The Advisory Committee on Immunization Practices (ACIP) recommends that all Americans 6 months and older who do not have contraindications receive the flu vaccine.

Health care providers should recommend the high-dose or adjuvanted flu vaccine for patients 65 and older. These 2 types of the vaccine are designed to spur a stronger immune response. The difference between adjuvanted and high-dose vaccines is that the adjuvanted vaccine is made with MF59 adjuvant, which is designed to enhance the immune response. The high-dose vaccine is designed for patients 65 and older and contains 4 times the amount of antigen as the regular flu vaccine. As such, it is associated with a stronger immune response, and patients who received the high-dose vaccine had 24% fewer influenza infections compared with those who received the standard-dose flu vaccine.

Children aged 6 months to 8 years who have never received the vaccine should receive 2 doses, the first as soon as it is available and the second about a month later.

showed that the vaccine significantly reduces a child’s risk of dying from the influenza virus. The study looked at data from 2010 to 2014 and found that the vaccine reduced the risk of flu-associated death by 51% among children with underlying high-risk medical conditions. Just 1 in 4 children who reportedly died from influenza had received the vaccine. As of March, 61 pediatric flu-related deaths had been reported in 2017.

From 1982-2016, peak influenza activity did not occur until January or later, but it can start as early as October.

Considering inconclusive evidence that delaying immunization may increase immunity in the latter half of the flu season, the ACIP recommends that patients get vaccinated early. The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

A potential safety signal associated with the flu vaccination of pregnant women has been raised. A case control study has reported that women early in pregnancy who have been vaccinated with vaccine containing the H1N1 component had a higher rate of spontaneous abortion within 28 days of vaccination. However, the ACIP has not changed its re

commendation on not vaccinating pregnant women in any trimester. There is an ongoing study involving pregnant patients and the flu vaccine that should produce results by 2018 or 2019.

According to the CDC, the flu vaccine is associated with decreased hospitalizations among patients with diabetes (79%) and chronic lung disease (52%).

Additionally, a meta-analysis suggests that the influenza vaccine is associated with a lower risk of major cardiovascular events in patients with active coronary disease.

With these statistics in mind, health care providers should be the most prominent advocates of the flu vaccine, especially concerning these special patient populations.

Another concern when considering the flu vaccine in certain patient populations is an egg allergy. The ACIP recommends that patients who have experienced urticaria after exposure to eggs should be vaccinated. Patients who have experienced severe reactions to eggs, such as angioedema or respiratory distress, or who require epinephrine, may receive any licensed and recommended flu vaccine. However, vaccine administration should be supervised by a health care provider who is trained to manage severe allergic reactions. As always, patients who have suffered an allergic reaction to the flu vaccine previously should not receive the vaccine.

One option for patients with severe egg allergies is Flublok, a vaccine that is not produced using chicken eggs. If a patient asks for the Flublok vaccine, it should be noted that the vaccine has a slightly shorter shelf life of 9 months from the production date.

Always remember the CDC’s SHARE method: Share the reasons that the influenza vaccine is right for patients, highlight positive experiences with the vaccine, address all patient questions, remind patients that influenza vaccines protect them and their loved ones, and explain the potential costs of getting the flu. It is important that patients understand the vaccine and the reasoning behind its recommendation so that they can make informed decisions about the flu and other vaccines.

Pharmacists, nurse practitioners, physician assistants, and physicians are vital to increasing influenza immunization rates. Patients trust health care providers to provide the latest evidence involving the vaccine and data surrounding special patient populations.

is a community pharmacy resident at the University of Georgia and Kroger Pharmacy.

1. CDC. Prevention and control of influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013-2014.

2. What you should know and do this flu season if you are 65 years and older. CDC website.

. Updated October 13, 2017. Accessed November 2, 2017.

3. Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season.

4. CDC study finds flu vaccine saves children’s lives [news release].  CDC. April 3, 2017.

cdc.gov/media/releases/2017/p0403-flu-vaccine.html

5. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices - United States, 2017-18 influenza season.

2017;66(2):1-20. doi: 10.15585/mmwr.rr6602a1.

