungoides (MF) (177 biopsies from 124 patients) and a variety of inflammatory lesions (45 biopsies from 45 patients). The authors detected the absence of pan-T- or majority-T-cell antigens, or of both T-cell subset antigens, from T cells in the epidermis but not the dermis in 15 MF biopsies (8%) from 11 MF patients (9%), but in none of the inflammatory skin lesions. The opposite picture, characterized by lack of antigen expression by the dermal T cells only, was not seen in any of the MF or inflammatory lesions. The absence of antigen expression by epidermal but not dermal T cells, which the authors have termed antigen discordance, was most prevalent for CD5, CD7, and TCR-beta, each being discordant in 6% to 7% of MF cases or patients tested. Among the MF biopsies showing antigen discordance, 14 of 15 biospies (93%) from 10 of 11 patients (91%) were discordant for two or more antigens. Antigen discordance was not an artifact of treatment, because none of the patients showing discordance was receiving treatment at the time of their initial discordant biopsy. The discordance was the only immunophenotypic abnormality detected in 8 of 15 (53%) of the discordant MF biopsies. Thus, this antigen discordance was an important diagnostic feature that allowed the immunophenotypic distinction of MF from a variety of inflammatory skin lesions.

Psoriasis patient support group and self-care efficacy as an adjunct to day care center treatment

Patients treated with chronic disabling psoriasis often have psychosocial concerns that need to be addressed. The weekly patient support group at Stanford, led by a psychiatrist, is an integral part of the Psoriasis Day Care program. Although not considered group therapy in the traditional sense due to its self-selective nature, the support group aims to reduce feelings of isolation and to enhance coping skills and self-efficacy. In this setting, patients explore their feelings about psoriasis enabling them to better adapt to a visible disease. Common topics for discussion include lifestyle changes, stressful relationships, associated emotional reactions, occupational limitations, and treatment concerns. Components of the Psoriasis Day Care Center that enhance treatment response and responsibility for self-care include: health education, psychosocial support systems, stress reduction, and enhanced coping skills acquired through shared experiences with other patients and medical personnel.

Mycosis fungoides and the Sézary syndrome: pathology, staging, and treatment

Mycosis fungoides and the Sézary syndrome are forms of cutaneous T-cell lymphoma. Mycosis fungoides is an uncommon disease: only about 500 new cases are diagnosed in the United States annually. The median age of onset is 55 years and there is a 2:1 male predominance. The etiology of mycosis fungoides is unknown. Although occupational exposures have been implicated, case control studies fail to support this hypothesis. Mycosis fungoides is typified by cutaneous plaques which may evolve into tumors over the course of time. It is often preceded by a lengthy pre-mycotic phase prior to the time of definitive diagnosis. In its earliest diagnostic phase, there may only be slightly scaling patches with a limited distribution. Indurated lesions evolve into plaques, which may become more generalized in their distribution. As the severity of skin involvement increases, there is an increasing likelihood of spread to extracutaneous sites. The pathology of this disease is marked by involvement of the epidermis (Pautrier microabscesses). Immunologic studies characterize these cells as belonging to the helper T-cell subset. Genotypic analysis demonstrates monoclonal rearrangements of the T-cell receptors of the infiltrating cells. The staging system for mycosis fungoides considers the extent of skin involvement, presence of lymph node or visceral disease, and detection of abnormal cells in the peripheral blood. Patients with disease limited to the skin (90% of newly diagnosed cases) are treated best with topical or cutaneous therapies. Common modalities include psoralen photochemotherapy (PUVA), topical chemotherapy (nitrogen mustard) and total skin electron beam therapy. Both topical nitrogen mustard and electron beam therapy have good initial response rates (73% and 100%) and may achieve long-term disease-free survival, especially in patients with initially limited disease. Even if the response is incomplete or relapse occurs, substantial and very important palliation is generally achieved with topical therapy. Recurrent or resistant cutaneous disease will require the use of sequential topical treatment. The median survival time of patients who present with disease limited to the skin is greater than 10 years, and many deaths in this group are from intercurrent causes, especially in patients with limited or generalized plaque disease. If cutaneous tumors are present, the majority of these patients will eventually die from disease-related causes. The prognosis of patients who develop extracutaneous disease is exceedingly poor (median survival time, approximately 1 year).(ABSTRACT TRUNCATED AT 400 WORDS)

Mycosis fungoides with CNS involvement: neuropsychiatric manifestations and complications of treatment with intrathecal methotrexate and whole-brain irradiation

The case of a 42-year-old Caucasian male with CNS dissemination of mycosis fungoides is described. This patient developed prominent mental status changes and subtle neurologic signs, and was treated with intrathecal methotrexate and whole-brain irradiation.

