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

For individuals driving with groups outside their households or using ride-share services, keeping the windows rolled down and wearing masks can decrease the risk of spreading COVID-19, according to research results from the University of Surrey in the United Kingdom.

A team at the university’s Global Centre for Clean Air Research (GCARE) used sensors to monitor the concentration of pollution particles to map how those particles varied during different settings in the vehicle and to evaluate exposure doses for 3 different ventilation settings. They evaluated scenarios with the air conditioning on and using fresh air, with air conditioning on and using air recirculation, and the windows open.

The team found that maintaining a continuous intake of fresh air by keeping the windows open while also wearing a mask is the best way to guard against the transmission of COVID-19, according to a statement.

However, this scenario also increases occupants’ exposure to toxic air pollution particles.

This creates a dilemma because guarding against air pollution in turn increases the risk of COVID-19. The study results showed that the probability of transmission increased by 28.5% when windows were closed and air recirculation was switched on.

To balance both these issues, the team found that the best chance of remaining safe from both air pollution and COVID-19 was to keep the windows closed while running the air conditioning on ambient mode, in which it draws in fresh air from outside. This approach avoids external air pollution while minimizing exposure to COVID-19.

Lead author Prashant Kumar, PhD, founding director of GCARE at the University of Surrey, said in the statement research like this is essential to end the COVID-19 pandemic.

“It’s vital that the scientific community provides society with the data it needs so we can learn from the painful experience of the past 2 years,” he said. “Our research found that if your priority is to reduce the risk of contracting COVID-19, wearing a mask and keeping car windows open is the ideal approach.”

The combination of mask wearing and keeping windows open is best for reducing COVID-19 risk in cars, finds a new study. University of Surrey. News release. August 24, 2021. Accessed August 27, 2021. 

https://www.surrey.ac.uk/news/combination-mask-wearing-and-keeping-windows-open-best-reducing-covid-19-risk-cars-finds-new-study

Guarding against external air pollution while reducing the risk of infection when driving presents a challenge. 

Keeping Windows Down, Wearing Masks Reduces COVID-19 Risk in Cars

Aislinn Antrim

New research has found strong evidence that dispatching mental health professionals instead of police officers to some nonviolent 911 emergencies could have significant benefits.

Researchers at Stanford studied a pilot 911 response program in Denver, Colorado, in which mental health specialists responded to calls involving trespassing and other nonviolent events. According to the study results, researchers found a 34% decrease in reported crimes during the 6-month trial. The study also found that direct costs of the alternative 911 approach were 4 times lower than police-only responses.

“We provide strong, credible evidence that providing mental health support in targeted, nonviolent emergencies can result in a huge reduction in less serious crimes without increasing violent crimes,” said researcher Thomas Dee, PhD, in the press release. “In our politically divisive times, this first-responder innovation provides a rare opportunity for consensus on meaningfully improving public safety and health.”

National discussions around police reform and first responders have become highly controversial, including growing awareness of the need for experts in situations involving mental health or substance abuse. Currently, a small but growing number of cities around the country are exploring programs that embed mental health care and other social services in first responder procedures. Despite the controversy, Dee said the study’s findings suggest that there are sensible ways to reinvent first responder services in approaches that could have universal appeal.

Several cities—including New York City; Austin, Texas; San Francisco and San Mateo, California; and Washington, DC—are experimenting with new approaches to responding to mental health emergencies through little or no law enforcement involvement. According to the study, cities have been motivated by not only high-profile cases of police brutality, but also by data suggesting that police spend more time responding to “low-priority” calls than any other type of emergency. According to the study authors, as many as two-thirds of these types of 911 calls could be directed to mental health experts.

Cities are generally exploring 3 alternative responses. In one model, police officers are trained to direct people in crisis situations to appropriate services. A second approach involves partnering law enforcement with mental health professionals. Finally, a third reform approach removes police altogether from some 911 calls.

Descriptive evidence from other studies suggests that these models may be effective, but until now, no studies have tied the cause-and-effect of these alternative approaches with empirical evidence that they work. However, a pilot program in Denver could offer this much-needed empirical evidence.