6. Flu vaccination & possible safety signal. CDC website.

cdc.gov/flu/professionals/vaccination/vaccination-possible-safety-signal.html

. Updated September 13, 2017. Accessed November 2, 2017.

Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis.

8. Flu vaccine and people with egg allergies. CDC website.

cdc.gov/flu/protect/vaccine/egg-allergies.htm

. Updated September 2, 2016. Accessed November 2, 2017.

9. Flublok seasonal influenza (flu) vaccine. CDC website.

cdc.gov/flu/protect/vaccine/qa_flublok-vaccine.htm

. Updated October 3, 2017. Accessed November 2, 2017.

10. When & how to wash your hands. CDC website.

cdc.gov/handwashing/when-how-handwashing.html

. Updated March 7, 2017. Accessed November 2, 2017.

The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

Influenza Prevention: Make Sure Patients Understand the Vaccine

Abby Case, PharmD

April is Alcohol Awareness Month, and we have simplified science on everything related—effects on the body, nutrition, and how an individual can still be on a quest with sound nutrition, making sense of how alcohol and calories mix. Patients often times have questions related to alcohol, its effects on medications, diet, and their health, so what better time to dive into this topic and share what the science has to say, to better arm healthcare providers, and to help patients.

named April National Alcohol Awareness Month in 1987 as a way to decrease the stigma associated with alcoholism, and to provide education to prevent unnecessary health risks.

There are some key terms, definitions, and implications that will prove helpful for healthcare providers to know, so that they can better educate their patients on alcohol, its effects, and the implications of certain drinking patterns.

National Council on Alcoholism and Drug Dependence

Excessive drinking is associated with a significant increase in acute health and safety risks, proportional to the amount of alcohol consumed. If this behavior becomes habitual, then over time it can lead to many other health complications.

Patients often times have questions related to alcohol, its effects on medications, diet, and their health, so what better time to dive into this topic and share what the science has to say.

The Buzz On Alcohol and the Body

Adam Martin, PharmD, ACSM-CPT

Death by external causes&#151;primarily accidents and suicide—take the lives of more than 5 million people each year, and it has evolved into a major health concern on a global scale. External causes also include violence, undetermined causes, and medical procedures.

In Japan, a country boasting one of the highest life expectancies across the globe, a recent study found that external causes take the lives of women 10 years earlier than those by all other causes. The study sought to investigate the association between female reproductive factors, and the risk of external causes of death among middle-aged women in Japan.

The study followed 49,279 women for 20 years; 8477 of the women died, and the researchers collected their death certificates to confirm their causes of death. Of these deaths, 328 were by external causes: 148 by suicide, and 167 by accident. The researchers found that women designated “ever parous” (carrying at least one pregnancy to 24 weeks) had a lower risk of suicide than those designated “never parous.” They also found that parous women who had ever breastfed were much less likely to die by accident.

The study suggests that the decreased risk of suicide in “ever parous” women is consistent with previous studies. They indicate that the presence of a child may significantly deter the decision to commit suicide, especially while the child is dependent.

In addition, researchers found that the lower risk of accidents seen among postmenopausal women may be linked to the protective effect of breastfeeding on osteoporosis, and subsequent fracture occurrences. Osteoporosis can turn a simple fall into a health crisis, ultimately traced back to an accident.

The study concludes that “suicide and accidents are never the consequence of a single cause; a combination of personal, cultural, social, and biological features likely interact with fluctuations in sex hormones among women.” The researchers acknowledge that the reproductive factors they studied are not modifiable, but emphasize that a better understanding could still help to reduce avoidable deaths by self-harm and accidents.

is a 2023 PharmD Candidate at the University of Connecticut in Storrs.

Female reproductive factors and risk of external causes of death among women: The Japan Public Health Center-based Prospective Study (JPHC Study).

9, 14329 (2019) doi:10.1038/s41598-019-50890-x

Death by external causesâ€”primarily accidents and suicideâ€”take the lives of more than 5 million people each year, and it has evolved into a major health concern on a global scale. External causes also include violence, undetermined causes, and medical procedures. 
 

