In a population of obese adults in the United States, migraineurs showed greater total health care utilization and expenses than non-migraineurs, a recent study found. Therefore, treatment plans that address risk factors associated with migraine and comorbidities may help reduce the utilization of health care services and costs. This 7-year retrospective study used longitudinal panel data from 2006 to 2013 from the Household Component of the Medical Expenditure Panel Survey to identify obese adults reporting migraines. Outcomes compared in migraineurs versus non-migraineurs were as follows: annualized per-person medical care, prescription drug, and total health expenses. Researchers found:

• In 23,596 obese adults, 4.7% reported migraine (n=1025) approximating 3 million civilian non-institutionalized individuals in the United States.
• Logistic regression showed that the following sociodemographic characteristics increased migraine risk: age (18–45 years), females, white race, poor perceived health status, and greater Charlson comorbidity index.
• Migraineurs showed $1401, $813, and $2213 greater annual medical, prescription drug, and total health expenses than non-migraineurs, respectively.
• After adjustment, total health expenses increased by 31.6% in migraineurs versus non-migraineurs.

Wu J, Davis-Ajami ML, Lu ZK. Impact of migraine on health care utilization and expenses in obese adults: A US population-based study. [Published online ahead of print December 31, 2018]. Clinicoecon Outcomes Res. doi:10.2147/CEOR.S189699.

In a population of obese adults in the United States, migraineurs showed greater total health care utilization and expenses than non-migraineurs, a recent study found. Therefore, treatment plans that address risk factors associated with migraine and comorbidities may help reduce the utilization of health care services and costs. This 7-year retrospective study used longitudinal panel data from 2006 to 2013 from the Household Component of the Medical Expenditure Panel Survey to identify obese adults reporting migraines. Outcomes compared in migraineurs versus non-migraineurs were as follows: annualized per-person medical care, prescription drug, and total health expenses. Researchers found:

• In 23,596 obese adults, 4.7% reported migraine (n=1025) approximating 3 million civilian non-institutionalized individuals in the United States.
• Logistic regression showed that the following sociodemographic characteristics increased migraine risk: age (18–45 years), females, white race, poor perceived health status, and greater Charlson comorbidity index.
• Migraineurs showed $1401, $813, and $2213 greater annual medical, prescription drug, and total health expenses than non-migraineurs, respectively.
• After adjustment, total health expenses increased by 31.6% in migraineurs versus non-migraineurs.

Wu J, Davis-Ajami ML, Lu ZK. Impact of migraine on health care utilization and expenses in obese adults: A US population-based study. [Published online ahead of print December 31, 2018]. Clinicoecon Outcomes Res. doi:10.2147/CEOR.S189699.

In a population of obese adults in the United States, migraineurs showed greater total health care utilization and expenses than non-migraineurs, a recent study found. Therefore, treatment plans that address risk factors associated with migraine and comorbidities may help reduce the utilization of health care services and costs. This 7-year retrospective study used longitudinal panel data from 2006 to 2013 from the Household Component of the Medical Expenditure Panel Survey to identify obese adults reporting migraines. Outcomes compared in migraineurs versus non-migraineurs were as follows: annualized per-person medical care, prescription drug, and total health expenses. Researchers found:

• In 23,596 obese adults, 4.7% reported migraine (n=1025) approximating 3 million civilian non-institutionalized individuals in the United States.
• Logistic regression showed that the following sociodemographic characteristics increased migraine risk: age (18–45 years), females, white race, poor perceived health status, and greater Charlson comorbidity index.
• Migraineurs showed $1401, $813, and $2213 greater annual medical, prescription drug, and total health expenses than non-migraineurs, respectively.
• After adjustment, total health expenses increased by 31.6% in migraineurs versus non-migraineurs.

Wu J, Davis-Ajami ML, Lu ZK. Impact of migraine on health care utilization and expenses in obese adults: A US population-based study. [Published online ahead of print December 31, 2018]. Clinicoecon Outcomes Res. doi:10.2147/CEOR.S189699.

Optimism and pessimism are associated with migraine and migraine‐related disability. This according to a recent study that found that people with migraine were less optimistic and more pessimistic than controls and endorsed higher levels of anxious and depressive symptoms. The sample population was selected through a stratified, multi‐stage area probability sample of households. A validated questionnaire eliciting data on demographics, headache features, migraine‐related disability, depression (PHQ‐9), anxiety (GAD‐7), optimism, and pessimism was administered to people with migraine and headache‐free control participants via trained interviewers. The odds for having migraine/no headache diagnosis were calculated by binary logistic regression, and ordinal regression was performed to check associations between migraine‐related disability and optimism. Researchers found:

• Out of 600 individuals, 302 met inclusion criteria and were included (140 controls [with no history of headache disorders] and 162 people meeting criteria for migraine [29 with chronic migraine, that is, ≥15 headache days/month]).
• Pessimism and anxiety were predictors of meeting criteria for migraine, while optimism was inversely associated with migraine‐related disability.

Peres MFP, Belitardo A, Mercante JP, et al. Optimism, pessimism, and migraine: A cross‐sectional, population‐based study. [Published online ahead of print January 19, 2019]. Headache. doi:10.1111/head.13471.

Optimism and pessimism are associated with migraine and migraine‐related disability. This according to a recent study that found that people with migraine were less optimistic and more pessimistic than controls and endorsed higher levels of anxious and depressive symptoms. The sample population was selected through a stratified, multi‐stage area probability sample of households. A validated questionnaire eliciting data on demographics, headache features, migraine‐related disability, depression (PHQ‐9), anxiety (GAD‐7), optimism, and pessimism was administered to people with migraine and headache‐free control participants via trained interviewers. The odds for having migraine/no headache diagnosis were calculated by binary logistic regression, and ordinal regression was performed to check associations between migraine‐related disability and optimism. Researchers found:

• Out of 600 individuals, 302 met inclusion criteria and were included (140 controls [with no history of headache disorders] and 162 people meeting criteria for migraine [29 with chronic migraine, that is, ≥15 headache days/month]).
• Pessimism and anxiety were predictors of meeting criteria for migraine, while optimism was inversely associated with migraine‐related disability.

Peres MFP, Belitardo A, Mercante JP, et al. Optimism, pessimism, and migraine: A cross‐sectional, population‐based study. [Published online ahead of print January 19, 2019]. Headache. doi:10.1111/head.13471.

Optimism and pessimism are associated with migraine and migraine‐related disability. This according to a recent study that found that people with migraine were less optimistic and more pessimistic than controls and endorsed higher levels of anxious and depressive symptoms. The sample population was selected through a stratified, multi‐stage area probability sample of households. A validated questionnaire eliciting data on demographics, headache features, migraine‐related disability, depression (PHQ‐9), anxiety (GAD‐7), optimism, and pessimism was administered to people with migraine and headache‐free control participants via trained interviewers. The odds for having migraine/no headache diagnosis were calculated by binary logistic regression, and ordinal regression was performed to check associations between migraine‐related disability and optimism. Researchers found:

• Out of 600 individuals, 302 met inclusion criteria and were included (140 controls [with no history of headache disorders] and 162 people meeting criteria for migraine [29 with chronic migraine, that is, ≥15 headache days/month]).
• Pessimism and anxiety were predictors of meeting criteria for migraine, while optimism was inversely associated with migraine‐related disability.