For 6 months in 2020, officials in Denver tested the third, more radical approach by removing police officers from specific 911 calls. In emergencies involving low-risk infractions, such as public intoxication, welfare checks, trespassing, and public disorder, the dispatchers would send a mobile team with 1 mental health specialist and 1 paramedic. The program was called the Support Team Assistance Response (STAR).

The initiative covered 8 precincts in Denver’s downtown neighborhoods, where 911 calls involving low-income, at-risk individuals in nonviolent situations were expected to be high. The team of responders handled nearly 750 incidents involving mental health, homelessness, and/or substance abuse issues during the pilot period.

Interestingly, not all incidence started with a 911 call. In some cases, STAR teams were contacted directly by police officers or they responded to situations that they encountered on their own. In each case, the STAR team would direct individuals to substance abuse treatment centers or other support services as needed.

Using granular crime data publicly released by the city, researchers were able to track all of the adult criminal offenses reported across the 36 police precincts from the period before STAR operations began as well as the time in which the program was active.

The investigators found that dispatching mental health workers made a dramatic difference. Over the span of the pilot program, reports of less serious crimes in STAR-patrolled neighborhoods fell by 34% relative to crime levels observed in neighborhoods where STAR was unavailable. This drop in crime is attributed to fewer citations for public intoxication and other low-level infractions, as well as the likelihood that potential repeat offenders were now getting necessary help.

“The community-response program has 2 benefits,” Dee explained in the press release. “One, it directs people in crisis to appropriate mental health care instead of directing them to the criminal justice system. Two, it prevents future criminal activity because the people who are now receiving mental health care are not committing more offenses.”

In a quality check of their data, the researchers also examined reports of more serious crimes that police, not STAR teams, responded to in the precincts covered. They found no detectable increase in those crime rates, which suggests that the STAR program drove the decrease in low-level criminal activity, according to the researchers.

The STAR program also saved money, with the direct cost of responding to each offense at $151 on average, which is 4 times less than the estimated average of $646 direct cost per minor criminal offense, according to the study.

“These results are extraordinarily promising,” Dee said in the press release, although he noted that more pilots and studies are needed to make sure that any permanent reforms are correctly implemented. “This is not something that every 911 system should be implemented tomorrow. This reform requires thoughtful and detailed implementation—from training people who field 911 calls to hiring the right kind of mental health interventionists and coordinating carefully with law enforcement agencies.”

A new Stanford study shows benefits to dispatching mental health specialists in nonviolent 911 emergencies. News release. Stanford News; June 8, 2022. Accessed June 23, 2022. 

https://news.stanford.edu/2022/06/08/stanford-study-shows-benefits-reinventing-911-responses/

Reports of less serious crimes in neighborhoods with the pilot program fell by 34% relative to crime levels observed in neighborhoods where the program was unavailable.



Dispatching Mental Health Specialists to Nonviolent 911 Emergencies Shows Benefits

Aislinn Antrim, Associate Editor

A phase 3 trial investigating the PD-1 inhibitor cemiplimab (Libtayo, Regeneron) in patients with recurrent or metastatic cervical cancer who had previously progressed on chemotherapy showed a significant improvement in overall survival (OS), with a reduction in the risk of death by 31% compared to chemotherapy in the overall population, according to a presentation at the European Society for Medical Oncology Virtual Plenary.

These positive results add to the previously reported data showing an improvement in OS with cemiplimab compared to chemotherapy. In light of these positive findings, the data from this trial will be used as the basis for regulatory submissions in 2021.

"Improvements in progression-free survival [PFS] and objective response rate [ORR] were also demonstrated in the overall population compared to chemotherapy. Taken together, this landmark trial—which enrolled patients regardless of PD-L1 expression status—helps support the use of [cemiplimab] as a potential new second-line treatment for women with advanced cervical cancer who face a poor prognosis and limited treatment options," said trial investigator Krishnansu S. Tewari, MD, professor and director of the Division of Gynecologic Oncology at the University of California, Irvine, in a press release.