Breastfeeding and Parity Linked to Lower Risk of Death by Accidents and Suicide

Adara Bochanis, PharmD Candidate

Patients with type 2 diabetes (T2D) who get the flu shot may have a reduced risk for hospitalization related to cardiovascular or respiratory issues, recent research suggests.

Researchers from the Imperial College London analyzed 7 years’ worth of flu-season data on nearly 125,000 patients with T2D seen in primary care clinic. They found that individuals who received the flu shot were 30% less likely to be admitted to the hospital for stroke, 22% less likely to be admitted for heart failure, and 15% less likely to be admitted for pneumonia or influenza than their unvaccinated counterparts.

Patients who received the flu shot also had a 24% reduced risk of all-cause mortality.

To better understand the effect of the flu vaccine on a patient’s risk for hospitalization, the researchers controlled for patients’ age, weight, smoking status, and gender. Also important to the researchers was whether or not patients had been diagnosed with or were taking prescriptions for other long-term chronic conditions, such as heart disease and asthma.

that individuals at high risk of serious flu complications include young children; pregnant women; patients with chronic health conditions like asthma, diabetes, or heart and lung disease; and those 65 years and older.

“The potential impact of influenza vaccine to reduce serious illness and death highlight the importance to renew efforts to ensure that people with diabetes receive the flu vaccine every year,” lead study author Eszter Vamos, a public health researcher at Imperial College London, told

The researchers noted that one study limitation is that those who opt to get the flu shot may be healthier overall, meaning they already had a reduced risk for hospitalization or death.

Causation notwithstanding, the best protection for those with chronic conditions is preventing the flu in the first place.

Nurse practitioners and retail clinicians should remind every patient at every visit about the importance of the flu shot.

Patients with type 2 diabetes who get the flu shot may have a reduced risk for hospitalization related to cardiovascular or respiratory issues, recent research suggests.

Flu Shot May Help Diabetes Patients Avoid Hospitalization, Death

Aine Cryts

The FDA has issued a letter to JUUL Labs Inc, requesting more information about the company&#39;s outreach and marketing practices of electronic nicotine delivery systems (ENDS) and related products. The letter specified concerns around marketing targeted at students. The FDA also issued a simultaneous warning letter regarding JUUL&#39;s marketing and advertising practices.

According to FDA policies, companies must scientifically demonstrate that their products pose less risk than traditional products before they are able to market products for reduced risk. Acting FDA Commissioner Ned Sharpless, MD, said JUUL has ignored this law in marketing their products.

The warning letter cited several statements examined during a July 2019 Congressional hearing on JUUL products. According to the testimony, a JUUL representative speaking with students at a school made statements that identified JUUL products as "much safer than cigarettes," and that a student "should mention JUUL to his [nicotine-addicted] friend...because that&#39;s a safer alternative than smoking cigarettes, and it would be better for the kid to use."

"The agency is concerned these statements and representations may convey that switching to JUUL is a safer alternative to cigarettes, in that using JUUL products poses less risk or is less harmful than cigarettes," said the FDA statement.

E-cigarette use has been under increasing scrutiny over the past year. The FDA conducted a

in October 2018, after concerns were raised regarding e-cigarette sales to minors.

was recorded in August 2019, according to the Illinois Department of Public Health.

According to the CDC, JUUL sales have rapidly increased since 2016. Between 2016 and 2017, JUUL sales increased from 2.2 million devices sold to 16.2 million devices, a total increase of 641%. The CDC expressed concern that 74% of youth who used JUUL said they bought the device directly from a retail store.

Like the CDC, the FDA also expressed concern regarding youth&#39;s perceptibility to marketing of e-cigarette products.

"Referring to your ENDS products as &#39;99% safer&#39; than cigarettes, &#39;much safer&#39; than cigarettes, &#39;totally safe,&#39; and &#39;a safer alternative than smoking cigarettes,&#39; is particularly concerning because these statements were made directly to children in school," the warning letter said. "Our concern is amplified by the epidemic rate of increase in youth use of ENDS products, including JUUL&#39;s products, and evidence that ENDS products contribute to use of, and addiction to, nicotine, to which youth are especially vulnerable."