Peres MFP, Belitardo A, Mercante JP, et al. Optimism, pessimism, and migraine: A cross‐sectional, population‐based study. [Published online ahead of print January 19, 2019]. Headache. doi:10.1111/head.13471.

Increased stroke risk in late life was observed in participants with late onset of migraine with aura (MA), as compared to participants with no headache in a recent ongoing, prospective, longitudinal, community‐based cohort study. Longer cumulative exposure to migraine with visual aura, however, was not associated with increased risk of ischemic stroke in late life. Participants were interviewed to ascertain migraine history at the third visit (1993–1995) and followed for ischemic stroke incidence over 20 years. Researchers performed a post hoc analysis to evaluate the association between the age of migraine onset and ischemic stroke. They found:

• There were 447 migraineurs with MA and 1128 migraineurs without aura (MO) identified among 11,592 black and white participants.
• There was an association between the age of MA onset at age ≥50 years (average duration=4.75 years) and ischemic stroke when compared to the no headache group (multivariable adjusted HR=2.17).
• MA onset at <50 years (average duration=28.17 years) was not associated with stroke (multivariable adjusted HR=1.31).
• MO was not associated with increased stroke regardless of the age of onset.

Androulakis XM, Sen S, Kodumuri N, et al. Migraine age of onset and association with ischemic stroke in late life: 20 years follow‐up in ARIC. [Published online ahead of print January 21, 2019]. Headache. doi:10.1111/head.13468.

Increased stroke risk in late life was observed in participants with late onset of migraine with aura (MA), as compared to participants with no headache in a recent ongoing, prospective, longitudinal, community‐based cohort study. Longer cumulative exposure to migraine with visual aura, however, was not associated with increased risk of ischemic stroke in late life. Participants were interviewed to ascertain migraine history at the third visit (1993–1995) and followed for ischemic stroke incidence over 20 years. Researchers performed a post hoc analysis to evaluate the association between the age of migraine onset and ischemic stroke. They found:

• There were 447 migraineurs with MA and 1128 migraineurs without aura (MO) identified among 11,592 black and white participants.
• There was an association between the age of MA onset at age ≥50 years (average duration=4.75 years) and ischemic stroke when compared to the no headache group (multivariable adjusted HR=2.17).
• MA onset at <50 years (average duration=28.17 years) was not associated with stroke (multivariable adjusted HR=1.31).
• MO was not associated with increased stroke regardless of the age of onset.

Androulakis XM, Sen S, Kodumuri N, et al. Migraine age of onset and association with ischemic stroke in late life: 20 years follow‐up in ARIC. [Published online ahead of print January 21, 2019]. Headache. doi:10.1111/head.13468.

Increased stroke risk in late life was observed in participants with late onset of migraine with aura (MA), as compared to participants with no headache in a recent ongoing, prospective, longitudinal, community‐based cohort study. Longer cumulative exposure to migraine with visual aura, however, was not associated with increased risk of ischemic stroke in late life. Participants were interviewed to ascertain migraine history at the third visit (1993–1995) and followed for ischemic stroke incidence over 20 years. Researchers performed a post hoc analysis to evaluate the association between the age of migraine onset and ischemic stroke. They found:

• There were 447 migraineurs with MA and 1128 migraineurs without aura (MO) identified among 11,592 black and white participants.
• There was an association between the age of MA onset at age ≥50 years (average duration=4.75 years) and ischemic stroke when compared to the no headache group (multivariable adjusted HR=2.17).
• MA onset at <50 years (average duration=28.17 years) was not associated with stroke (multivariable adjusted HR=1.31).
• MO was not associated with increased stroke regardless of the age of onset.

Androulakis XM, Sen S, Kodumuri N, et al. Migraine age of onset and association with ischemic stroke in late life: 20 years follow‐up in ARIC. [Published online ahead of print January 21, 2019]. Headache. doi:10.1111/head.13468.

Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.

In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
 

Where did you get your education?

I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.

Was your intention always to be a PA?

During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.

How did you become interested in hospital medicine?

When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.

What is your current role and title at Ochsner?

From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.

What are your areas of interest or research?

I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.

I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.

What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?

When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.

The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.

I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.

How does a hospitalist PA work differently from a PA in other care settings?

The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.

How does SHM support hospitalist PAs?

SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.

There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.

What’s on the horizon for NPs and PAs in hospital medicine?

One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.

One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.

But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.

Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.

In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
 

Where did you get your education?

I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.

Was your intention always to be a PA?

During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.

How did you become interested in hospital medicine?

When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.

What is your current role and title at Ochsner?

From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.

What are your areas of interest or research?

I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.

I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.

What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?

When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.

The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.

I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.

How does a hospitalist PA work differently from a PA in other care settings?

The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.

How does SHM support hospitalist PAs?

SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.

There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.

What’s on the horizon for NPs and PAs in hospital medicine?

One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.

One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.

But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.

Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.

In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
 

Where did you get your education?

I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.

Was your intention always to be a PA?

During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.

How did you become interested in hospital medicine?

When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.

What is your current role and title at Ochsner?

From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.

What are your areas of interest or research?

I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.

I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.

What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?

When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.

The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.

I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.

How does a hospitalist PA work differently from a PA in other care settings?

The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.

How does SHM support hospitalist PAs?

SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.

There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.

What’s on the horizon for NPs and PAs in hospital medicine?

One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.

One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.

But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.

Estrogen and androgen deficiency from menopause causes vulvovaginal and urogenital changes and a plethora of symptoms, most prominently dyspareunia. 

Read the supplement and earn CME credit for your knowledge of the following:

• The pathophysiology of dyspareunia due to vulvovaginal atrophy (VVA) of menopause.
• The underrecognition and undertreatment of dyspareunia due to VVA.
• Efficacy results of randomized placebo controlled trials of ospemifene.
• Adverse events associated with ospemifene.
• Safety data of ospemifine as well as other oral selective estrogen receptor modulators and estrogens.

Click on the image above or here to read the supplement and earn credit

Estrogen and androgen deficiency from menopause causes vulvovaginal and urogenital changes and a plethora of symptoms, most prominently dyspareunia. 

Read the supplement and earn CME credit for your knowledge of the following:

• The pathophysiology of dyspareunia due to vulvovaginal atrophy (VVA) of menopause.
• The underrecognition and undertreatment of dyspareunia due to VVA.
• Efficacy results of randomized placebo controlled trials of ospemifene.
• Adverse events associated with ospemifene.
• Safety data of ospemifine as well as other oral selective estrogen receptor modulators and estrogens.

Click on the image above or here to read the supplement and earn credit

Estrogen and androgen deficiency from menopause causes vulvovaginal and urogenital changes and a plethora of symptoms, most prominently dyspareunia. 

Read the supplement and earn CME credit for your knowledge of the following:

• The pathophysiology of dyspareunia due to vulvovaginal atrophy (VVA) of menopause.
• The underrecognition and undertreatment of dyspareunia due to VVA.
• Efficacy results of randomized placebo controlled trials of ospemifene.
• Adverse events associated with ospemifene.
• Safety data of ospemifine as well as other oral selective estrogen receptor modulators and estrogens.

