Verizon Announces Free Access Offer to Medical Data Exchange Network — Open to All 2.3 Million American Medical Providers

Verizon Business recently made a big splash with plans to offer free access and usage of their Medical Data Exchange system to over two million US healthcare providers. Sounds like a pretty generous offer, right? On first pass, I’d certainly have to agree though I have a sneaking suspicion it may not turn out to be quite as altruistic as many of the headlines I saw make it sound. As one report (

The credentials will allow doctors and clinicians to access medical data via the Verizon Medical Data Exchange through a secure, private inbox. The inbox is part of Verizon’s Healthcare Provider Portal, which it has added to the exchange.

) is primarily designed to enable exchange of information between different electronic medical record platforms, with this personal inbox component added later. What this offer focuses on is individual healthcare providers and that’s precisely what makes it both interesting and disappointing.

The potential for benefit to the healthcare community here is in engaging individual and small private practices, not yet using an electronic health record or lacking in sufficient scale to be able to integrate into a healthcare information exchange, in some sort of electronic data exchange. Larger practices, hospitals, and health systems will already have dedicated staff or departments for medical records. The Verizon system, much like those proposed in recent reform legislation, is merely a conduit rather than a repository of information — no information will actually be stored centrally here. So what this offering really does is give many physicians the opportunity to transmit information in safe and legal ways.

The fundamental flaw in this system, however, is that it requires an extra step. When I admit a patient to the hospital, I go through all the records we have on them in our EHR. When I need records from elsewhere, it requires that the patient sign some forms, either I or other medical staff call the relevant office to request information, fax the forms, and then wait — a wait that can be critical when it comes to deciding on procedures, imaging, and so on. What we really need is central storage of information.

While this may seem like a bit of a let down, it’s worth remembering that the healthcare industry is currently in the midst of a continuing consolidation trend into large healthcare systems. According one report (

), in 2008 there were nearly 1,400 merger/acquisition deals in the industry in the prior two decades, with particular concentration in urban markets. The EHRs that these new systems have or will soon have will therefore cover a large portion of the American population, all potential sources of data for information exchanges.

So what I see in this offer is (1) a promotional offer that is really meant to attract (paying) hospitals/healthcare organizations to its core “conduit” business in the long term and (2) a temporary help in reducing barriers to information exchange when it comes to smaller healthcare practices especially. Verizon’s MDE is certainly bound to be an important and prominent feature of future healthcare IT systems and its user-to-user data exchange system will be helpful. But the real gains are with more centrally stored information and hopefully all of these systems are just a step in that direction.

ID Compendium: A Persiflager’s Guide — LITE

With content updates until June 2012, this hyperlinked, quick reference guide to infectious diseases provides more than 600 pages of information on antibiotics, organisms, and diseases. The app, written over 10 years by a practicing infectious disease physician, is intended for non-infectious disease practitioners. Check out the Pro version of the app for lifetime monthly content updates, full-text search, and custom user notes linked to topics.

Use this app to determine whether your patient is an appropriate candidate for cardiac radionuclide imaging based on the 2009 Appropriate Use Criteria, a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Enter information about the patient, based on questions like “Is the patient within 3 months of acute coronary syndrome?” and “Has the patient undergone prior revascularization?” to be provided with a 0-9 score—7-9 equals appropriate, 4-6 uncertain, and 1-3 inappropriate.

This program displays low-resolution drawings depicting the skull, some cranial and cervical nerves, and a two-part brain: the cerebellum and the cerebrum. Different layers or structures can be removed, but this does not actually result in revealing of more structures or detail. One part of the program allows you to take an individual coronal slice and rotate it 360 degrees in any direction. Unfortunately, there is insufficient detail represented in each slice to make this exercise revealing of any recognizable structure. No structures are labeled, so this program is not at all helpful for learning neuroanatomy. In fact, I don’t see any rationale for any medical person to purchase this program.

4.5 stars (14 ratings, current version/754 ratings, all versions)

This blood pressure-tracking and analysis tool uses color icons to indicate when a user’s blood pressure value is normal, high, or hypertensive, based on information entered after taking a reading (not done by the app). Interactive graphs allow patients to display values by week, month, year, and time of day. Users are encouraged to share the information documented by the app with their physician. We couldn’t find a negative review—“just what anyone who is tracking their BP needs,” and “This is an excellent tool for keeping track of my blood pressure. My doctor also likes it” were among them.

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Several studies (not to mention common sense) have shown that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. This approach to disease management has been greatly facilitated by Web-based monitoring and reporting tools, smartphones, and other technologies. The question confronting physicians, patients, and payers as we move ahead is: does any of this work?