The FDA requested documents and information on several issues, including JUUL&#39;s use of nicotine salts in its e-liquids and the concentration of nicotine in its products. Nicotine salts were described at the Congressional hearing as a tool to mask the harshness of nicotine.

The FDA also asked JUUL to provide information on why they use a nicotine concentration of 5% in their products, which could potentially increase addictiveness.

The FDA has requested that JUUL provide the requested documents and information within 30 days of the letter.

FDA warns JUUL Labs for marketing unauthorized modified risk tobacco products, including in outreach to youth [news release]. Silver Spring, MD; September 9, 2019: FDA website. https://www.fda.gov/news-events/press-announcements/fda-warns-juul-labs-marketing-unauthorized-modified-risk-tobacco-products-including-outreach-youth. Accessed September 9, 2019.

FDA Takes New Steps to Address Epidemic of Youth E-Cigarette Use, Including a Historic Action Against More than 1300 Retailers and 5 Major Manufacturers for their Roles Perpetuating Youth Access [news release]. Silver Spring, MD; September 11, 2018: FDA website. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/UCM620184.htm. Accessed September 9, 2019.

Illinois Resident Experiencing Respiratory Illness After Vaping Dies. Springfield, Illinois [news release]. Springfield, IL; August 23, 2019: IDPH website. https://www.dph.illinois.gov/news/illinois-resident-experiencing-respiratory-illness-after-vaping-dies. Accessed August 26, 2019.

Sales of JUUL E-cigarettes Skyrocket, Posing Danger to Youth [news release]. Atlanta, GA; October 2, 2018: CDC Newsroom. https://www.cdc.gov/media/releases/2018/p1002-e-Cigarette-sales-danger-youth-html. Accessed October 2, 2018.

Sharpless N. JUUL Labs, Inc. - 509050 - 09/09/2019. Silver Spring, MD; September 9, 2019: FDA website. https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/juul-labs-inc-590950-09092019. Accessed September 9, 2019.

The FDA has issued a letter to JUUL Labs Inc, requesting more information about the company's outreach and marketing practices of electronic nicotine delivery systems (ENDS) and related products. The letter specified concerns around marketing targeted at students. The FDA also issued a simultaneous warning letter regarding JUUL's marketing and advertising practices.

FDA Warns E-Cigarette Company of Advertising, Marketing Concerns

Aislinn Antrim

New research suggests that CBD can reduce inflammation and reduce the cytokine storm that causes lung damage and death in many patients with coronavirus disease 2019 (COVID-19).

Investigators at the Dental College of Georgia and Medical College of Georgia had previously found that CBD improves oxygen levels and reduces inflammation and physical lung damage in their model of adult respiratory distress syndrome (ARDS). In their new study, the team found that apelin levels significantly decrease during COVID-19, but that CBD quickly helps normalize those levels.

“CBD almost brought [apelin] back to a normal level,” said co-author Jack Yu, MD, in a press release.

COVID-19 enters human cells via the angiotensin-converting enzyme 2 (ACE2) receptor, which typically works with apelin to control blood pressure. The authors hypothesized that an upregulation of both ACE2 and apelin may be helpful in cardiovascular disease by decreasing blood pressure and increasing the heart’s ability to pump.

Similar to other diseases, however, the investigators said COVID-19 appears to upset the partnership between apelin and ACE2. The binding of the virus to ACE2 has been shown to decrease the receptor’s levels and increase levels of angiotensin II, because angiotensin II is degraded and fewer vasodilators are produced.

In the researchers’ ARDS models, blood levels of apelin dropped close to zero but quickly increased 20 times over with CBD, according to the study published in the 

Journal of Cellular and Molecular Medicine.

 Apelin—a pervasive peptide created by cells in the heart, lungs, brain, fat tissue, and blood—is essential in regulating both blood pressure and inflammation.