Click on the image above or here to read the supplement and earn credit

Turoctocog alfa, a recombinant Factor VIII molecule, was effective in preventing bleeding episodes and was well tolerated in more than 200 males with hemophilia A who were part of the Guardian 2 extension trial.

The open label, phase 3b study included patients who had completed the Guardian 1 or Guardian 3 phase 1 pharmacokinetics trials and who chose to continue prophylaxis with turoctocog alfa (Novoeight).

In total, 214 patients were enrolled and 213 were exposed to treatment. Prophylaxis was given as a standard dose level of 20-50 IU/kg once every second day or 20-60 IU/kg three times weekly. Less frequent prophylaxis was available at 40-60 IU/kg twice weekly or once every third day. For on-demand treatment, the recommended dose level was 20-50 IU/kg.

“The final results of guardian 2 are consistent with data from previous interim analyses,” Steven R. Lentz, MD, PhD, of the University of Iowa, Iowa City, and his colleagues wrote in Haemophilia. “Turoctocog alfa was well tolerated, with no unexpected safety signals and no development of FVIII inhibitors.”

Among the 207 patients on prophylaxis, 1,782 bleeds were reported. The overall median annualized bleeding rate (ABR) for this group was 1.37. More than 88% of these bleeds were stopped with one or two injections and the success rate for treatment of bleeds was more than 90%.

The median ABR dropped to zero, with a range of 0.00‐9.91, for the 27 patients who were on the less-frequent prophylaxis regimen. In this group, more than 75% of the 34 bleeds that occurred were stopped with one injection and the success rate for treatment of bleeds was about 94%.

“These data suggest a subset of patients might be well managed with less‐frequent dosing,” the researchers wrote.

For the 19 patients who received on-demand treatment, there were 391 bleeds reported. The overall median ABR was 30.44. Nearly 80% of bleeds were stopped with one injection and more than 15% with two injections. The treatment success rate in this group was more than 96%.

There were no Factor VIII inhibitors reported in the extension trial.

In total, there were 1,260 adverse events reported for 183 patients, corresponding to less than two adverse events per patients per years of exposure to the treatment.

The most common adverse event, seen in 14.6% of patients, was nasopharyngitis. Serious adverse events occurred in 18.3% of patients but all expect one event was deemed unlikely to be related to treatment. The one fatal event in the trial was deemed unlikely to be related to treatment.

The study was funded by Novo Nordisk. Dr. Lentz reported being a paid consultant to Novo Nordisk and receiving research funding from the company.

mschneider@mdedge.com

SOURCE: Lentz SR et al. Haemophilia. 2018 Nov;24(6):e391-4.

Turoctocog alfa, a recombinant Factor VIII molecule, was effective in preventing bleeding episodes and was well tolerated in more than 200 males with hemophilia A who were part of the Guardian 2 extension trial.

The open label, phase 3b study included patients who had completed the Guardian 1 or Guardian 3 phase 1 pharmacokinetics trials and who chose to continue prophylaxis with turoctocog alfa (Novoeight).

In total, 214 patients were enrolled and 213 were exposed to treatment. Prophylaxis was given as a standard dose level of 20-50 IU/kg once every second day or 20-60 IU/kg three times weekly. Less frequent prophylaxis was available at 40-60 IU/kg twice weekly or once every third day. For on-demand treatment, the recommended dose level was 20-50 IU/kg.

“The final results of guardian 2 are consistent with data from previous interim analyses,” Steven R. Lentz, MD, PhD, of the University of Iowa, Iowa City, and his colleagues wrote in Haemophilia. “Turoctocog alfa was well tolerated, with no unexpected safety signals and no development of FVIII inhibitors.”

Among the 207 patients on prophylaxis, 1,782 bleeds were reported. The overall median annualized bleeding rate (ABR) for this group was 1.37. More than 88% of these bleeds were stopped with one or two injections and the success rate for treatment of bleeds was more than 90%.

The median ABR dropped to zero, with a range of 0.00‐9.91, for the 27 patients who were on the less-frequent prophylaxis regimen. In this group, more than 75% of the 34 bleeds that occurred were stopped with one injection and the success rate for treatment of bleeds was about 94%.

“These data suggest a subset of patients might be well managed with less‐frequent dosing,” the researchers wrote.

For the 19 patients who received on-demand treatment, there were 391 bleeds reported. The overall median ABR was 30.44. Nearly 80% of bleeds were stopped with one injection and more than 15% with two injections. The treatment success rate in this group was more than 96%.

There were no Factor VIII inhibitors reported in the extension trial.

In total, there were 1,260 adverse events reported for 183 patients, corresponding to less than two adverse events per patients per years of exposure to the treatment.

The most common adverse event, seen in 14.6% of patients, was nasopharyngitis. Serious adverse events occurred in 18.3% of patients but all expect one event was deemed unlikely to be related to treatment. The one fatal event in the trial was deemed unlikely to be related to treatment.

The study was funded by Novo Nordisk. Dr. Lentz reported being a paid consultant to Novo Nordisk and receiving research funding from the company.

mschneider@mdedge.com

SOURCE: Lentz SR et al. Haemophilia. 2018 Nov;24(6):e391-4.

Turoctocog alfa, a recombinant Factor VIII molecule, was effective in preventing bleeding episodes and was well tolerated in more than 200 males with hemophilia A who were part of the Guardian 2 extension trial.

The open label, phase 3b study included patients who had completed the Guardian 1 or Guardian 3 phase 1 pharmacokinetics trials and who chose to continue prophylaxis with turoctocog alfa (Novoeight).

In total, 214 patients were enrolled and 213 were exposed to treatment. Prophylaxis was given as a standard dose level of 20-50 IU/kg once every second day or 20-60 IU/kg three times weekly. Less frequent prophylaxis was available at 40-60 IU/kg twice weekly or once every third day. For on-demand treatment, the recommended dose level was 20-50 IU/kg.

“The final results of guardian 2 are consistent with data from previous interim analyses,” Steven R. Lentz, MD, PhD, of the University of Iowa, Iowa City, and his colleagues wrote in Haemophilia. “Turoctocog alfa was well tolerated, with no unexpected safety signals and no development of FVIII inhibitors.”

Among the 207 patients on prophylaxis, 1,782 bleeds were reported. The overall median annualized bleeding rate (ABR) for this group was 1.37. More than 88% of these bleeds were stopped with one or two injections and the success rate for treatment of bleeds was more than 90%.

The median ABR dropped to zero, with a range of 0.00‐9.91, for the 27 patients who were on the less-frequent prophylaxis regimen. In this group, more than 75% of the 34 bleeds that occurred were stopped with one injection and the success rate for treatment of bleeds was about 94%.

“These data suggest a subset of patients might be well managed with less‐frequent dosing,” the researchers wrote.

For the 19 patients who received on-demand treatment, there were 391 bleeds reported. The overall median ABR was 30.44. Nearly 80% of bleeds were stopped with one injection and more than 15% with two injections. The treatment success rate in this group was more than 96%.

