Philadelphia, Pa. (November 20, 2012) – The time has come to develop a pituitary “centers of excellence” (CoE) designation for hospitals with high-level surgical skills and other capabilities needed to provide state-of-the-art care for patients with pituitary tumors, according to an article in the November issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Recent advances in surgical and medical management—along with the high prevalence and impact of pituitary tumors—warrant development of a voluntary system for designating pituitary centers of excellence, according to the special article by four leading U.S. neurosurgeons including Daniel Kelly and Nancy McLaughlin (John Wayne Cancer Institute & Saint John’s Health Center, Santa Monica, CA), Edward Laws, (Brigham & Women’s Hospital, Boston, MA) and Nelson Oyesiku (Emory University, Atlanta, GA), as well as a leading endocrinologist (Laurence Katznelson, Stanford University, Palo Alto, CA).

Designation Recognizes Surgical Skills and Coordinated Care for Pituitary Tumors

Tumors of the pituitary gland, located directly under the brain in the skull base, pose difficult challenges in both diagnosis and treatment. Known as the body’s “master gland,” the pituitary produces hormones that control a wide range of bodily functions. In recent years, studies have shown that pituitary adenomas and other related tumors are more common than previously thought—affecting perhaps 1 out of 1,000 people. These tumors can lead to conditions of hormonal excess such as acromegaly, Cushing’s disease and prolactinoma, as well as hormonal loss, visual loss and headaches.

The idea of a CoE designation reflects specialized skills and expertise needed to provide top-level care for patients with particular types of problems. Perhaps the best-known example is the designation of level I to IV trauma centers, based on criteria such as the volume of severely injured patients treated, levels of specialist staffing, and the presence of educational and outreach programs.

The authors believe it’s time for a similar approach to identifying hospitals and medical centers with the capacity to provide optimal clinical management for patients with pituitary tumors. Care is best provided in a “multidisciplinary collaborative environment,” including neurosurgeons and endocrinologists with special experience in managing pituitary disorders. The treatment team should also include a wide range of other medical and surgical subspecialists who play important roles in managing these complex cases, such as neuro-ophthalmologists, radiation oncologists and otolaryngologists (ENT).

The call for a CoE designation reflects the rapid evolution of highly specialized surgical techniques for pituitary tumors, known as transsphenoidal surgery, increasingly performed with endoscopy, as well as new medical approaches to treating the hormonal abnormalities these tumors can produce. Advances in radiology and pathology have also raised the standard of skills needed for diagnosis and management.

As with other advanced surgical procedures, studies have shown that centers performing a larger volume of transsphenoidal surgeries achieve better outcomes with lower complication rates. Such high levels of volume and expertise are also essential for training the next generation of pituitary surgeons, who may not be getting the experience they need at some residency programs.

“[O]ptimal care for pituitary patients is best provided by experienced practitioners, working in a collaborative environment using state-of-the-art techniques and therapies,” the authors write. They outline a “preliminary proposal” for a pituitary CoE designation, based on three key missions:

• Providing comprehensive care and support to patients with pituitary disorders.
• Providing residency training, fellowship training, and/or continuing medical education in the management of pituitary and neuroendocrine disease.
• Contributing to research in pituitary disorders.

The authors acknowledge that many questions remain to be answered, such as what organization would oversee the effort and how to ensure that expertise is adequately distributed across regions. As time goes on, it will be important to show that pituitary centers of excellence are truly effective in improving patient outcomes and reducing health care costs. They conclude, “Such an effort would enhance patient care, increase public awareness, promote training and expertise, and advance research in the management of pituitary tumors and related hormonal disorders.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (August 30, 2012) – A “contingency management” approach—offering incentives for negative drug tests—can help promote drug abstinence among pregnant women with heroin or cocaine addiction, reports a study in the September Addictive Disorders & Their Treatment.  The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Contingency management (CM) works just as well whether the incentives are increased (escalating) or fixed over time, the study finds.  Incentives may also be useful in promoting other healthy behaviors during pregnancy, such as quitting smoking.  “These results further the scientific knowledge regarding CM treatment in opioid-dependent pregnant women by supporting the finding that the escalating and fixed CM schedules produce similar amounts of drug negatives urine samples early in treatment,” according to the new research by Hendrée E. Jones, PhD, and colleagues of The Johns Hopkins University School of Medicine, Baltimore.

Whether Fixed or Increasing, Incentives Promote Drug Abstinence

The researchers evaluated two approaches to contingency management in pregnant women being treated for addiction to opioids (heroin and related drugs) or cocaine.  Especially combined with poverty and mental health issues, cocaine and/or heroin abuse during pregnancy can lead to adverse health outcomes for both mother and child.

The study included 90 opioid-addicted women being treated at the Center for Addiction and Pregnancy in Baltimore.  Two-thirds of the women were randomly assigned to contingency management.  In the contingency management approach, patients receive incentives in the form of vouchers as a “reward” for achieving desired outcomes—in this case, negative urine tests showing abstinence from drugs.