“Monitoring of live-feed data from the homes of the elderly or infirm will tell clinicians and family members about medication taking, ambulation, consumption, and other aspects of autonomous daily living. Implantable devices with wireless feeds will report patients’ physiological status to physicians and monitoring centers and will report functional anomalies to the manufacturer and relevant federal agencies. And that is not to mention inputs about weight and reaction times from automobiles, ambient environmental sampling data linked to one’s location by wearable global positioning system (GPS) devices, exercise data from implantable stress monitors, and sensors at one’s desk for other kinds of stress. In short, the future of interoperability is to bind together a wide network of real-time, life-critical data that not only transform health care but become health care.” 

— David J. Brailer, MD, PhD, Former National Health Information Technology Coordinator (

Just five years after Brailer’s Orwellian forecast, most of these predictions are already reality, spawned by our need to control an epidemic of chronic disease.

Chronic illness accounts for most of the disease burden in the United States. The cost, in lives and dollars, is staggering. Almost one out of every two adults has at least one chronic illness, and 70% of deaths are attributable to chronic disease (

). Chronic diseases consume 70% of healthcare expenditures, with a current estimated financial cost of $2 trillion per year and a projected cost of over $4 trillion by 2023 as the population continues to age (

). Most chronic diseases cannot be cured and, given our refractory lifestyle choices, are unlikely to be prevented. Can they at least be better managed?

Disease management (DM) evolved from the rational notion that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. The concept was enthusiastically embraced, perhaps prematurely, by insurers and large employers eager to find ways to reign in health care costs and improve the health of their beneficiaries.

Early models of DM involved the development of call centers staffed with nurses who routinely contacted at-risk patients to provide follow-up and advice. Interventions were targeted toward those with the most common chronic diseases: asthma, congestive heart failure, depression, diabetes, and hypertension. Poorly controlled diabetics might, for example, be asked to communicate daily blood sugars and symptoms to nurses trained to adjust insulin dosages, with the hope that the need for hospital admissions might be preempted. Such programs were liked by patients and were generally accepted as being of value, although this latter conclusion may have been supported more on the basis of commonsense assumptions rather than rigorous financial analysis. Nonetheless, DM has grown into what is currently a $2.5 billion-per-year industry (

As interventions expanded beyond the call center, a wider concept of what constitutes DM evolved. DM is now broadly defined as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (

Not surprisingly, technology is extending the reach and scope of DM. Advances in monitoring devices allow for less obtrusive, real-time patient monitoring, while the Internet is replacing the telephone as a means of educating patients and allowing them to communicate with their providers. Adoption has been further accelerated by the availability of devices that work faster, cost less, and are easier to use, coupled with greater access to broadband and wireless pipelines by more segments of the population.

Web-enabled disease management: no longer science fiction

Effective DM depends on frequent, regular monitoring of patients. Devices now exist that can unobtrusively monitor a wide variety of physiologic data with little or no effort on the part of patients. For example, a band-aid like device is currently available that can monitor respirations, oximetry, patient movement, temperature, and electrocardiogram—and display that information on an individual’s cell phone or transmit it via the Internet (

). A sensor wire (the diameter of two human hairs) can be inserted under the skin by a diabetic patient to allow continuous wireless monitoring of blood sugars (

). A “smart-pill” system allows physicians to monitor medication adherence by attaching tiny microchips to patients’ pills; as each pill passes the stomach, the patient’s prescriber is notified by the patient’s smartphone via the Internet (

). For $3,500, one can even purchase an “Intelligence Toilet” system, capable of measuring sugar levels in urine, blood pressure, body fat, and weight (

). The toilet automatically transfers its data to a home network for analysis on a personal computer. Each of these devices is already commercially available. Other wearable innovations, such as a “smart tee shirt” used by the military to monitor vital signs and remotely detect gunshot wounds, will undoubtedly soon find their way into the DM armamentarium (

The biggest current obstacle to smarter DM is not sensor technology, however. According to Steven

Eisenberg, MD, senior vice president and chief science officer at LifeMasters Supported SelfCare Inc, “Physicians are never going to have the time to spend going through volumes and volumes of data, so it is going to be up to the computers themselves to integrate, correlate, and analyze” (

). Currently, device technology leads development of those systems, but the latter will undoubtedly catch up.

Ultimately, however, it is the non-technological factors that will likely determine the face of DM in the 21st century. Continuous transmission of intimate physiologic details over wireless networks and the Internet demands rigorous security and personal privacy protections. Indeed, such technologies may well challenge society to re-examine the definition of “personal space” (

). Furthermore, DM must prove itself cost-effective in an era of dwindling economic resources and competing societal priorities.