There were no Factor VIII inhibitors reported in the extension trial.

In total, there were 1,260 adverse events reported for 183 patients, corresponding to less than two adverse events per patients per years of exposure to the treatment.

The most common adverse event, seen in 14.6% of patients, was nasopharyngitis. Serious adverse events occurred in 18.3% of patients but all expect one event was deemed unlikely to be related to treatment. The one fatal event in the trial was deemed unlikely to be related to treatment.

The study was funded by Novo Nordisk. Dr. Lentz reported being a paid consultant to Novo Nordisk and receiving research funding from the company.

mschneider@mdedge.com

SOURCE: Lentz SR et al. Haemophilia. 2018 Nov;24(6):e391-4.

Chill out, kid

What do you do when your child has constant tantrums? A simple edible could do the trick, according to a Hollywood physician.

Courtesy Wikimedia Commons/Coaster420/Creative Commons License

The natural medicine physician is in hot (bong) water after recommending marijuana cookies as treatment for a 4-year-old child’s ADHD and bipolar disorder. The icing on the cake (or cookie) is that both diagnoses weren’t even accurate. Perhaps the doctor was sampling his own treatments before the office visit?

The progressive physician has had his license revoked for the “grossly negligent” diagnosis, which he made in 30 minutes without consulting the child’s teachers, his father, or a psychiatrist. Probably not the best way to handle it, said the state medical board. Perhaps he should have suggested some CBD-infused Coke, instead?
 

Gator saver

Dogs, cats, peacocks – these are the animals that many people with anxiety, depression, and other mental health issues use for emotional support. But now, enter Wally, the emotional support alligator.

mphillips007/iStockphoto.com

Spanning 5 feet long and sporting way too many teeth, Wally is the constant companion of a 65-year-old Pennsylvania man with depression. Wally’s owner decided to forgo pharmacologic treatment for something decidedly more reptilian.

Wally, who was rescued from Florida, loves chicken wings, hugs, and his adopted gator brother, Scrappy. He also has the potential to reach 16 feet long, which is … concerning. Something tells me you can’t take Wally on a plane as a service gator.

But don’t worry, Wally has been approved by a doctor. Rumors that Wally had the doctor’s arm in his jaws before approval are unsubstantiated.

Synergy is not always a good thing

Since it is generally agreed that two heads are better than one, three heads must be even better than two, right? But what if we’re not talking about heads? Suppose, instead, that the subject is global pandemics. Would it be better if three of the greatest threats to humanity’s existence on the planet decided to join forces?

MatiasEnElMundo/gettyimages

The Lancet Global Syndemic Commission, a group of more than 40 international experts, said that obesity, undernutrition, and climate change “constitute a syndemic, or synergy of epidemics, because they co-occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers” (Lancet. 2019 Jan. 27. doi: 10.1016/S0140-6736[18]32822-8).

It gets better: The commission suggested that the “three interconnected health pandemics [have been] effectively orchestrated by the shadowy manipulations and influence of vested commercial interests – an entity collectively defined as ‘Big Food,’ ” according to Science Alert.

This all seems like a lot to overcome, but we here at LOTME have faith in science, and in the scientists who are working to solve these problems. After all, it’s not like anyone’s out there disregarding the science and saying that this stuff isn’t really happening. … Wait, what? … Climate change deniers? … Really? … The president tweeted what? … We’re doomed.
 

I prefer my medication sunny side up

Here’s a hypothetical question for you: If you were to have cancer, how would you prefer to be treated? Would you rather go through the rigors of chemotherapy? Or would you rather eat an omelet?

paci77/iStockphoto.com

Okay, it probably wouldn’t work quite like that, but a group of physicians from the University of Edinburgh have successfully modified chickens to lay eggs containing a pair of human proteins within the egg white.

One of these proteins has antiviral and anticancer effects, and the other can help damaged tissue repair itself. The researchers added that the protein in the egg white could be modified to make the key ingredients for other protein-based drugs such as Avastin and Herceptin, which are used for treating cancer.

We know what you’re thinking: It’ll probably take a thousand eggs to make one dose – but no, it only takes three. Over the course of a year, one chicken could produce a hundred doses, and do it for far cheaper than is currently possible. We hate jumping on the social media bandwagon here, but frankly, this is an egg worth giving millions of Instagram likes.

Chill out, kid

What do you do when your child has constant tantrums? A simple edible could do the trick, according to a Hollywood physician.

Courtesy Wikimedia Commons/Coaster420/Creative Commons License

The natural medicine physician is in hot (bong) water after recommending marijuana cookies as treatment for a 4-year-old child’s ADHD and bipolar disorder. The icing on the cake (or cookie) is that both diagnoses weren’t even accurate. Perhaps the doctor was sampling his own treatments before the office visit?

The progressive physician has had his license revoked for the “grossly negligent” diagnosis, which he made in 30 minutes without consulting the child’s teachers, his father, or a psychiatrist. Probably not the best way to handle it, said the state medical board. Perhaps he should have suggested some CBD-infused Coke, instead?
 

Gator saver

Dogs, cats, peacocks – these are the animals that many people with anxiety, depression, and other mental health issues use for emotional support. But now, enter Wally, the emotional support alligator.

mphillips007/iStockphoto.com

Spanning 5 feet long and sporting way too many teeth, Wally is the constant companion of a 65-year-old Pennsylvania man with depression. Wally’s owner decided to forgo pharmacologic treatment for something decidedly more reptilian.

Wally, who was rescued from Florida, loves chicken wings, hugs, and his adopted gator brother, Scrappy. He also has the potential to reach 16 feet long, which is … concerning. Something tells me you can’t take Wally on a plane as a service gator.

But don’t worry, Wally has been approved by a doctor. Rumors that Wally had the doctor’s arm in his jaws before approval are unsubstantiated.

Synergy is not always a good thing

Since it is generally agreed that two heads are better than one, three heads must be even better than two, right? But what if we’re not talking about heads? Suppose, instead, that the subject is global pandemics. Would it be better if three of the greatest threats to humanity’s existence on the planet decided to join forces?

MatiasEnElMundo/gettyimages

The Lancet Global Syndemic Commission, a group of more than 40 international experts, said that obesity, undernutrition, and climate change “constitute a syndemic, or synergy of epidemics, because they co-occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers” (Lancet. 2019 Jan. 27. doi: 10.1016/S0140-6736[18]32822-8).

It gets better: The commission suggested that the “three interconnected health pandemics [have been] effectively orchestrated by the shadowy manipulations and influence of vested commercial interests – an entity collectively defined as ‘Big Food,’ ” according to Science Alert.

This all seems like a lot to overcome, but we here at LOTME have faith in science, and in the scientists who are working to solve these problems. After all, it’s not like anyone’s out there disregarding the science and saying that this stuff isn’t really happening. … Wait, what? … Climate change deniers? … Really? … The president tweeted what? … We’re doomed.
 

I prefer my medication sunny side up

Here’s a hypothetical question for you: If you were to have cancer, how would you prefer to be treated? Would you rather go through the rigors of chemotherapy? Or would you rather eat an omelet?

paci77/iStockphoto.com

Okay, it probably wouldn’t work quite like that, but a group of physicians from the University of Edinburgh have successfully modified chickens to lay eggs containing a pair of human proteins within the egg white.