When blood pressure increases, the investigators said apelin levels should grow in the correct place to help bring it down. It should also increase in order to normalize significant spikes in lung inflammation and related breathing difficulties associated with ARDS.

“Ideally, with ARDS it would increase in areas of the lungs where it’s needed to improve blood and oxygen flow to compensate and to protect,” said Babak Baban, PhD, the study’s corresponding author.

However, Baban added that this did not prove to be true in their ARDS model, with apelin decreasing in both the lung tissue itself and the general circulation.

Although the investigators did not attribute all of CBD’s benefits to apelin levels, they said the peptide does play an important role. More research is needed in order to understand whether COVID-19 or CBD have a direct impact on apelin or if these are downstream consequences.

“It is an association; we don’t know yet about causative, but it is a very good indicator of the disease,” Baban said.

CBD helps reduce lung damage from COVID by increasing levels of protective peptide [news release]. EurekAlert!; October 19, 2020. 

https://www.eurekalert.org/pub_releases/2020-10/mcog-chr101620.php

Although the investigators did not attribute all of CBD’s benefits to apelin levels, they said the peptide does play an important role.

Study: CBD Increases Levels of Protective Peptide, Reducing COVID-19 Lung Damage

Aislinn Antrim, Assistant Editor

A diet rich in flavan-3-ols, more commonly referred to as flavanols, includes food and beverages such as tea, apples, and berries. According to the European Prospective Investigation into Cancer (EPIC) Norfolk study published in 

, this type of diet may lower blood pressure, indicating its ability to support the maintenance of cardiovascular (CVD) health on a population scale.

Flavanols are a group of bioactive compounds that have demonstrated an ability to help vascular function in prior intervention studies. For this reason, the researchers were interested in investigating flavanols as dietary support in the prevention of CVD diseases due to a lack of reliable data from observational studies on the subject. They noted that such a lack may be in part because of the high variability in the flavanol content of food, making estimates of actual intake difficult without nutritional biomarkers.

The researchers assessed the biomarker-estimated flavanol intake of 25,618 citizens of Norfolk in the United Kingdom in relation to their blood pressure and other CVD risk markers, as well as longitudinal associations with CVD risk. However, the researchers strayed from common practice in studies of this kind by not relying on the reported diets of participants, and instead measured flavanol intake through nutritional biomarkers, such as indicators of dietary intake, metabolism, or nutritional status present in the blood.

"Previous studies of large populations have always relied on self-reported data to draw conclusions, but this is the first epidemiological study of this scale to objectively investigate the association between a specific bioactive compound and health,” said lead author Gunter Kuhnle, PhD, a professor of nutrition at the University of Reading, in a press release.

The results demonstrated that participants with the lowest 10% of flavanol intake and participants with the highest 10% of intake had a difference in blood pressure between 2 and 4 mmHg. Such significant changes in blood pressure are comparable to those with a Mediterranean diet or moderate salt reduction.

"What this study gives us is an objective finding about the association between flavanols—found in tea and some fruits—and blood pressure. This research confirms the results from previous dietary intervention studies and shows that the same results can be achieved with a habitual diet rich in flavanols. In the British diet, the main sources are tea, cocoa, apples and berries,” Kuhnle said.

Kuhnle explained that the methodology of the study was also of importance in their research.

“This is one of the largest ever studies to use nutritional biomarkers to investigate bioactive compounds. Using nutritional biomarkers to estimate intake of bioactive food compounds has long been seen as the gold standard for research, as it allows intake to be measured objectively. The development, validation and application of the biomarker was only possible because of the long-term commitment of all collaborators. In contrast to self-reported dietary data, nutritional biomarkers can address the huge variability in food composition. We can therefore confidently attribute the associations we observed to flavanol intake," Kuhnle said.

Following this study, researchers from the University of Reading; Cambridge University; University of California, Davis; and Mars, Incorporated assessed the data of the participants from the EPIC Norfolk study and observed that the greatest change in blood pressure due to diet was observed in participants with the highest blood pressure.

The researchers noted this finding suggests that an increase in flavanol intake among the general public could result in an overall reduction in CVD disease incidence.