Critics and skeptics are quick to point out that DM has not yet convincingly been demonstrated to be an effective strategy. A 2009 Rand report concluded that DM could increase employer and government spending in Massachusetts by $6.7 billion over 10 years with little overall benefit (

). This followed a 2008 analysis of a Medicare pilot project of 200,000 patients, which concluded that DM did not reduce hospitalizations, emergency room visits, or deaths from chronic disease. Proponents of DM argue that the study included patients who were not representative of those most likely to benefit and that Medicare did not extend the study long enough to see benefits. They cite contrasting studies, such as one study of elderly veterans that found a combination of home telemonitoring, video visits, and coordinated care resulted in a 40% reduction in emergency room visits, a 63% reduction in hospital admissions, a 60% reduction in hospital bed days of care, and similar reductions in nursing home care (

Both sides of the debate note that studies of DM to date have been of variable quality, often involved small numbers of patients, and may have used flawed assumptions in their cost-effectiveness analyses. A study published last month in the 

) addressed these methodological concerns (also, see the accompanying editorial at 

). This randomized controlled trial followed 1,653 patients recruited from 33 cardiology practices across the US who were recently discharged following hospitalization for heart failure.

The study demonstrated that telemonitoring did not reduce readmission rates or death over the six month follow-up period. Not surprisingly, the researchers found that by the final week of the study period, only 55% of patients were still using the system at least three times per week; 14% of patients in the telemonitoring group never used the system. (These latter observations are probably not unexpected by physicians; technological solutions alone are unlikely to ever overcome the intrinsic difficulties of motivating and changing human behavior.)

The authors concluded that their results “underscore the need for rigorous, independent evaluation of disease-management systems before their adoption. In an environment in which vendors promote their products to health systems that are under increasing pressure to reduce readmission rates, the knowledge that telemonitoring is ineffective suggests the need to consider alternative approaches to improving care” (

). Studies of DM in other conditions should be forthcoming (http://hcp.lv/dBirb1).

In the meantime, action-oriented business leaders are already convinced; DM programs are currently offered by three-quarters of large companies and most Medicaid programs (

). Given this level of commitment by business and government, the future of DM would seem secure over the near term. The shape it will take, however, is less certain.

Currently, most formal DM is administered by disease management organizations contracted to insurers and employers. But this model has been criticized as being too remote from patients, both physically and personally. In an article in 

), General Electric’s Chief Medical Officer, Robert S. Galvin, MD, expressed skepticism that chronically ill employees would change unhealthy behavior at the direction of unfamiliar nurses calling from remote offices. This seems a salient point; behavior change is the ultimate determinate of effective self care, and most chronic diseases are, at least in part, the result of unhealthy habits. Galvin, a former primary care physician, stated it this way: “If you are going to influence someone, you need a social relationship with them.” He and others thus favor a different model of incentivizing patients’ own physicians to provide DM services from their offices.

Physician-directed DM is a central premise of the “patient-centered medical home,” a concept endorsed in a joint position statement by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association (

). In this model, it is the primary care physician who directs, provides, and coordinates DM within the context of an ongoing patient—physician relationship. Primary care physicians would, of course, expect reimbursement for providing these services, including the time spent reviewing and responding to remotely acquired patient data. There is uniform agreement that without major reimbursement reform, the patient-centered medical home and a shift toward physician-directed DM is unlikely to succeed.

Although the eventual form and ultimate impact of DM over the next decade remains speculative, the epidemic of chronic illness ensures that DM will play an increasing role in healthcare policy and delivery. Evolving technology will undoubtedly overcome remaining barriers, providing us with the capability to broadly scrutinize measures of health, disease, and behavior. These capabilities will continue to challenge our concepts of privacy and prompt us to re-examine fundamental assumptions, such as “What constitutes reasonable care?” “How should we prioritize healthcare funding?” and “What is the ideal patient—physician relationship?” In the end, however, we are still faced with the most daunting obstacle to chronic disease management: human behavior. Technology alone is unlikely to overcome this final fundamental barrier to better health.

editorial board member and program director, Internal Medicine Residency and associate professor of Clinical Medicine, Department of Medicine, University of Illinois College of Medicine, Peoria, IL. 

Cover Story

Breaking Boundaries with Web-based Disease Management

Strategies for the Diagnosis and Treatment of Restless Legs Syndrome: A Practical Approach

This CME program consists of three parts—“Strategies for the Diagnosis and Treatment of Restless Legs Syndrome: A Practical Approach,” “Strategies for the Clinical Identification and Diagnosis of Restless Legs Syndrome,” and “Treatment Strategies for Restless Legs Syndrome”&mdash;the feature discussions with experts in restless legs syndrome. Practical approaches to recognition of RLS, the impact of RLS on one’s quality of life, both pharmacologic and nonpharmacologic therapies, and strategies for overcoming augmentation are explored.