One of these proteins has antiviral and anticancer effects, and the other can help damaged tissue repair itself. The researchers added that the protein in the egg white could be modified to make the key ingredients for other protein-based drugs such as Avastin and Herceptin, which are used for treating cancer.

We know what you’re thinking: It’ll probably take a thousand eggs to make one dose – but no, it only takes three. Over the course of a year, one chicken could produce a hundred doses, and do it for far cheaper than is currently possible. We hate jumping on the social media bandwagon here, but frankly, this is an egg worth giving millions of Instagram likes.

Chill out, kid

What do you do when your child has constant tantrums? A simple edible could do the trick, according to a Hollywood physician.

Courtesy Wikimedia Commons/Coaster420/Creative Commons License

The natural medicine physician is in hot (bong) water after recommending marijuana cookies as treatment for a 4-year-old child’s ADHD and bipolar disorder. The icing on the cake (or cookie) is that both diagnoses weren’t even accurate. Perhaps the doctor was sampling his own treatments before the office visit?

The progressive physician has had his license revoked for the “grossly negligent” diagnosis, which he made in 30 minutes without consulting the child’s teachers, his father, or a psychiatrist. Probably not the best way to handle it, said the state medical board. Perhaps he should have suggested some CBD-infused Coke, instead?
 

Gator saver

Dogs, cats, peacocks – these are the animals that many people with anxiety, depression, and other mental health issues use for emotional support. But now, enter Wally, the emotional support alligator.

mphillips007/iStockphoto.com

Spanning 5 feet long and sporting way too many teeth, Wally is the constant companion of a 65-year-old Pennsylvania man with depression. Wally’s owner decided to forgo pharmacologic treatment for something decidedly more reptilian.

Wally, who was rescued from Florida, loves chicken wings, hugs, and his adopted gator brother, Scrappy. He also has the potential to reach 16 feet long, which is … concerning. Something tells me you can’t take Wally on a plane as a service gator.

But don’t worry, Wally has been approved by a doctor. Rumors that Wally had the doctor’s arm in his jaws before approval are unsubstantiated.

Synergy is not always a good thing

Since it is generally agreed that two heads are better than one, three heads must be even better than two, right? But what if we’re not talking about heads? Suppose, instead, that the subject is global pandemics. Would it be better if three of the greatest threats to humanity’s existence on the planet decided to join forces?

MatiasEnElMundo/gettyimages

The Lancet Global Syndemic Commission, a group of more than 40 international experts, said that obesity, undernutrition, and climate change “constitute a syndemic, or synergy of epidemics, because they co-occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers” (Lancet. 2019 Jan. 27. doi: 10.1016/S0140-6736[18]32822-8).

It gets better: The commission suggested that the “three interconnected health pandemics [have been] effectively orchestrated by the shadowy manipulations and influence of vested commercial interests – an entity collectively defined as ‘Big Food,’ ” according to Science Alert.

This all seems like a lot to overcome, but we here at LOTME have faith in science, and in the scientists who are working to solve these problems. After all, it’s not like anyone’s out there disregarding the science and saying that this stuff isn’t really happening. … Wait, what? … Climate change deniers? … Really? … The president tweeted what? … We’re doomed.
 

I prefer my medication sunny side up

Here’s a hypothetical question for you: If you were to have cancer, how would you prefer to be treated? Would you rather go through the rigors of chemotherapy? Or would you rather eat an omelet?

paci77/iStockphoto.com

Okay, it probably wouldn’t work quite like that, but a group of physicians from the University of Edinburgh have successfully modified chickens to lay eggs containing a pair of human proteins within the egg white.

One of these proteins has antiviral and anticancer effects, and the other can help damaged tissue repair itself. The researchers added that the protein in the egg white could be modified to make the key ingredients for other protein-based drugs such as Avastin and Herceptin, which are used for treating cancer.

We know what you’re thinking: It’ll probably take a thousand eggs to make one dose – but no, it only takes three. Over the course of a year, one chicken could produce a hundred doses, and do it for far cheaper than is currently possible. We hate jumping on the social media bandwagon here, but frankly, this is an egg worth giving millions of Instagram likes.

As gender disparities persist in interventional cardiology, a new survey is shedding light on what is keeping women away from the field.

With women representing only 9% of interventional cardiologists in the United States as of 2017, researchers under the direction of the American College of Cardiology Women in Cardiology Leadership Council sought to asses the perspectives of fellows-in-training (FIT) regarding the factors influencing their cardiology subspecialty decisions.

A total of 574 FIT completed the survey, with 190 respondents anticipating pursuit of a career in interventional cardiology. The results of the survey were published online in JACC: Cardiovascular Interventions. According to the report, unlike other studies that looked at gender disparities in interventional cardiology that focused on the training (residency) or later (practicing cardiologists), this is the first to look at the time when the decision is made during general cardiology fellowship.

The goal of the survey was “to try to understand in the current realm of our millennials who are studying and are in fellowship and in training and in the trenches, what is dissuading them to be in the subspecialty of interventional cardiology,” Roxana Mehran, MD, Icahn School of Medicine at Mount Sinai, New York, and coauthor of the study, said in an interview.

Lead author Celina Yong, MD, and her colleagues wrote in their report on the survey that women “were more likely to express interest in all other cardiovascular specialties (general/clinical cardiology, advanced imaging, heart failure/transplant, adult congenital, and other), with the exception of electrophysiology (13% women vs. 87% men, P = .001).”

Researchers analyzed the 504 remaining survey responses after excluding those considering electrophysiology to get a better understanding about the influencing factors related to the decision to pursue interventional cardiology.

“Logistic regression of all demographic characteristics revealed that male sex was the most significant predictor of a career choice in interventional cardiology [odds ratio, 3.98; P less than 0.001],” the authors noted.

All respondents who intended to pursue a career in interventional cardiology had a list of 15 options to select the reasons for choosing this path. The top five, in descending order, were the opportunity to pursue hands-on procedures, personal interest in the specialty subject area, the opportunity for immediate gratification or sense of accomplishment, the thrill of treating ill patients in critical situations, and having mentors or role models the respondent identified with.

“When disaggregated by gender, there were six attributes that were significantly different between men and women in terms of reasons for pursuing” interventional cardiology, the authors stated. “Men were more likely to be driven by innovation in the field, importance of being an expert, likelihood of employment after completion of training, financial advantages, and prestige. Women were more likely to be driven by having a female mentor or role model.”

For those not pursuing a career in interventional cardiology, the top five reasons, in descending order, were an uncontrollable or unpredictable lifestyle, concern over long work hours and poor work/life balance, greater interest in another field, a desire for different type of patient contact, and wanting to have children in the next 5 years.

“There were seven attributes identified that negatively influenced IC choice differently by sex,” noted Dr. Yong, of VA Palo Alto (Calif.) Medical Center, and her colleagues. “Women were more likely to be negatively influenced by all seven of these factors compared to men (in descending order)”:

1) Greater interest in another field.

2) Little flexibility in job prospects/opportunities over a lifetime.