Leu-8/CD7 antigen expression by CD3+ T cells: comparative analysis of skin and blood in mycosis fungoides/Sézary syndrome relative to normal blood values

Deficiencies of Leu-8 and CD7 antigens are exhibited by CD3+ T cells in the skin lesions of most patients with mycosis fungoides/Sézary syndrome. To determine whether these antigenic abnormalities are limited to involved skin, we studied Leu-8/CD7 expression in 21 skin lesions of mycosis fungoides/Sézary syndrome obtained from 16 patients and compared them with their peripheral blood leukocytes obtained concurrently. There was no correlation between Leu-8/CD7 values in skin lesions versus blood. Blood values were relatively uniform; most patients had 50% or greater of CD3+, Leu-8+ T cells and CD3+, CD7+ T cells. In contrast, skin values were highly heterogeneous; most patients lacked expression of Leu-8 or CD7 by the majority of lesional CD3+ T cells. Furthermore, Leu-8/CD7 antigen deficiency was present in lesional skin in one patient with mycosis fungoides but not in her concurrently sampled pityriasis lichenoides chronica or blood. These findings suggest that Leu-8/CD7 antigen deficiencies in skin lesions of mycosis fungoides/Sézary syndrome do not represent generalized antigenic abnormalities of CD3+ T cells in other body compartments and that within the skin, these deficiencies are disease specific within individual patients with more than one dermatosis. Comparative peripheral blood immunophenotyping of the patients with mycosis fungoides/Sézary syndrome and of the control subjects indicated that the control ranges of CD3+/Leu-8+ and CD3+/CD7+ T cells (33% or greater) extend lower than reported previously (60% or greater) and suggested that leukemic involvement in patients with mycosis fungoides/Sézary syndrome may correlate with percentages of CD3+, Leu8+ and/or CD3+, CD7+ T cells that fall below the revised control range.

Mycosis fungoides and occupational exposures. Is there an association?

In a case-control study, the author and coinvestigators found no positive association between occupational or chemical exposures and the risk of mycosis fungoides. Thus, there was no support for the hypothesis that chronic antigenic stimulation is an etiologic factor in this disease.

Cutaneous lymphoid hyperplasia. Immunologic characteristics and assessment of criteria recently proposed as diagnostic of malignant lymphoma

Fifteen cases of cutaneous lymphoid hyperplasia were studied immunohistologically with a large panel of monoclonal antibodies to determine their immunoarchitectural composition and to determine whether immunologic criteria recently proposed to identify lymphoma ever occur in benign skin lesions. All lesions were composed of T cells, polytypic B cells, macrophages, and Langerhans cells. Although only six cases containing lymphoid follicles were recognized in routinely stained sections, an additional five were identified in immunoperoxidase-stained sections. These follicles were of both the primary and secondary types and contained dendritic reticulum cell networks. The immunophenotypic features of these follicles were similar to those of reactive follicles in lymphoid organs and contrasted sharply with those reported previously for follicular lymphomas. Helper T cells were predominant in 11 cases. With regard to proposed criteria for T cell lymphoma, we did not detect loss of pan T cell antigens CD2, CD3, CD5, or BF-1, nor did we find populations of T cells with abnormal co-expression or loss of subset antigens such as CD4-8- or CD4+8+. Two cases in which relatively sparse infiltrates were present, however, were moderately CD7-deficient. This finding suggests that the CD7 criterion for cutaneous T cell neoplasia be modified in this situation. As observed previously, Leu-8 antigen deficiency was a common, nonspecific finding. With regard to proposed criteria for B cell lymphoma, we did not detect populations of B cells that were immunoglobulin-negative, nor did we observe preferential loss of one or more B-lineage antigens, histocompatibility complex-associated antigens, or lymphocyte function-associated antigens. We also did not identify any CD5+ B cells. On the basis of a comparison of our current data with prior studies of cutaneous lymphomas, we conclude that the immunologic findings recently proposed as general criteria for the differentiation of lymphoma from lymphoid hyperplasia are, in fact, applicable to cutaneous lymphoid lesions.