Poor Effect of Guideline Based Treatment of Restless Legs Syndrome in Clinical Practice

 Journal of Neurology, Neurosurgery, and Psychiatry

 (September 30, 2010; online ahead of print)

 “To prospectively assess the success of RLS treatment in the clinical setting and to evaluate potential demographic factors and comorbidities that may influence the response to therapy.”

 In both initially untreated and pretreated patients, no statistically significant improvements were seen in RLS symptoms or quality of life after 12 months of treatment based on RLS treatment guidelines from the German Neurological Society. Poor treatment was associated with the presence of neuropsychiatric comorbidity, including somatoform disorders (41% prevalence), chronic pain (32%), anxiety (20%), and major depression (16%). Thus, Godau and colleagues concluded that improve overall outcome in patients with RLS may be better achieved by targeting and treating neuropsychiatric comorbidity.

Prevalence and Disease Burden of Primary Restless Legs Syndrome: Results of a General Population Survey in the United States

(November 10, 2010; online ahead of print)

 “To assess prevalence, disease burden, and costs of primary restless legs syndrome (RLS) in the US.”

The use of validated diagnostic tools and exclusion of patients with medical conditions that are likely to cause RLS from a representative US panel “provide a very conservative estimate of US census-weighted prevalence of 2.4% for primary RLS and 1.5% for primary RLS sufferers.” Of respondents, roughly one-third had a physician diagnosis of RLS, with primary RLS sufferers experiencing a mean productivity loss of one day per week. “All RLS-related costs increased with RLS symptom severity, with increasingly significant decrements in health status, sleep disturbance, and work productivity.” Allen and colleagues concluded that even their “very conservative approach finds RLS in this cohort to be common, under-diagnosed, and carried a significant personal and social burden.”

Restless Legs Syndrome and Near-infrared Light: An Alternative Treatment Option

 (October 26, 2010; online ahead of print)

 Mitchell U, Myrer J, Johnson A, Hilton S

To evaluate “the effectiveness of monochromatic near-infrared light treatment in decreasing symptoms associated with” restless legs syndrome (RLS), as few options are available for managing RLS, leaving new treatment options highly sought after.

 A steady decrease in RLS-associated symptoms was seen over four weeks in subjects who underwent 12 30-minute treatments to their lower legs with near-infrared light, leading to significantly greater improvement in these symptoms at treatment, and even four weeks following treatment, than seen in a control group, compared to baseline. “This new noninvasive method of treating RLS might become a valuable new management option,” wrote the authors, adding that more “research is needed to determine the mechanism(s) behind infrared light treatment and RLS.”

Suggested Immobilization Test for Early Detection of Restless Legs Syndrome Augmentation

To find a method for the early detection of medications that when taken for some time make the condition worse so that this problem can be either prevented or corrected.

Sleep Disorders Management, Health and Safety in Police

Centers for Disease Control and Prevention

To “develop and test a sleep health detection and treatment program that we aim to apply nationwide to reduce police officer fatigue and stress; enhance the ability of officers and their families to cope with police work; improve the health, safety and performance of law enforcement officers; and thereby improve public safety.” Sleep disorders that will be examined include obstructive sleep apnea and restless legs syndrome.

The “Multiple Sclerosis” section at MayoClinic.com is written by Mayo Clinic staff and includes a great deal of information. Under the “Basics” tab, site visitors can read about symptoms, cause, risk factors, complications, preparing for a doctor appointment, tests and diagnosis, treatments and drugs, lifestyle and home remedies, and coping and support. Patients can click the “In-Depth” tab to learn about polysomnography, including what to expect and how to interpret results of the test.

The National Institute of Neurological Disorders and Stroke offers this resource (updated less than a month before writing), which provides in-depth answers to eight common questions about restless legs syndrome. Common signs and symptoms, causes, diagnosis, treatment, and prognosis are explained—as is done, be it in less detail, at other sites. But This site goes beyond that to discuss current research and provide information on where patients can learn more. The fact sheet is also available in Spanish.

Restless Legs Syndrome: Differential Diagnosis and Management with Rotigotine

reviews the diagnostic criteria and differential diagnosis of restless legs syndrome (RLS) and the chemical and clinical characteristics of rotigotine in the management of RLS. Specifically, the three characteristics of sleep-related movement disorder on which the diagnosis of RLS is based (sensory, motor, and circadiain), conditions that mimick RLS based on motor restlessness or by an abnormal motor pattern at sleep onset or during sleep, conditions that mimick RLS based on their ability to cause leg pains or discomfort, and the management of RLS with rotigotine are explored.

Treatment of Restless Legs Syndrome with Pregabalin: A Double-blind, Placebo-controlled Study

This course from the American Academy of Neurology—available only to academy members or subscribers to 

reviews the “efficacy and potential side effects of pregabalin for restless leg syndrome.”