"This study adds key insights to a growing body of evidence supporting the benefits of dietary flavanols in health and nutrition,” said Hagen Schroeter, PhD, chief science officer at Mars Edge, in a press release. “But, perhaps even more exciting was the opportunity to apply objective biomarkers of flavanol intake at a large scale. This enabled the team to avoid the significant limitations that come with past approaches which rely on estimating intake based on self-reported food consumption data and the shortcomings of current food composition databases."

Ottaviani JI, Britten A, Lucarelli D, et al. Biomarker-estimated flavan-3-ol intake is associated with lower blood pressure in cross-sectional analysis in EPIC Norfolk. 

. 10,17964(2020). doi: 10.1038/s41598-020-74863-7.

High flavanol diet may lead to lower blood pressure. Reading, UK: University of Reading; October 21, 2020. eurekalert.org/pub_releases/2020-10/uor-hfd101620.php. Accessed October 28, 2020.

According to a recent study, a flavanol-rich diet may lower blood pressure, indicating its ability to support the maintenance of cardiovascular (CVD) health on a population scale.

Flavanol-rich Diet May Lower Blood Pressure

Alana Hippensteele, Editor

Since 2000, nurse practitioners have enhanced the availability and quality of primary care for Americans, especially aging baby boomers. However, if the primary-care health care delivery system remains fundamentally unchanged through 2020, experts project a shortage of 20,400 primary care physicians. The Health Resources and Services Administration indicates that the supply of primary care nurse practitioners (NPs) will increase by 30%, from 55,400 in 2010 to 72,100 in 2020. With proper integration of NPs and physicians’ assistants into our health care system, the physician shortage will shrink to about 6000.

Full prescriptive authority lets NPs integrate properly into the health care system.

Nurses’ roles began evolving during the Vietnam War in the 1960s, when concerns about the delivery of primary health care initially arose. The role continued to progress through many different certifications before NPs, such as certified nurse-midwives, certified registered nurse anesthetists, and clinical nurse specialists, became commonplace. These elevated roles existed mainly in acute inpatient settings and specialty units.

For NPs to practice most advantageously, they must have prescriptive authority, promulgated in state scope of practice laws as 2 distinct types: authority legislated by regulations or nursing statutes, and delegable authority.

The types of prescriptive authority permitted in nursing legislation are further broken down into 2 categories: dependent authority, under which physicians must cosign the order, and independent authority, under which NPs can prescribe alone.

Results of a study, conducted in North Carolina, showed that NPs with full prescriptive authority provide cost-effective care with high-quality outcomes.

Delegable authority mandates an initial patient-physician relationship. It is further broken down into 3 categories: physician determination of patient-specific medications, prescription renewal by the nurse, and standing order/protocols.

Barriers to full prescriptive authority come from federal and state legislature, and organization’ business structures. For example, under Medicare’s Physician Fee Schedule, NP services are paid at 85% of the physicians’ rate, which financially gives primary care practices an incentive to bill under the physician’s name. Additionally, federal regulations require physician cosigners on home care service orders. At the state level, 29 states still restrict NP practice and/or prescriptive authority by requiring collaborative relationships or physician supervision. Organizationally, in the primary care setting, physicians can employ medical assistants (MAs) to help support their practices, but NPs cannot. Results from a 2014 study showed that patient cost was cut by 9% to 12% if NPs could hire MAs as supportive personnel in primary care.

In 2016, the Department of Veteran Affairs (VA) issued a rule giving full practice and prescriptive authority to NPs. Even in states requiring physician supervision, NPs at the VA can practice with full practice rights within the scope of their VA employment.

NPs employed in pediatric intensive care units (PICUs) are also front-runners. In a 2017 national survey of 112 PICU medical directors of various organizations, 49% reported that NPs have full practice authority, and 73% reported that NPs have prescriptive authority in line with state laws.

Joy Elwell, director of the doctor of nurse practice program at the University of Connecticut in Storrs,said it best: “In all 50 states and 5 districts, NPs have some level of prescriptive authority.”