3) Physically demanding nature of job (e.g., wearing heavy lead).

4) Radiation exposure concerns during childbearing.

5) “Old boys club” culture.

6) Lack of female role models.

7) Gender discrimination or harassment.

Dr. Mehran said that despite some limitations, the survey results were not surprising.

“Unfortunately, surveys are very subjective,” she said. Also, one can question how biased some of these questions are. “But nonetheless, I think the result is very similar to what we had expected and have been talking about.”

She noted that the subspecialty of interventional cardiology needs to be more family friendly.

“I think we are going to lose a lot of good men also who are not choosing interventional cardiology,” she said. “There is no question that we have to think about how we can enhance and improve and pave the way for men and women, but mostly women because there are hardly any women and that’s important. The family friendly environment is very, very important in interventional cardiology.”

The patriarchal culture is another area that needs to be addressed, she said.

“I feel that, hopefully, that’s a perception and not much of a reality,” Dr. Mehran said, though she did note that there are plenty of examples where female doctors do not get shown the same level of respect their male counterparts do. She noted, for example, at scientific meetings, when a woman is on a panel and speaking, audience members can be seen tuning out, using it as opportunity to look at phones. Sometimes the women on the panels are not even referred to as “doctor.”

“I think we have to have a standard that those kinds of things will not be tolerated, that people will be called out if they didn’t do the extra work to find the best women for those important panels and leadership roles. There has to be a code of conduct that is equal and gender neutral,” she said, adding: “I think we are trying to work very hard to equalize the playing field but we have to come up with solutions.”

To that end, Dr. Mehran created a not-for-profit organization, Women As One, to tackle these gender disparities.

“We are really looking for solutions,” she said. “We will hold several think tanks with key opinion leaders, men and women, to come up with how best can academic organizations make sure that there is gender equality, good representation, and no discrimination on the basis of sex. ... We have to come up with solutions. Otherwise we just keep showing the same statistics over and over again and its not improving.”

gtwachtman@mdedge.com

SOURCE: JACC: Cardiovasc Interven. 2019 Jan; doi: 10.1016/j.jcin.2018.09.036

As gender disparities persist in interventional cardiology, a new survey is shedding light on what is keeping women away from the field.

With women representing only 9% of interventional cardiologists in the United States as of 2017, researchers under the direction of the American College of Cardiology Women in Cardiology Leadership Council sought to asses the perspectives of fellows-in-training (FIT) regarding the factors influencing their cardiology subspecialty decisions.

A total of 574 FIT completed the survey, with 190 respondents anticipating pursuit of a career in interventional cardiology. The results of the survey were published online in JACC: Cardiovascular Interventions. According to the report, unlike other studies that looked at gender disparities in interventional cardiology that focused on the training (residency) or later (practicing cardiologists), this is the first to look at the time when the decision is made during general cardiology fellowship.

The goal of the survey was “to try to understand in the current realm of our millennials who are studying and are in fellowship and in training and in the trenches, what is dissuading them to be in the subspecialty of interventional cardiology,” Roxana Mehran, MD, Icahn School of Medicine at Mount Sinai, New York, and coauthor of the study, said in an interview.

Lead author Celina Yong, MD, and her colleagues wrote in their report on the survey that women “were more likely to express interest in all other cardiovascular specialties (general/clinical cardiology, advanced imaging, heart failure/transplant, adult congenital, and other), with the exception of electrophysiology (13% women vs. 87% men, P = .001).”

Researchers analyzed the 504 remaining survey responses after excluding those considering electrophysiology to get a better understanding about the influencing factors related to the decision to pursue interventional cardiology.

“Logistic regression of all demographic characteristics revealed that male sex was the most significant predictor of a career choice in interventional cardiology [odds ratio, 3.98; P less than 0.001],” the authors noted.

All respondents who intended to pursue a career in interventional cardiology had a list of 15 options to select the reasons for choosing this path. The top five, in descending order, were the opportunity to pursue hands-on procedures, personal interest in the specialty subject area, the opportunity for immediate gratification or sense of accomplishment, the thrill of treating ill patients in critical situations, and having mentors or role models the respondent identified with.

“When disaggregated by gender, there were six attributes that were significantly different between men and women in terms of reasons for pursuing” interventional cardiology, the authors stated. “Men were more likely to be driven by innovation in the field, importance of being an expert, likelihood of employment after completion of training, financial advantages, and prestige. Women were more likely to be driven by having a female mentor or role model.”

For those not pursuing a career in interventional cardiology, the top five reasons, in descending order, were an uncontrollable or unpredictable lifestyle, concern over long work hours and poor work/life balance, greater interest in another field, a desire for different type of patient contact, and wanting to have children in the next 5 years.

“There were seven attributes identified that negatively influenced IC choice differently by sex,” noted Dr. Yong, of VA Palo Alto (Calif.) Medical Center, and her colleagues. “Women were more likely to be negatively influenced by all seven of these factors compared to men (in descending order)”:

1) Greater interest in another field.

2) Little flexibility in job prospects/opportunities over a lifetime.

3) Physically demanding nature of job (e.g., wearing heavy lead).

4) Radiation exposure concerns during childbearing.

5) “Old boys club” culture.

6) Lack of female role models.

7) Gender discrimination or harassment.

Dr. Mehran said that despite some limitations, the survey results were not surprising.

“Unfortunately, surveys are very subjective,” she said. Also, one can question how biased some of these questions are. “But nonetheless, I think the result is very similar to what we had expected and have been talking about.”

She noted that the subspecialty of interventional cardiology needs to be more family friendly.

“I think we are going to lose a lot of good men also who are not choosing interventional cardiology,” she said. “There is no question that we have to think about how we can enhance and improve and pave the way for men and women, but mostly women because there are hardly any women and that’s important. The family friendly environment is very, very important in interventional cardiology.”

The patriarchal culture is another area that needs to be addressed, she said.

“I feel that, hopefully, that’s a perception and not much of a reality,” Dr. Mehran said, though she did note that there are plenty of examples where female doctors do not get shown the same level of respect their male counterparts do. She noted, for example, at scientific meetings, when a woman is on a panel and speaking, audience members can be seen tuning out, using it as opportunity to look at phones. Sometimes the women on the panels are not even referred to as “doctor.”

“I think we have to have a standard that those kinds of things will not be tolerated, that people will be called out if they didn’t do the extra work to find the best women for those important panels and leadership roles. There has to be a code of conduct that is equal and gender neutral,” she said, adding: “I think we are trying to work very hard to equalize the playing field but we have to come up with solutions.”

To that end, Dr. Mehran created a not-for-profit organization, Women As One, to tackle these gender disparities.

“We are really looking for solutions,” she said. “We will hold several think tanks with key opinion leaders, men and women, to come up with how best can academic organizations make sure that there is gender equality, good representation, and no discrimination on the basis of sex. ... We have to come up with solutions. Otherwise we just keep showing the same statistics over and over again and its not improving.”

gtwachtman@mdedge.com

SOURCE: JACC: Cardiovasc Interven. 2019 Jan; doi: 10.1016/j.jcin.2018.09.036

As gender disparities persist in interventional cardiology, a new survey is shedding light on what is keeping women away from the field.