Pregabalin in Idiopathic Restless Legs Syndrome Patients

To “investigate the efficacy and tolerability of pregabalin in treating idiopathic RLS patients for up to 12 months.”

Polysomnography Study of Pregabalin and Pramipexole Versus Placebo in Patients with Restless Legs Syndrome and Associated Sleep Disturbance

To “assess the efficacy and safety of pregabalin and pramipexole versus placebo in the treatment of restless legs syndrome and associated sleep disturbance.”

Patients with restless legs syndrome often experience symptoms for years before receiving an accurate diagnosis. Pharmacists are in a unique position to probe patients for this condition, which negatively impacts health and quality of life.

Net Guide

Restless Legs Syndrome

Associations Between Oxaliplatin-induced Peripheral Neuropathy and Polymorphisms of the ERCC1 and GSTP1 Genes

International Journal of Clinical Pharmacology and Therapeutics

 To “explore the pharmacogenetic association between oxaliplatin-induced neuropathy and polymorphisms of the excision repair cross-complementation Group 1 (ERCC1) and glutathione-S-transferases pi 1 (GSTP1) genes.”

ERCC1, C118T and GSTP1 Ile105Val polymorphisms are more strongly related to the time until onset of neuropathy than to the grade of neuropathy,” most likely influencing neuropathy sensitivity.

European Federation of Neurological Societies/Peripheral Nerve Society Guideline on Management of Paraproteinemic Demyelinating Neuropathies. Report of a Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Society—First Revision

 Journal of the Peripheral Nervous System

 (October 28, 2010; online ahead of print)

 Hadden R, Nobile-Orazio E, Sommer C, et al.

To “update the 2006 EFNS/PNS guideline on management of patients with a demyelinating neuropathy and a paraprotein (paraproteinemic demyelinating neuropathy [PDN]) by review of evidence and expert consensus.”

(1) patients with PDN should be investigated for a malignant plasma cell dyscrasia; (2) a monoclonal gammopathy of undetermined significance is more likely to be causing the neuropathy if it is immunoglobulin (Ig)M, anti-neural antibodies are present, and the clinical phenotype is chronic distal sensory neuropathy; (3) patients with IgM PDN usually have predominantly distal sensory impairment, prolonged distal motor latencies, and often anti-myelin-associated glycoprotein antibodies; (4) IgM PDN may respond to immunomodulatory therapies. Their potential benefit should be balanced against possible side effects and the usually slow disease progression; (5) IgG and IgA PDN may be indistinguishable from chronic inflammatory demyelinating polyradiculoneuropathy; and (6) Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, and Skin changes syndrome is a multi-system malignant PDN.”

Peripheral Neuropathy in Patients with Gynecologic Cancer Receiving Chemotherapy: Patient Reports and Provider Assessments

“To analyze the incidence of chemotherapy-induced neuropathy in a set of patients with gynecologic cancer who were treated with known neurotoxic agents, to identify correlative factors related to patients' experience of neuropathy, and to analyze providers' assessment and treatment of neuropathy.”

 Findings suggest that completion of first-line therapy for gynecologic malignancy allows for improved neuropathy, with second-line therapies not necessarily correlating with worsening scores.

Pilot Study: Does Lower Extremity Night Splinting Assist in the Management of Painful Peripheral Neuropathy in the HIV/AIDS Population?

 Journal of the International Association of Physicians in AIDS Care

 (November 12, 2010; online  ahead of print)

 To “assess the effects of using night splints on pain and sleep quality” in patients living with HIV/AIDS and a diagnosis of peripheral neuropathy.

 Significant changes in pain and sleep index scores were seen following the use of night splints.

Diffusion Tensor Imaging of Sural Nerves in Diabetic Peripheral Neuropathy

To “validate magnetic resonance imaging and diffusion tensor imaging (MRI/ DTI) analysis as a non-invasive method for the assessment of myelinated nerve fibers loss in diabetic peripheral neuropathy.”

Efficacy of Inhaled Cannabis in Diabetic Painful Peripheral Neuropathy

To “determine if vaporized cannabis is effective as an analgesic for the treatment of painful diabetic neuropathy.”

Electrical Stimulation Therapy Using the MC5-A Scrambler in Reducing Peripheral Neuropathy Caused by Chemotherapy

To “determine if MC5-A Scrambler therapy will improve the pain associated with chemotherapy-induced peripheral neuropathy in cancer patients by 20%.”

Resources for professionals at this site include recent research news items, ongoing clinical trials, how to apply for grant funding, and hospitals and universities associated with the FPN that may help physicians find new treatment options. The “Living with Peripheral Neuropathy” section includes information about causes, symptoms, and coping skills that physicians can direct patients to. The FPN also provides physicians with information about upcoming conferences and events, and a monthly newsletter that discusses “research news, treatment options, and more.”

