Giuliana Grossi

After conducting a one-year retrospective chart review, investigators found that the use of telehealth did not negatively impact laboratory response to hydroxyurea (HU) in patients with 

A team of investigators led by Sarah Shaner, University of Alabama at Birmingham School of Medicine, conducted a one-year retrospective chart review in order to analyze hydroxyurea laboratory and clinical response based on socioeconomic status and clinic location for patients with sickle cell anemia.

The National Institutes of Health (NIH) estimates 22 million residents live in rural areas with a shortage of healthcare providers. The University of Alabama at Birmingham (UAB) Pediatric Sickle Cell program utilizes satellite clinics paired with telehealth to reduce the issue of transportation and offer an alternative to traveling to the university-based clinic.

The US Centers for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion has recognized that rural patients living with chronic diseases are more likely to have poor outcomes. Telehealth is one of the ways they recommend improving outcomes in rural populations.

With the extra convenience, however, comes less immediacy. For patients who received hydroxyurea therapy at a satellite clinic, their labs were obtained on the day of their clinic visit but the complete blood count (CBC) was performed in a local lab and sent back to University of Alabama at Birmingham. Then, the fetal hemoglobin levels are processed by the medical team on campus.

With this procedure, sickle cell providers weren’t able to have access to the hydroxyurea dosing labs during the patient’s satellite clinic visit. This is where telehealth came in.

Investigators were able to develop a telehealth model that streamlined the patient’s lab results to a nurse who would evaluate the values relevant to the institutional hydroxyurea dosing guidelines, confirm dosing changes with a sickle cell provider, and then call the patient to review results and changes and answer any questions.

The investigators questioned if the use of telehealth dosing adjustments had an impact on hydroxyurea laboratory and clinical response compared with university-based patients. Results showed no significant negative impact.

There was no difference identified in fetal hemoglobin, mean corpuscular volume, or absolute neutrophil count when comparing the satellite clinics to the university based-clinic.

Clinic location also had no impact on the overall number of hospital admissions or the number of pain admissions. Although, acute pain visits were higher among patients visiting the university-based clinic.

The socioeconomic indicators for patients who attended the satellite clinics were significantly worse when compared with the university-based clinic. The poverty level was higher, the median household income lower, and the amount of adults in the community without a high school degree was higher.

As the investigators predicted, nonadherence to hydroxyurea was associated with the highest number of hospital admissions. Of 149 patients who had more than 1 visit, 97 patients had more than 65% of clinic visits with a correct dose adjustment.

No statistical difference was identified in correct dosing adjustment between the locations. Overall, establishing satellite clinics and telehealth practices has shown to be just as effective in treating patients with hydroxyurea therapy as at the traditional university-based treatment.

Impact of telehealth visits on hydroxyurea response in sickle cell anemia

Articles

New study finds that telehealth is a viable option for treating sickle cell anemia patients in rural populations. 

Evaluating the Impact of Telehealth on Hydroxyurea Response

Investigators found that when choosing biologic medications, patients with 

preferred oral medications. Avoiding severe complications was also a top priority for patients. Next, patients wanted to maintain the ability to attend work and normal activities and avoid infection more than clinical measures of efficacy.

Daniel Sumpton, PhD, Sydney School of Public Health, University of Sydney, and a team of investigators conducted a discrete choice experiment (DCE) in patients with psoriatic arthritis from 3 rheumatology centers in Sydney, Australia. There were 150 participants that completed the study with a median age of 53.5 years.

Discrete choice experiments are often used with the intention of quantifying patient treatment preferences. The aim was to determine the most important factors for patients in real-life scenarios when making choices about their treatment.

The goal of the study was to assess patient preferences for the characteristics and outcomes of biologic and targeted synthetic disease modifying anti-rheumatic drugs (DMARDs) to manage psoriatic arthritis. The results showed a preference for an oral route compared with subcutaneous and intravenous routes.

Data showed the attributes in order of preference were, avoiding severe side effects, increasing ability to attend to normal activities, avoiding infections, improvement in enthesitis pain, improvement in psoriasis, increasing chance of remission, and improvement in joint pain.

There were two groups of participants shown in the latent class model. The first group (LC-1) preferred avoiding serious complications, the ability to work or attend to normal activities, and improvement in joint pain. The second group (LC-2) prioritized characteristics related to the route and frequency of the medications.

This suggests that LC-1 patients who preferred avoiding serious complications of biologics but also value the ability to attend to work and social activities have less experience and knowledge of biologics and have earlier disease duration.

As opposed to LC-2 patients who were more experienced with biologic use and had higher perceived knowledge of their use and were more likely to be comfortable with the most frequently used subcutaneous methods of treatment.

For the route and frequency of medication, the patients in LC-2 preferred subcutaneous injections 1-2 times weekly while the patients in LC-1 preferred to avoid that attribute above all else.

There’s consistency between these results and qualitative data suggesting that fear of severe side effects and short term side effects are significant factors for patients with psoriatic arthritis and spondyloarthropathy when choosing medications.

Overall, avoiding severe side effects or adverse events was the priority, followed by the ability to return to work and normal activities and avoiding severe infection. These were prioritized above clinical measures of disease improvement including improvement in joint pain, enthesitis or skin disease.