With women representing only 9% of interventional cardiologists in the United States as of 2017, researchers under the direction of the American College of Cardiology Women in Cardiology Leadership Council sought to asses the perspectives of fellows-in-training (FIT) regarding the factors influencing their cardiology subspecialty decisions.

A total of 574 FIT completed the survey, with 190 respondents anticipating pursuit of a career in interventional cardiology. The results of the survey were published online in JACC: Cardiovascular Interventions. According to the report, unlike other studies that looked at gender disparities in interventional cardiology that focused on the training (residency) or later (practicing cardiologists), this is the first to look at the time when the decision is made during general cardiology fellowship.

The goal of the survey was “to try to understand in the current realm of our millennials who are studying and are in fellowship and in training and in the trenches, what is dissuading them to be in the subspecialty of interventional cardiology,” Roxana Mehran, MD, Icahn School of Medicine at Mount Sinai, New York, and coauthor of the study, said in an interview.

Lead author Celina Yong, MD, and her colleagues wrote in their report on the survey that women “were more likely to express interest in all other cardiovascular specialties (general/clinical cardiology, advanced imaging, heart failure/transplant, adult congenital, and other), with the exception of electrophysiology (13% women vs. 87% men, P = .001).”

Researchers analyzed the 504 remaining survey responses after excluding those considering electrophysiology to get a better understanding about the influencing factors related to the decision to pursue interventional cardiology.

“Logistic regression of all demographic characteristics revealed that male sex was the most significant predictor of a career choice in interventional cardiology [odds ratio, 3.98; P less than 0.001],” the authors noted.

All respondents who intended to pursue a career in interventional cardiology had a list of 15 options to select the reasons for choosing this path. The top five, in descending order, were the opportunity to pursue hands-on procedures, personal interest in the specialty subject area, the opportunity for immediate gratification or sense of accomplishment, the thrill of treating ill patients in critical situations, and having mentors or role models the respondent identified with.

“When disaggregated by gender, there were six attributes that were significantly different between men and women in terms of reasons for pursuing” interventional cardiology, the authors stated. “Men were more likely to be driven by innovation in the field, importance of being an expert, likelihood of employment after completion of training, financial advantages, and prestige. Women were more likely to be driven by having a female mentor or role model.”

For those not pursuing a career in interventional cardiology, the top five reasons, in descending order, were an uncontrollable or unpredictable lifestyle, concern over long work hours and poor work/life balance, greater interest in another field, a desire for different type of patient contact, and wanting to have children in the next 5 years.

“There were seven attributes identified that negatively influenced IC choice differently by sex,” noted Dr. Yong, of VA Palo Alto (Calif.) Medical Center, and her colleagues. “Women were more likely to be negatively influenced by all seven of these factors compared to men (in descending order)”:

1) Greater interest in another field.

2) Little flexibility in job prospects/opportunities over a lifetime.

3) Physically demanding nature of job (e.g., wearing heavy lead).

4) Radiation exposure concerns during childbearing.

5) “Old boys club” culture.

6) Lack of female role models.

7) Gender discrimination or harassment.

Dr. Mehran said that despite some limitations, the survey results were not surprising.

“Unfortunately, surveys are very subjective,” she said. Also, one can question how biased some of these questions are. “But nonetheless, I think the result is very similar to what we had expected and have been talking about.”

She noted that the subspecialty of interventional cardiology needs to be more family friendly.

“I think we are going to lose a lot of good men also who are not choosing interventional cardiology,” she said. “There is no question that we have to think about how we can enhance and improve and pave the way for men and women, but mostly women because there are hardly any women and that’s important. The family friendly environment is very, very important in interventional cardiology.”

The patriarchal culture is another area that needs to be addressed, she said.

“I feel that, hopefully, that’s a perception and not much of a reality,” Dr. Mehran said, though she did note that there are plenty of examples where female doctors do not get shown the same level of respect their male counterparts do. She noted, for example, at scientific meetings, when a woman is on a panel and speaking, audience members can be seen tuning out, using it as opportunity to look at phones. Sometimes the women on the panels are not even referred to as “doctor.”

“I think we have to have a standard that those kinds of things will not be tolerated, that people will be called out if they didn’t do the extra work to find the best women for those important panels and leadership roles. There has to be a code of conduct that is equal and gender neutral,” she said, adding: “I think we are trying to work very hard to equalize the playing field but we have to come up with solutions.”

To that end, Dr. Mehran created a not-for-profit organization, Women As One, to tackle these gender disparities.

“We are really looking for solutions,” she said. “We will hold several think tanks with key opinion leaders, men and women, to come up with how best can academic organizations make sure that there is gender equality, good representation, and no discrimination on the basis of sex. ... We have to come up with solutions. Otherwise we just keep showing the same statistics over and over again and its not improving.”

gtwachtman@mdedge.com

SOURCE: JACC: Cardiovasc Interven. 2019 Jan; doi: 10.1016/j.jcin.2018.09.036

SAN DIEGO – Thrombin generation may edge out baseline factor activity as a biomarker for predicting bleeding severity among patients with mild and moderate hemophilia, according to a study of 81 patients with nonsevere hemophilia.

Both baseline factor activity and thrombin generation had a similar correlation with bleeding severity, but thrombin generation had a higher sensitivity when differentiating between bleeding severities, Fadi Nossair, MD, of Children’s Hospital of King’s Daughters in Norfolk, Va., reported in a poster at the annual meeting of the American Society of Hematology.

Nonsevere cases of hemophilia A and B account for about half of all hemophilia cases in which factor level does not consistently correlate with bleeding phenotype. That makes it difficult to determine prophylaxis or surgery and highlights the need for a predictive biomarker, the investigators noted.

In the study, 81 patients had their bleeding assessed using standardized, self-administered and investigator-administered questionnaires. Bleeding phenotypes were also collected from EMRs.

One-time venous blood samples were collected after a washout period, when applicable. Additionally, platelet poor plasma was obtained to measure thrombin generation, phospholipid-dependent factor Xa initiated clotting time, factor VIII and IX activities, and von Willebrand factor.

Nearly three-quarters of patients in the study had a low bleeding score.

Both baseline factor level and thrombin generation values obtained with a regular reagent (5 pM of tissue factor) demonstrated a significant correlation with bleeding score (P less than .05). Values obtained with other reagents and biomarkers did not show a significant correlation, according to the researchers.

However, a sensitivity and specificity analysis that helped the researchers narrow down the optimal cutoff values for differentiating between bleeding severities also found that thrombin generation had superior sensitivity, compared with baseline factor level. All thrombin generation values had a higher sensitivity to predict bleeding severity, compared with baseline factor level (57%-62% versus 29%).

“Long-term prospective studies should evaluate the utility of this approach in predicting bleeding severity in this population,” the researchers said.

The study was supported by grants from Novo Nordisk. Dr. Nossair reported financial disclosures related to Novo Nordisk.

mschneider@mdedge.com

SOURCE: Nossair F et al. ASH 2018, Poster 3788.

SAN DIEGO – Thrombin generation may edge out baseline factor activity as a biomarker for predicting bleeding severity among patients with mild and moderate hemophilia, according to a study of 81 patients with nonsevere hemophilia.