Mycosis fungoides in relation to environmental exposures and immune response: a case-control study

Mycosis fungoides is a cutaneous T-cell lymphoma of unknown etiology, thought to be a rare sequela of chronic antigenic stimulation that may occur, for example, with exposure to contact allergens. To explore this possibility, we interviewed 174 patients with mycosis fungoides and 294 randomly selected control subjects in the San Francisco, Los Angeles, and Seattle areas concerning their lifetime histories of employment, chemical exposures, allergy, atopy, and certain medical conditions. Patients reported higher prevalence of cancers other than the non-Hodgkin's lymphomas and skin cancers (relative risk = 3.3, P less than .001) and were more likely than controls to burn when exposed to the sun (for nonblacks, relative risk = 1.7, P = .01). The latter difference may reflect a manifestation rather than a precursor of the disease. We found no consistent or biologically plausible differences between patients and controls with respect to types of jobs held, or to occupational or vocational exposures to chemicals. These findings do not support the hypothesis that persistent antigenic stimulation by contact allergens is etiologically important in the pathogenesis of mycosis fungoides.

Cutaneous manifestations of immunosuppression in organ transplant recipients

Skin disease is a significant cause of morbidity in chronically immunosuppressed patients, including organ transplant recipients. Cutaneous drug reactions may be caused by immunosuppressive therapy that commonly includes corticosteroids, cyclosporine, azathioprine, and antithymocyte and antilymphocyte globulins. Immunosuppressive drugs can also potentiate the effects of other carcinogens, such as ultraviolet radiation, that cause premalignant lesions and squamous cell carcinoma. The risk of Kaposi's sarcoma is increased in these immunosuppressed patients, particularly in renal transplant recipients. Oncogenic viruses such as the Epstein-Barr virus have been associated with the development of non-Hodgkin's lymphoma in transplant recipients. In transplant patients human papillomavirus infections may be predisposed to malignant transformation, particularly at genital sites. Opportunistic infections caused by bacteria, fungi, viruses, or protozoa are the most common cause of death in transplant recipients. Skin manifestations of infection in immunosuppressed patients may be an important clue to their presence.

Clonal rearrangements of immunoglobulin genes and progression to B cell lymphoma in cutaneous lymphoid hyperplasia

Cutaneous lymphoid hyperplasia (CLH) is a disorder characterized by the development of one or more skin lesions containing dense lymphoid infiltrates that exhibit the histopathologic features of a benign, reactive process. Nevertheless, some cases have been associated with the subsequent development of clinically overt lymphomas. This suggests that monoclonal populations may exist in some cases of CLH and that these cases may represent a subset more likely to evolve into lymphoma. To determine if such a subset of CLH can be distinguished, Southern blot analysis of DNA was used to study the immunogenotypic features of lesions from 14 patients with clinical, histopathologic, and immunopathologic findings characteristic of CLH. Five cases exhibited detectable clonal rearrangements of immunoglobulin genes. Furthermore, one of these five cases evolved into overt diffuse large cell lymphoma of B cell lineage during a 2-year follow-up of recurrent disease at the original cutaneous site. The immunoglobulin gene rearrangements of this lymphoma were identical to those of the prior CLH lesion. There was no evidence of detectable t(14;18) chromosomal translocations or clonal rearrangements of the beta gene of the T cell receptor in any case. It was concluded that CLH can be divided into two subsets based on the presence or absence of a clonal B cell population, and that overt lymphoma can arise from the former subset and contain the same B cell clone identified in the pre-existent CLH lesion.

Expression of T-cell receptor antigens in mycosis fungoides and inflammatory skin lesions

Using immunohistologic methods, we studied the expression of the T-cell receptor (TCR)-associated antigens CD3, TCR-beta, and TCR-delta by cutaneous T cells in mycosis fungoides (MF) (36 patients) and a variety of inflammatory diseases (16 patients). Most T cells in the inflammatory diseases and patch/plaque mycosis fungoides expressed the immunophenotype characteristic of the vast majority of mature peripheral T cells: CD3+ TCR-beta+ TCR-delta-. In contrast, abnormal CD3/TCR-beta antigen expression was seen in 3 of 6 cases (50%) of tumor stage mycosis fungoides. Furthermore, we were able to document its evolution from the normal pattern present in earlier patch/plaque lesions of the two cases in which serial biopsies were available for study. Divergence of epidermal versus dermal CD3/TCR-beta antigen expression was seen in 2 of 34 (6%) of biopsies of patch/plaque mycosis fungoides but not in inflammatory controls. The TCR-delta+ cells were generally rare regardless of diagnosis. We conclude that inflammatory skin diseases and most patch/plaque mycosis fungoides are typically composed of T lymphocytes that resemble mature peripheral T cells in regard to their expression of TCR-associated antigens. In contrast, aberrant patterns of TCR-associated antigen expression can be seen in tumor stage MF, and, more rarely in patch/plaque MF.