For the treatment of psoriatic arthritis, results showed that patients preferred oral treatments over subcutaneous or intravenous routes.

“There is a growing awareness of the importance of understanding the priorities of patients with psoriatic arthritis to improve their care,” investigators wrote. When selecting a biologic medication, there’s a need to understand the factors most important to patients and identify their main concerns and priorities.

Preferences for biologic treatment in patients with psoriatic arthritis: a discrete choice experiment

Results show how patients with psoriatic arthritis prioritize their decisions when choosing medication.

Biologic Treatment Preferences Revealed Among Psoriatic Arthritis Patients

. The US Pain Foundation shared that staggering statistic in a video they released in honor of 

 aims to allow a glimpse into the life of someone who experiences chronic pain. In the video, 5 people are featured sharing their personal experiences with chronic pain.

“The pain is like the beginnings of an F5 hurricane or a tornado,” Cheryl from Lake Louise, AK, said. “It starts off small but as it goes along it picks up debris, right, and starts to destroy things.”

Twenty million Americans live with “high-impact pain” or pain that significantly impacts their life. Another statistic that’s shared in the video. Despite how prevalent pain is, individuals often have difficulty finding the care they need.

The #PainCounts initiative is striving to improve the level of understanding surrounding chronic pain. Many face stigmatization due to the lack of understanding from the public, the health care system, and insurance providers.

The National Institutes of Health (NIH) dedicate less than 2% of funding to pain research and as of 2018, 96% of medical schools in the US did not require students to take courses on pain medicine, according to “

“At one point, I was so depressed,” Millie, from Rochester, NY, said in the video. “I had depression and anxiety, I wouldn’t get out of bed.”

Unfortunately, pain and depression can often feed off of each other. An especially harrowing statistic shared in the video stated that 10% of all suicides involve someone with chronic pain.

The US Pain Foundation is seeking to change this by partnering with Sunbeam for 

. The goal is a higher understanding, more research, better training and less stigma. 

Videos

The US Pain Foundation starts off September strong for Pain Awareness Month by releasing a touching video that gets personal about chronic pain. 

The US Pain Foundation Sets September Initiative for Awareness with #PainCounts

Rotation to buprenorphine was accomplished successfully in patients with 

 who were receiving long-term opioid therapy. Using buprenorphine long term was found to be more successful than tapering off the treatment.

Investigators, led by Victoria D. Powell, MD, Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, systematically reviewed literature from 22 studies regarding rotation to buprenorphine in individuals with chronic pain who used long-term opioid therapy. 

Overall, adverse effects were mild and very rarely were they severe enough to require discontinuation of buprenorphine.

Long-term opioid use comes with risks even though there are modest improvements in pain and functioning. Some risks include opioid misuse, suppression of immune and endocrine function, and accidental overdose.

Tapering off of long term opioid therapy when risks outweigh benefits can pose a challenge. Some patients experience increased pain and psychological distress. Therefore, rotation to buprenorphine may be a more viable alternative.

Buprenorphine, a partial mu opioid receptor (MOR) agonist, is associated with less respiratory depression, fatal overdose, and overall mortality than full MOR agonists such as morphine sulfate or oxycodone hydrochloride. It also has fewer adverse effects.

According to 4 randomized controlled trials and 6 uncontrolled observational studies, rotation to buprenorphine was associated with little harm to patients.

Adverse effects included headache, gastrointestinal symptoms like nausea, vomiting, constipation, and appetite changes, lightheadedness or dizziness, sedation, and sleep disruption. Transdermal buprenorphine was associated with skin irritation.

In 12 of 17 studies, rotation to buprenorphine displayed a decrease in pain severity. One study for example, Roux et al, stated that at higher doses, buprenorphine treatment was associated with better pain control.

On the McGill Pain Questionnaire, scores significantly decreased under the highest dose condition (OR, 0.42; 95% CI, 0.20-0.90). The median McGill Pain Questionnaire score decreased from 38 to 21  (

In the remaining 5 studies there was no association between buprenorphine and pain. It was indicated that participants who were rotating from higher doses of full MOR agonists experienced less analgesia after rotation to buprenorphine. However, investigators said the evidence was very low quality.

Investigators found substantial heterogeneity in timing of pain assessments, with some assessing pain immediately after the administration of buprenorphine and other studies assessing pain at the end of the study period. Detailed, validated instruments to assess pain were only used in 7 studies.

Of the 22 studies that were reviewed, 5 were randomized clinical trials, 7 were case-control or cohort studies, and 10 were uncontrolled pre-post studies. There was a variety of pain and opioid use among participants.

Reasons for buprenorphine rotation included inadequate analgesia, intolerable adverse effects, risky opioid regimens, and aberrant opioid use. Previously, there hasn’t been much guidance on how to conduct a rotation.

Investigators did a systematic review of literature to synthesize the evidence regarding rotation to buprenorphine from full MOR agonists among individuals undergoing long-term opioid therapy and chronic pain.

This includes the outcomes of precipitated opioid withdrawal, pain intensity, pain interference, treatment success, adverse events or effects, mental health condition, and health care use.

Investigators indicate that future studies are needed to ascertain the ideal starting dose, formulation, and administration frequency of buprenorphine as well as the best approach to buprenorphine rotation.

Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

Patients with chronic pain may benefit from rotation to buprenorphine. 