This site’s description of the peripheral nervous system includes a written discussion and an illustration of the human body, with the different nervous systems highlighted. The differences between polyneuropathy and mononeuropathy, as well as how the two can develop, are explained. Causes of PN include poor nutrition, diabetes, hereditary disorders, and more. The site explains how each cause can lead to PN, signs and symptoms, diagnostic tests, and treatment options.

http://millercenter.uchicago.edu/learnaboutpn/aboutpn/whatispn/index.shtml

Ongoing research efforts, support groups, and facts about neuropathy—signs and symptoms, treatments, and more&mdash;are all discussed here. Patients can share stories about living with neuropathy, learn about ongoing research, and read about recent neuropathy news. Two videos featured on the site discuss how volunteering can improve health and feelings of wellness, and the introduction of new legislation that is attempting to “remedy inadequate Medicare reimbursements currently restricting patient access to IVIG.”

http://www.neuropathy.org/site/PageServer?pagename=homepage

In addition to general information about PN, including signs, risk factors, complications and more, this site also includes a slide show of brain anatomy. These slides provide a general overview of the brain’s structure and how nerves work. Pharmacologic treatment options are explored, and the site also discusses how patients can use alternative medicine or make lifestyle changes to manage symptoms.

http://www.mayoclinic.com/health/peripheral-neuropathy/DS00131

Trauma, systemic diseases, infections and autoimmune disorders, and genetics are all causes of PN. This site discusses how each different one can lead to PN, and how the symptoms of each vary. Diagnosis, treatment options, and ongoing research of PN in general, and the types that are caused by something specific, such as diabetic PN or inherited PN, are also discussed.

http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm

Combination Pain Therapy in HIV Neuropathy

 National Institute of Allergy and Infectious Diseases

 To compare methadone alone to duloxetine alone and combination duloxetine and methadone in ability to reduce neuropathy-associated pain in people living with HIV infection.

Duloxetine in Treating Peripheral Neuropathy Caused by Chemotherapy in Patients with Cancer

 To “determine the efficacy of duloxetine hydrochloride in cancer patients with painful chemotherapy-induced (taxane or platinum agent) peripheral neuropathy,” looking particularly at functional status and quality of life.

Peripheral Neuropathy

Generalized Anxiety Disorder (American College of Physicians PIER)

This activity was developed “to facilitate the highest quality professional work in clinical applications, teaching, consultation, or research.” Specifically, the program addresses brief interventions that may prevent further anxiety symptoms in children but not adults, appropriate instruments for screening for generalized anxiety disorder (GAD), hospitalization of patients with GAD who are suicidal, non-drug and drug therapy, the importance of patient education, follow-up care.Enter the below URL in your Web browser window, search for “generalized anxiety disorder,” and chose “physician” as your profession to access this course.

Insights Into Generalized Anxiety Disorder

How to recognize GAD, even when comorbid psychiatric conditions are present, how comorbid conditions affect the course of GAD and quality of life of those with the disorder, the neurobiology of patients with GAD and how it differs from people without GAD, available treatments for GAD, and individualized treatments for patients with refractory GAD form the focus of this program.

Pharmacotherapy for Children and Adolescents with Anxiety Disorders

Part of a program that requires participants to read three other articles (“Pharmacotherapy for Pediatric Major Depression,” “Pharmacotherapy of Autism and Related Disorders,” and “Practical Guide to ADHD Pharmacotherapy”) before obtaining credit, this article reviews recent evidence on the effectiveness of pharmacotherapy for treating children and adolescents with anxiety disorders. Psychotropic medication for the treatment of pediatric anxiety disorders and the relative risks and benefits of medication use for children with anxiety disorders compared to psychotherapy alone or combined psychotherapy and medication.

Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-analysis

To review evidence that computerized cognitive behavior therapy (CBT) “for the anxiety and depressive disorders is acceptable to patients and effective in the short and longer term.”

For those with anxiety and depressive disorder who might otherwise go without treatment, computerized CBT, especially when administered via the Internet, is capable of providing effective, acceptable, and practical care.

http://dx.doi.org/10.1371/journal.pone.0013196

Electrocortical Evidence for Vigilance-avoidance in Generalized Anxiety Disorder

To examine “the time-course of neural activity during emotional processing” in patients with generalize anxiety disorder, as both “exaggerated and attenuated responses to emotional stimuli have been documented” in this population.