Detection of clonal T-cell receptor gene rearrangements in the peripheral blood of patients with mycosis fungoides/Sezary syndrome

Involvement of the peripheral blood in mycosis fungoides/Sezary syndrome (MF/SS) has a significant impact upon prognosis, but it is often difficult to distinguish circulating cells of MF/SS from atypical reactive lymphocytes. We compared the standard morphologic method of identifying leukemic cells, the Sezary preparation, to a genotypic method using Southern blot analysis of T-cell receptor gene rearrangements in concurrent blood samples. We studied 26 MF/SS patients, five of them in remission, together with five controls from cases of various non-MF/SS skin diseases. Six of 26 MF/SS patients had morphologically atypical circulating leukocytes (3%, 4%, 5%, 14%, 16%, 19%). Seven of 26 MF/SS patients had clonal T-cell receptor gene rearrangements, including the four patients with the greatest percentages of atypical cells and three patients lacking atypical cells. Six of seven patients had skin disease at the time of sampling, including three with erythroderma, two with generalized thick plaques, and one with generalized patches, while one patient was in clinical remission. All five controls lacked morphologic and genotypic evidence of atypical or clonal T-cells. Relative to genotyping, in our series the Sezary preparation was less sensitive and less specific. There were three apparent false negative results in the Sezary preparations, and two potential false positive (patients with 3% and 4% atypical leukocytes); however, there was agreement between the two techniques in most cases. We conclude that gene rearrangement studies may provide an effective test with which to assess the peripheral blood of MF/SS patients.

Low dose alcohol contracts the human umbilical artery in vitro

Beginning at very low concentrations (0.001 g/100 ml), alcohol elicited dose-dependent contractions of the human umbilical artery in vitro. Additionally, 16 of the 108 arteries tested had a 5-10-min spasm in response to alcohol. Alcohol (0.2 g/100 ml) also increased tension developed in response to all angiotensin II doses, but had no effect on serotonin-induced contractions. These results suggest that alcohol may increase umbilicoplacental resistance in vivo, thus decreasing fetal-placental blood flow.

Benign and malignant forms of erythroderma: cutaneous immunophenotypic characteristics

In order to determine if immunohistologic features are useful in distinguishing benign from malignant types of erythroderma, we studied the immunophenotype of lesional T cells in 20 patients (8 mycosis fungoides/Sézary syndrome, 12 benign) and found them to be generally similar. In all cases, the majority of T cells were Leu-1+, Leu-4+, and Leu-5+, as is typical of mature T cells. Although in most cases a majority of Leu-3+ (helper/phenotype) T cells were present, in 2 there was a majority of the Leu-2+ (cytotoxic/suppressor) subset and in 12 others, a significant minority (20%-40%) of these cells. Low percentages of Leu-2+ cells (less than or equal to 10%), resulting in high Leu-3+/Leu-2+ ratios, did not distinguish benign from malignant erythroderma. Leu-8 antigen deficiency was common in both mycosis fungoides/Sézary syndrome and benign cases (62% vs 75%, respectively). In contrast, Leu-9 antigen deficiency was present in only one patient in each group. The lack of combined Leu-8/9 antigen deficiency in our patients may be due to a heavy inflammatory T cell component, obscuring the antigen deficiencies seen in most nonerythrodermic mycosis fungoides cases. We conclude that immunophenotypic studies with the use of the current antibody panel show many similarities between benign and malignant forms of erythroderma, as well as some minor differences that may prove diagnostically useful if corroborated by future studies.

Clonal rearrangement of the T cell receptor beta gene in the circulating lymphocytes of erythrodermic follicular mucinosis

Follicular mucinosis is a condition characterized by the abnormal accumulation of acidic mucopolysaccharides in hair follicles. It is classically described as occurring idiopathically in young persons and within the infiltrates of mycosis fungoides in older individuals. We report a 12-year-old girl who had erythrodermic follicular mucinosis, hypereosinophilia, circulating Sezary cells, and both immunophenotypic and genotypic evidence of T cell neoplasia. Erythrodermic follicular mucinosis may represent an unusual variant of the Sezary syndrome, which to date has not been described in children or adolescents.