These levels are restricted by the state’s individual scope of practice, as noted above. Today, 23 states and the District of Columbia allow full practice authority, independent of physicians’ collaborative/supervision agreements. The most recent state to give NP full practice authority was Oklahoma, in March 2017.

Elwell also said, “As of 2017, NPs in Florida and Georgia can prescribe [some] controlled substances.” The other 27 states require either supervisory or collaborative practice.

“In general, the Northeast [Connecticut, Maine, New York, and Vermont], Northwest [Nevada, Oregon, Utah, and Washington], and Southwest [Arizona, New Mexico, and Wyoming] have excellent scope of practice laws,” Elwell said. “They give NPs practice and prescriptive authority equal to physicians. In the Southeast, the laws are less favorable. NPs can diagnosis, treat, and prescribe, but they must do so under supervisory/ collaborative practice with physicians.”

One of the most restrictive states is Alabama, Elwell said.

Alabama’s scope of practice law states that the supervising physician in a collaborative practice must be on-site 10% of the time. Parts of Alabama are extremely rural, and the collaborating physician may need to travel long distances. If the physician fails to arrive at the clinic, the state will close the practice, and suspend the NP’s license. Many times, the area has no other primary care practice, so patient care suffers. California, Massachusetts, New Jersey, Ohio, Pennsylvania, and Texas, among others, which have restrictive scopes of practice, have bills in their state legislatures to grant full prescriptive authority (Figure).

Patients, payers, and pharmacists tend to accept NPs without pushback.

“The American Medical Association [AMA] exerts pushback on a national level,” Elwell said. “Politically, the AMA says that physicians should resist legislation that promotes NP scope of practice.”

However, most local physicians disagree because they want to help provide health care to the 300 million-plus Americans.

The American Association of Nurse Practitioners is lobbying for change at the national level and supporting state-specific efforts. Each state also has its own NP association pushing to advance practice.

NPs have made great strides toward full practice, and prescriptive authority over the past 2 decades. Advocates, such as Elwell, think that over the next 10 years, more than 30 states will change their scope of practice laws to allow NPs to have full practice authority. As our population ages, and more people have access to health care, Americans will need NPs backed by advanced education and law to provide much-needed health care.

For updates on the different states’ scope of practice, visit

scopeofpracticepolicy.org/practitioners/nurse-practitioners

Alexandra R. Cambra, PharmD, is a graduate of the University of Connecticut in Storrs and works for CVS.

Health Resources & Services Administration. Projecting the supply and demand for primary care practitioners through 2020. bhw.hrsa.gov/health-workforce-analysis/primary-care-2020. Updated October 2016. Accessed April 10, 2018.

Edmunds MW, Cawley J. Historical review of prescriptive authority: the role of nurses (NPs, CNMs, CRNAs, and CNSs) and physician assistants. Basicmedical Key. basicmedicalkey.com/historical-review-of-prescriptive-authority-the-role-of-nurses-nps-cnms-crnas-and-cnss-and-physician-assistants/. Published July 22, 2016. Accessed April 10, 2018.

Conover C, Richards R. Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina.

. 2015;63(5):585-92. doi:10.1016/j.outlook.2015.05.009.

Poghosyan L. Federal, state, and organizational barriers affecting nurse practitioner workforce and practice.

Gigli KH, Buerhaus PI, Minnick AF, Dietrich MS. Regulation of pediatric intensive care unit nurse practitioner practice: A national survey.

Journal of the American Association of Nurse Practitioners

The Health Resources and Services Administration indicates that the supply of primary care nurse practitioners (NPs) will increase by 30% in 2020. Full prescriptive authority lets NPs integrate properly into the health care system. 

Nurse Practitioners: Prescriptive Authority Update

Alexandra R. Cambra, PharmD

will be held on September 27-28, 2019 in New York City, featuring a rigourous agenda of presentations, question and answer sessions, and lightning rounds highlighting topics across the breadth of neurology.

International Congress on the Future of Neurology

The Congress, which will take place at the InterContinental New York Times Square, will be chaired by Stephen D. Silberstein, MD, professor of neurology and director of the Jefferson Headache Center in Philadelphia, and will feature programming highly relevant to physicians and other heathcare providers who treat neurological disorders.