One group received escalating incentives, with increasing rewards for each negative urine test.  The other group received fixed incentives—the same reward for each negative test.  Previous research has shown that incentives can quickly increase rates of targeted behavior in patients with substance abuse problems.

The vouchers could be exchanged for merchandise or gift certificates.  In the escalating group, the vouchers had a starting value of $7.50, which increased by $1 per sample day (MWF) as long as the tests remained negative.  In the fixed group, the vouchers were worth $25 for each negative urine test.

Both incentive programs continued for thirteen weeks.  All women received other standard counseling and treatment, including methadone replacement therapy for heroin addiction.

All measures of opioid and heroin dependence were similar in the two contingency management groups.  With 14 opportunities to provide urine samples, the average number of negative test results was 8.1 in the escalating incentive group and 7.4 in the fixed incentive group.

There was a tendency toward higher cocaine abstinence rates among women receiving escalating incentives.  However, after five weeks there was no significant difference between groups.

Added to previous studies, the new results strengthen the evidence that providing incentives for staying drug-free is a useful part of the treatment strategy for pregnant women with opioid dependency.  The researchers believe contingency management may be especially valuable in pregnant women—to quickly reduce drug exposure to the developing fetus, and to help in meeting the goal of having both the mother and baby be drug-free at delivery.

Other reports have suggested promising effects of incentive programs in reducing smoking among pregnant women with substance use disorders.  “One recent study found that voucher reinforcement for smoking reductions  during pregnancy had a significant impact on the  smoking reduction and abstinence rates in this vulnerable population,” comments coauthor Michelle Tuten, LCSW-C.  “These interventions appear to have a clinically meaningful impact on birth outcomes as well, although larger studies are needed to more fully explore birth outcome differences.”  Professor Tuten is conducting further research on contingency management to reduce exposure to maternal smoking.

For her work in developing behavioral and drug treatments for substance abuse in pregnant and parenting women, Dr Jones has been selected to receive the 2012 Association for Medical Education and Research in Substance Abuse (AMERSA) Betty Ford Award.  The award will be presented during this year’s AMERSA national conference on November 1 in Bethesda, Md., where Dr Jones will discuss new research affecting the clinical management of opioid dependence during pregnancy.

About Addictive Disorders & Their Treatment

Addictive Disorders & Their Treatment is a quarterly international journal devoted to practical clinical research and treatment issues related to the misuses of alcohol and licit and illicit drugs and the study and treatment of addictive disorders and their behaviors. The journal publishes broad-spectrum, patient-oriented coverage of all aspects of addiction, directed toward an audience of psychiatrists, clinical psychologists, psychopharmacologists, and primary care practitioners

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (August 7, 2012) – A new study supports what neurosurgeons have long suspected—that pregnancy is an important risk factor for bleeding from arteriovenous malformations (AVMs) in the brain, reports the August issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The best available data suggest that pregnant women with AVMs face an eight percent risk of rupture and bleeding during pregnancy—far higher than the risk in non-pregnant women. Based on their findings, Bradley A. Gross, MD, and Rose Du, PhD, of Harvard Medical School outline some recommendations for women with AVMs who want to have children or are already pregnant.

Risk of AVM Bleeding Is Eight Times Higher During Pregnancy

Drs. Gross and Du reviewed the records of 54 women with confirmed AVMs between 2002 and 2010. Arteriovenous malformations are tangled complexes of interconnected arteries and veins that are prone to rupture and bleeding, which can lead to death or serious disability.

The researchers calculated the total risk of bleeding AVMs in terms of the total number of “patient-years” at risk. They then assessed the risk of bleeding events during the total time their patients were pregnant. The 54 patients had a total of 62 pregnancies during follow-up. Four of the women had a total of five bleeding events while pregnant.

Based on the data, the researchers calculated an AVM bleeding risk of 8.1 percent per pregnancy, or 10.8 per year. By contrast, the rate of bleeding while the women were not pregnant was 1.1 percent per year.

Thus the risk of bleeding from an AVM was about eight times higher during pregnancy. On analysis of follow-up data to age 40, the risk of bleeding during pregnancy appeared even greater—18 times higher.

Neurosurgeons have long regarded pregnancy as a risk factor for bleeding AVMs. However, because ruptured AVMs are relatively rare, it is difficult to calculate the true risks.

Within the limitations of the data, the study strongly suggests that the risk of bleeding AVMs is substantially higher during pregnancy. In the authors’ four cases, bleeding AVMs caused sudden headache and other symptoms between 22 and 39 weeks of pregnancy. With prompt treatment, all of the women and their infants survived (although one of the mothers was left with permanent disability).

Based on their findings, Drs. Gross and Du recommend treatment for any woman with an AVM who is considering having children—especially if they’ve previously had an episode of bleeding. If an unruptured AVM is discovered during pregnancy, they recommend “comprehensive patient counseling,” discussing the risks of treatment versus “cautious continuation” of pregnancy without treatment.

When it’s time for delivery, they recommend cesarean section. While noting that other doctors and hospitals may follow a different approach, Drs. Gross and Du hope their study and recommendations will “incite thought and invoke added caution in women with known, untreated AVMs planning to bear children.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com