After asking 21 people with generalized anxiety disorder and 25 healthy controls to passively view emotional and neutral images while their event-related potentials, the researches found an “enhanced P1 for unpleasant compared to neutral images” that was larger in patients with generalized anxiety disorder than in controls. Further, the increased late positive potential to unpleasant versus neutral images was diminished in the former group. The researchers concluded that their findings “provide evidence for early hypervigilance for emotional stimuli, followed by failure to engage in elaborative processing, in” generalized anxiety disorder.

Specificity of Interpersonal Problems in Generalized Anxiety Disorder Versus Other Anxiety Disorders and Depression

Uhmann S, Beesdo-Baum K, Becker E, Hoyer J

To examine “the diagnostic specificity of interpersonal problems (IP) in generalized anxiety disorder (GAD),” with the expectation of “generally higher interpersonal distress, and specifically higher levels of nonassertive, exploitable, overly nurturant, and intrusive behavior in 

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition

 GAD compared with patients with post-traumatic stress disorder (

 = 47), and unipolar depressive disorders (

In both patients with GAD alone and comorbid GAD, specificity in the sense of heightened interpersonal distress was not supported by any of the above scales, even after accounting for the degree of depressiveness using the Beck Depression Inventory. “GAD patients are rather not characterized by more self-ascribed IPs although they may worry more about interpersonal issues in general,” concluded the authors.

Attention Training for Generalized Anxiety Disorder

To “develop and test a new computerized treatment for generalized anxiety disorder” based on a four-week attention modification program protocol consisting of eight 30-minute sessions.

The Impact of Generalized Anxiety Disorder

and Social Anxiety Disorder on the Processing of Information and Learning

To increase researchers' understanding of the biological basis of generalized anxiety disorder and social anxiety disorder” through an understanding of “how the brain activity associated with specific thoughts and feelings may play a role in these anxiety disorders,” with the hope that this “knowledge will be used to design interventions to help those with these illnesses.”

Mechanisms of Sleep Disturbance in Children with Generalized Anxiety Disorder

To “examine the sleep characteristics of children with generalized anxiety disorder (GAD) compared to a control group of children without GAD to see how sleep behaviors and daytime behaviors are related.”

Anxiety Disorders Association of America: Generalized Anxiety Disorder (GAD)

Direct patients to this resource from the Anxiety Disorders Association of America for an overview of generalized anxiety disorder. Here, they can also learn about the difference between GAD and general anxiety about the economy, link to information on cognitive-behavioral therapy, learn about available medications, complete a self-test for GAD, download a brochure, and link to more on available treatment options. Also of great use are a couple stories of hope: “Working Hard at Life” and “Redefining My Life.”

Generalized Anxiety Disorder (GAD): Symptoms, Treatment, and Self-Help

This site from Helpguide—a non-profit website created by a couple who lost their daughter to a suicide they feel could have been avoided if she had easy access to supportive health information&mdash;thoroughly reviews GAD. Information is provided in short paragraphs and bulleted lists for easy review. Along with the review of normal worrying vs. GAD, signs and symptoms, self-help, when to seek professional help, and treatment options, the site provides links to related articles on understanding anxiety, therapy for anxiety, medications for anxiety, and how to stop worrying.

From the always-reliable National Institute of Mental Health comes this resource, last reviewed just days before writing, which thoroughly covers generalize anxiety disorder, OCD, panic disorder, PTSD, and social phobia/SAD. Along with sections for each specific disorder listed above—covering symptoms, treatment, diagnosis, and much more, the resource offers information on finding mental health services in one’s local area, related news, feature publications, and a link to current trials that are studying at anxiety. Site visitors should be sure to use the table of contents on the right side of page once they’ve selected a specific disorder to learn about more, so they don’t miss out on the wealth of information that isn’t immediately provided on the opening page. Many of the sections locate here are also available in Spanish.

A Study in Pediatric Patients with Generalized Anxiety Disorder

To determine “if duloxetine (60-120 mg) given once a day by mouth for 10 weeks to children and adolescents, is better than placebo when treating generalized anxiety disorder.”

Duloxetine in Elderly Generalized Anxiety Disorder

Generalized Anxiety Disorder

A Neural Signature of Anorexia Nervosa in the Ventral Striatal Reward System

 subscribers), $300/year (non-subscribers)

Based on the article of the same name printed in the 

, this course will enable participants to better demonstrate an increase in their knowledge of clinical medicine. “Participants should be able to understand the contents of a selected research or review article and to apply the new findings to their clinical practice.”

The various types of eating disorders, the need for clinically evaluating patients for eating disorders, and available treatments for managing eating disorders form the focus of this activity.

An Off-line Pilot Evaluation of a Web-based Systemic Cognitive-behavioral Intervention for Carers of People with Anorexia Nervosa

International Journal of Eating Disorders 

(November 15, 2010; online ahead of print)

To “evaluate the feasibility and acceptability of a novel systemic cognitive behavior therapy-based intervention for carers of people with anorexia nervosa (AN),” with the intervention providing information and promoting “skills development in managing the illness” and offering caregivers professional support.