Sessions focused on dementia and Alzheimer disease, epilepsy, headache and migraine, movement disorders, multiple sclerosis, neuromuscular disorders, stroke, and sleep disorders will be led by leaders in the field, where the latest data and best practices will be discussed to better inform clinical decision-making.

Karl Doghramji, MD, professor of psychiatry, neurology, and medicine at Thomas Jefferson University, Medical Director, Jefferson Sleep Disorders Center, and Program Director, Fellowship in Sleep Medicine, will moderate the sleep disorders session, titled "Beyond Counting Sheep: Effective Therapies for Sleep Disorders," where experts in the field will discuss new therapeutic approaches for insomnia, how to best manage narcolepsy and risk for therapeutic abuse, as well as navigating the physiologic and psychologic crossroads at play in excessive daytime sleepiness and obstructive sleep apnea.

, Doghramji discussed some of the central issues currently at play in sleep disorder medicine.

The importance of quality sleep is becoming more top-of-mind for people given an increased focus on wellness; yet, screening for sleep disorders is still lacking in the neurology community. Do you have a call to action for your peers to help encourage screening and diagnosis?

Disturbed sleep is associated with a myriad of impairments. It enhances the risk of future mood disorders, contributes to cognitive impairments, enhances the risk of cardiometabolic disorders, and even shortens lifespan. Sleep disorders also enhance the risk of stroke, and contribute to repeat stroke. It is critical, therefore, that neurologists develop a strategy to identify and manage sleep disorders in clinical settings.

With several new therapies available or up-and-coming for both insomnia and narcolepsy, what are some of the advantages of these new therapeutic classes compared to current treatment modalities?

Hypnotic agents are being developed that are not only effective for the management of insomnia, but are also safer than those utilized decades ago, particularly in the realm of daytime residual effects and respiratory compromise. Whereas the older agents were primarily GABA receptor agonists, more recently introduced agents antagonize the orexin receptor, thus muting the arousal drive, which is thought to be exaggerated in insomnia.

What are some of the challenges of implementing alternative therapies such as cognitive behavioral therapy for sleep disorders like insomnia?

Some of the main challenges faced when trying to incorporate nonpharmaceutical treatments like CBT-I are a shortage of properly trained therapists, third party payer support, and time limitations. Given that CBT-I is indicated as a first-line treatment for insomnia, it is imperitive that the healthcare community works harder to better prepare for and provide these therapies to patients, and work closely with payers to ensure access to this treatment modality.

This article first appeared in Neurology Live.

The International Congress on the Future of Neurology will take place this Fall in New York City, converging experts in neurology to discuss the latest data and best practices to better inform clinical decision-making.

Future of Neurology Congress Will Offer Expert Insights on Hot Topics

Alicia Bigica

Patients with asthma with certain genotype combinations demonstrate more intense symptoms when combined with a close proximity to roadways, suggesting that traffic-related air pollution exposure may affect the likelihood of asthma diagnosis and exacerbations, according to a recent

The researchers examined the associations between single nucleotide polymorphisms (SNPs) and the combinations of SNPs in the toll-like receptor 4 (TLR) pathway, residential distance to roadway as a proxy for traffic-related air pollution exposure, and asthma diagnosis and exacerbations.

The study considered individual data on genotype, residential address, asthma diagnosis, and exacerbations from the Environmental Polymorphisms Registry. Patients were divided into 3 groups—hyper-responders, hypo-responders, and neither&mdash;and they measured the participants' distance between their residence and nearest major road.

Patients with certain genetic profiles had exhibited more intense symptoms following exposure to traffic pollution. Furthermore, patients with asthma who lacked this genetic profile did not have the same sensitivity to traffic pollution and do not experience worse asthma symptoms.

Patients with asthma with certain genotype combinations demonstrate more intense symptoms when combined with a close proximity to roadways, suggesting that traffic-related air pollution exposure may affect the likelihood of asthma diagnosis and exacerbations, according to a recent study.