Currently, cervical cancer is the fourth leading cause of cancer mortality in women globally, with the most frequently diagnosed age group being women aged 35 to 44 years. Every year, approximately 570,000 women are diagnosed with cervical cancer, with deaths among those diagnosed totaling more than 250,000 annually. In the United States alone, there are approximately 14,500 patients diagnosed annually, with approximately 4000 women dying from the disease each year.

Although human papillomavirus infection is the cause of a majority of cases, approximately 80% are also classified as squamous cell carcinoma (SCC), which occurs from within cells in the lining at the bottom of the cervix. The remaining 20% of cases are classified as adenocarcinomas, which arises from glandular cells in the upper cervix. When detected early, cervical cancer is generally curable and can be managed; however, in advanced stages, the treatment options available become limited.

In the overall patient population, the investigators found that OS, PFS, and ORR significantly improved for those treated with cemiplimab (n=304), compared to chemotherapy (n=304). Specifically, the investigators observed a 31% reduction in mortality risk (hazard ratio [HR]: 0.69; 95% confidence interval [CI]: 0.56-0.84; one-sided p=0.00011), a 25% reduction in disease progression risk (HR: 0.75; 95% CI: 0.63-0.89; one-sided p=0.00048), and 16% ORR (50 patients; 95% CI: 13-21%; one-sided p=0.00004), compared to 6% with chemotherapy (19 patients).

Among this population, the median duration of response was 16 months with cemiplimab (95% CI: 12 months to not yet evaluable) and 7 months with chemotherapy (95% CI: 5-8 months), per Kaplan-Meier estimates.

Seventy-eight percent of trial participants were found to have advanced cervical cancer classified as SCC and also went on to experience significant improvements following treatment with cemiplimab (n=239) versus chemotherapy (n=238).

Specifically, patients in this population experienced a 27% reduction in mortality risk (HR: 0.73; 95% CI: 0.58-0.91; one-sided p=0.00306), a 29% reduction in disease progression risk (HR: 0.71; 95% CI: 0.58-0.86; one-sided p=0.00026), and 18% ORR (42 patients; 95% CI: 13-23%) compared to 7% with chemotherapy (16 patients; 95% CI: 4-11%).

Although the investigators did not set the assessment of adenocarcinoma as a pre-specified endpoint, a post-hoc analysis demonstrated that patients treated with cemiplimab (n=65) compared to chemotherapy (n=66) experienced a 44% reduction in mortality risk (HR: 0.56; 95% CI: 0.36-0.85; nominal one-sided p<0.005), a 9% reduction in disease progression risk (HR: 0.91; 95% CI: 0.62-1.34), and 12% ORR (8 patients; 95% CI: 6-23%), compared to 5% with chemotherapy (3 patients; 95% CI: 1-13%).

Additionally, the phase 3 trial demonstrated that patients treated with cemiplimab experienced an improvement or maintenance of their baseline Global Health Status/Quality of Life (GHS/QOL) over time. However, patients treated with chemotherapy experienced a deterioration that was clinically significant by cycle 8, per the European Organisation for Research and Treatment of Cancer QLQ-C30 (overall estimated mean change [95% CI]: improvement of 1.01 [-2.033, 4.047] for Libtayo, worsening of -6.81 [-10.977, -2.637] for chemotherapy; difference: 7.81; one-sided nominal p=0.00040).

The investigators observed no safety signals for patients treated with cemiplimab. The investigators had assessed safety in patients who received at least 1 dose of study treatment, which included 300 patients in the cemiplimab group (median duration of exposure: 15 weeks; range: 1-101 weeks) and 290 patients in the chemotherapy group (median duration of exposure: 10 weeks; range: 1-82 weeks).

In terms of adverse events (AEs) observed during the trial, investigators found 88% of cemiplimab patients and 91% of chemotherapy patients experienced AEs. In 15% or more of cemiplimab patients, AEs included anemia (25% cemiplimab, 45% chemotherapy), nausea (18% cemiplimab, 33% chemotherapy), fatigue (17% cemiplimab, 16% chemotherapy), vomiting (16% cemiplimab, 23% chemotherapy), decreased appetite (15% cemiplimab, 16% chemotherapy), and constipation (15% cemiplimab, 20% chemotherapy).