Following intervention, the researchers saw significant decreases in anxiety, depression, negative experiences of caregiving, and expressed emotion, as well as significant increases in positive experiences in caregiving, with most improvements maintained at follow-up. The intervention was well-received by participants.

Demographic and Clinical Characteristics of Individuals Utilizing an Internet-based Digital Coaching Program for Recovering from Binge Eating

International Journal of Eating Disorder 

(October 26, 2010; online ahead of print)

To examine “demographic and clinical characteristics of adults who accessed a self-help program for binge eaters made available to them via their employers or health plans,” as few studies have examined who uses the digital coaching self-help interventions that are offered increasingly on the Internet for facilitation behavioral change.

 With more women (3,053) than men (998), mostly those who report binge eating below levels of frequency required for a clinical diagnosis, few people who had received prior treatment for an eating disorder, and many reporting high levels of motivation to overcome their eating disorders taking advantage of the intervention, the researchers concluded that “digital coaching programs may be a viable treatment option, particularly for individuals with infrequent binge eating who otherwise might not seek or receive treatment.”

Evaluation of a Guided Internet Self-treatment Programme for Bulimia Nervosa in Several European Countries

 (September 21, 2010; online ahead of print)

 Carrard I, Fernandez-Aranda F, Lam T, et al.

 To “evaluate the use of an online guided self-treatment programme for bulimia nervosa (BN) and to determine predictors of outcome” using data “collected in four European countries where the programme was simultaneously used.”

Following a four-month intervention using a cognitive behavioral therapy-based, online-guided, self-help program, significant improvements were seen in severity of eating disorder symptoms and general psychopathology. At the end of treatment, one-third of patients were symptom free. The dropout rate was roughly 25%.

Motivation to Exercise in People with Anorexia Nervosa

 To “determine the importance and level of physical activity in people with anorexia nervosa.”

To “investigate thought processes and neural mechanisms that may contribute to the development of habitual behaviors,” based on the hypothesis that patients with anorexia nervosa “will perform differently than people without eating disorders on a series of neuropsychological tasks and will show different neural activation patterns in functional neuroimaging scans.”

Online Cognitive Behavioral Therapy for Bulimia Nervosa

 University of North Carolina (UNC), Chapel Hill

 To compare cognitive behavioral therapy delivered via face-to-face group therapy to online group therapy delivered through Cognitive Behavioral Therapy for Bulimia Nervosa, a research program funded by the National Institute of Mental Health and conducted by the UNC Eating Disorders Program and the University of Pittsburgh Medical Center.

	Mirror Mirror is a site developed by an eating disorder survivor to share experiences with other affected patients; the emphasis here is on providing support, not medical advice. The site does offer brief overviews of eating disorders, an exploration of the recovery process from the perspective of the survivor, and a “Myths vs. Realities” section. Visitors can also view (or add their name to) the Survivor’s Wall, an online display comprising the names and comments of people dealing with eating disorders.

National Eating Disorders Association: Information for Family and Friends

This section of the NEDA website states, “Parents, siblings and close friends play a significant role in guiding and supporting others. In many cases, individuals with eating disorders cannot recognize a need for help in themselves, and it takes a strong, caring individual to reach out.” To that end, the resource offers general information on eating disorders, an FAQ section where site visitors can also ask their own question of an expert, stories of hope, and the NEDA Parent Toolkit. The latter, updated by two physicians in March 2009, was developed for parents “in response to requests for a simple, easy-to-use way to get answers to questions and concerns” and covers common myths, treatment, getting help, insurance issues, and more.

SAMHSA’s National Mental Health Information Center — Center for Mental Health Services: Eating Disorders

This website’s fact sheet covers the three most common eating disorders: anorexia nervosa, bulimia nervosa, and binge-eating disorder. Descriptions the eating disorders, who sufferers from them, and what symptoms include are all covered. Factors considered in the formal labeling of eating disorders are described, which may enable unknowing patients to better identify that they have an illness. National resources will help patients find help closer to their home.

Eating Disorders Coalition for Research, Policy, and Action

Among the resources available at the online home of the EDC—which include legislative updates, congressional briefings, and event information&mdash;are reports and disorder information, where physicians can read the American Public Opinion on Eating Disorders, 2005, which shows Americans agree that eating disorders are illnesses, not choices. Statistics here also display the seriousness of eating disorders.

December 2010

App Wrap

Breaking Boundaries with Web-based Disease Management

Restless Legs Syndrome

Peripheral Neuropathy

Generalized Anxiety Disorder

Anorexia & Bulimia