Additionally, grade 3 or higher AEs were observed in 45% of cemiplimab patients and 53% of chemotherapy patients, whereas in 15% or more of patients, certain grade 3 or higher AEs were observed more frequently in the cemiplimab group. These AEs included asthenia (2% cemiplimab, 1% chemotherapy) and pyrexia (less than 1% cemiplimab, 0% chemotherapy).

The investigators also observed immune-related AEs in 16% of cemiplimab patients and fewer than 1% of chemotherapy patients. The AEs at grade 3 or higher occurred in 6% of cemiplimab patients and fewer than 1% of chemotherapy patients. However, patients discontinuing treatment due to AEs only occurred among 8% of cemiplimab patients and 5% of chemotherapy patients.

Positive Phase 3 Libtayo® (cemiplimab) Results in Advanced Cervical Cancer Presented at ESMO Virtual Plenary. Tarrytown, NY: Regeneron Pharmaceuticals; May 12, 2021. 

https://investor.regeneron.com/news-releases/news-release-details/positive-phase-3-libtayor-cemiplimab-results-advanced-cervical

A phase 3 trial investigating the PD-1 inhibitor cemiplimab in patients with recurrent or metastatic cervical cancer who had previously progressed on chemotherapy showed a significant improvement in overall survival.

Positive Results for the Treatment of Advanced Cervical Cancer 

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.

Study: Genetic Profile and Proximity to Roadways Affect Asthma Symptoms

Alison Rodriguez

Influenza A virus is a prominent cause of morbidity and mortality in children, even more so than in adults.

Last year’s flu season saw 146 pediatric deaths.

Overall, influenza has an annual prevalence rate estimated at 5% to 10% in adults and 20% to 30% in children, which is a stark difference.

Although the exact reason behind this phenomenon is unknown, a few theories were recently summed up in a review article published in

It has been speculated that the increased influenza severity and incidence in children may be due to increased viral replication, decreased ability to clear the virus, greater inflammatory response, more susceptibility to secondary bacterial infections, or a combination of all of these factors.

In a study on rhesus monkeys, increased viral replication and decreased secretion of interferon alpha (IFN-α), which is involved in the destruction of foreign pathogens, was found in infant monkeys, but not in their adult counterparts. In addition, studies in both mice and human infants suggest that there is also a decrease in the secretion of interferon gamma (IFN-γ), which is primarily secreted from natural killer (NK) cells.

IFN-γ has direct antiviral activity and aids in clearing pathogens. Non-functional NK cells may be the cause of the decrease in IFN-γ.

An emerging theory for the increased prevalence of influenza A virus in children is that they have an enhanced inflammatory response leading to increased morbidity and mortality. Several studies have found that increased pro-inflammatory cytokine interleukin-6 (IL-6) in the pediatric population has a direct effect on flu severity.

A recent prospective study also found that infants and young children had higher levels of inflammatory nasal cytokines and type I IFNs than adults—which coincides with the theory that inflammation, not innate immune deficiency, is to blame for the difference in morbidity and mortality.

Possibly due to a counter response of excessive inflammation, interleukin-10 (IL-10) seems to be elevated in children. Because IL-10 has anti-inflammatory properties, it is potentially detrimental to the host because it increases the risk for secondary bacterial infection.

Co-infection has been reported in 43% to 75% of fatal cases of influenza A virus in children.

These review findings provide a roadmap for future research to determine why the pediatric population is more prone to serious flu infection.

1. US Centers for Disease Control and Prevention. FluView: Influenza-Associated Pediatric Mortality. http://gis.cdc.gov/GRASP/Fluview/PedFluDeath.html. Accessed October 20, 2015.

2. World Health Organization. Influenza (seasonal). http://www.who.int/mediacentre/factsheets/fs211/en/. Published March 2014. Accessed October 20, 2015.

3. Coates BM, Staricha KL, Wiese KM, Ridge KM. Influenza A Virus Infection, Innate Immunity, and Childhood.

Authors