Both baseline factor activity and thrombin generation had a similar correlation with bleeding severity, but thrombin generation had a higher sensitivity when differentiating between bleeding severities, Fadi Nossair, MD, of Children’s Hospital of King’s Daughters in Norfolk, Va., reported in a poster at the annual meeting of the American Society of Hematology.

Nonsevere cases of hemophilia A and B account for about half of all hemophilia cases in which factor level does not consistently correlate with bleeding phenotype. That makes it difficult to determine prophylaxis or surgery and highlights the need for a predictive biomarker, the investigators noted.

In the study, 81 patients had their bleeding assessed using standardized, self-administered and investigator-administered questionnaires. Bleeding phenotypes were also collected from EMRs.

One-time venous blood samples were collected after a washout period, when applicable. Additionally, platelet poor plasma was obtained to measure thrombin generation, phospholipid-dependent factor Xa initiated clotting time, factor VIII and IX activities, and von Willebrand factor.

Nearly three-quarters of patients in the study had a low bleeding score.

Both baseline factor level and thrombin generation values obtained with a regular reagent (5 pM of tissue factor) demonstrated a significant correlation with bleeding score (P less than .05). Values obtained with other reagents and biomarkers did not show a significant correlation, according to the researchers.

However, a sensitivity and specificity analysis that helped the researchers narrow down the optimal cutoff values for differentiating between bleeding severities also found that thrombin generation had superior sensitivity, compared with baseline factor level. All thrombin generation values had a higher sensitivity to predict bleeding severity, compared with baseline factor level (57%-62% versus 29%).

“Long-term prospective studies should evaluate the utility of this approach in predicting bleeding severity in this population,” the researchers said.

The study was supported by grants from Novo Nordisk. Dr. Nossair reported financial disclosures related to Novo Nordisk.

mschneider@mdedge.com

SOURCE: Nossair F et al. ASH 2018, Poster 3788.

SAN DIEGO – Thrombin generation may edge out baseline factor activity as a biomarker for predicting bleeding severity among patients with mild and moderate hemophilia, according to a study of 81 patients with nonsevere hemophilia.

Both baseline factor activity and thrombin generation had a similar correlation with bleeding severity, but thrombin generation had a higher sensitivity when differentiating between bleeding severities, Fadi Nossair, MD, of Children’s Hospital of King’s Daughters in Norfolk, Va., reported in a poster at the annual meeting of the American Society of Hematology.

Nonsevere cases of hemophilia A and B account for about half of all hemophilia cases in which factor level does not consistently correlate with bleeding phenotype. That makes it difficult to determine prophylaxis or surgery and highlights the need for a predictive biomarker, the investigators noted.

In the study, 81 patients had their bleeding assessed using standardized, self-administered and investigator-administered questionnaires. Bleeding phenotypes were also collected from EMRs.

One-time venous blood samples were collected after a washout period, when applicable. Additionally, platelet poor plasma was obtained to measure thrombin generation, phospholipid-dependent factor Xa initiated clotting time, factor VIII and IX activities, and von Willebrand factor.

Nearly three-quarters of patients in the study had a low bleeding score.

Both baseline factor level and thrombin generation values obtained with a regular reagent (5 pM of tissue factor) demonstrated a significant correlation with bleeding score (P less than .05). Values obtained with other reagents and biomarkers did not show a significant correlation, according to the researchers.

However, a sensitivity and specificity analysis that helped the researchers narrow down the optimal cutoff values for differentiating between bleeding severities also found that thrombin generation had superior sensitivity, compared with baseline factor level. All thrombin generation values had a higher sensitivity to predict bleeding severity, compared with baseline factor level (57%-62% versus 29%).

“Long-term prospective studies should evaluate the utility of this approach in predicting bleeding severity in this population,” the researchers said.

The study was supported by grants from Novo Nordisk. Dr. Nossair reported financial disclosures related to Novo Nordisk.

mschneider@mdedge.com

SOURCE: Nossair F et al. ASH 2018, Poster 3788.

Civilian patients with mild traumatic brain injury (TBI) who are black, have psychiatric history or lower education, or whose injury was caused by assault might be at greater risk of developing posttraumatic stress disorder or major depression, a longitudinal study suggests.

Stockdevil/Thinkstock

“Our findings may have implications for surveillance and treatment of mental disorders after TBI,” wrote Murray B. Stein, MD, MPH, and his associates. The study was published Jan. 30 in JAMA Psychiatry.

The researchers looked at the risk factors for and prevalence of posttraumatic stress disorder (PTSD) and major depressive disorder among 1,155 patients. The patients were enrolled at 11 level 1 trauma centers across the United States after they were evaluated for mild TBI in emergency departments as part of a prospective study called Transforming Research and Clinical Knowledge in Traumatic Brain Injury, or TRACK-TBI. The comparison group was 230 patients with nonhead orthopedic trauma injuries, wrote Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego, and his associates.

They found that each additional year of education was associated with a significant 11% reduction in the risk of developing PTSD after mild TBI (P = .005). Also, black patients had a greater than fivefold higher risk of PTSD (P less than.001) than that of individuals who were not black.

Among patients with a history of mental illness and those who had experienced their injury as a result of assault or violence – as opposed to a motor vehicle accident or fall, for example – both had a greater than threefold higher risk of developing PTSD (odds ratio, 3.57 and 3.43 respectively). A prior TBI was nonsignificantly associated with an increased risk of developing PTSD.

Lower education duration, being black, or a history of mental illness also were all significantly associated with an increased risk of developing major depressive disorder after mild TBI.

However, duration of lost consciousness or posttraumatic amnesia, evidence of brain injury on CT, or hospitalization did not predict an increased risk of PTSD or major depression.

“Although MDD and PTSD are prevalent after TBI, little is known about which patients are at risk for developing them,” Dr. Stein and his associates wrote.

Noting that having a prior mental health problem was an “exceptionally strong” risk factor for PTSD and MDD after TBI, the authors said this could represent continuation or exacerbation of the prior mental health issue, or the triggering of a new episode in a person with a past history who had recovered.

“However, in either case this finding underscores the importance of clinicians being aware of the mental health history of their patients with [mild TBI], as this information is central to expectations regarding both short-term and long-term outcome,” they wrote.

Dr. Stein and his associates cited as a limitation their reliance on patient or family report. In addition, they said, the elevated risk for mental disorders among black individuals after mild TBI, which was independent of socioeconomic status or cause of injury, was not understood. “Unmeasured covariates may be part of the explanation; this is a topic needing further study,” they wrote.

The study was supported by the National Institutes of Health, the U.S. Department of Defense, Abbott Laboratories, and One Mind. Four authors declared consultancies, advisory board positions, speaking fees, and shares or stock options with the pharmaceutical and private industry. Two authors declared grants from the study sponsors.

SOURCE: Stein MB et al. JAMA Psychiatry. 2019. Jan 30. doi: 10.1001/jamapsychiatry.2018.4288.

Civilian patients with mild traumatic brain injury (TBI) who are black, have psychiatric history or lower education, or whose injury was caused by assault might be at greater risk of developing posttraumatic stress disorder or major depression, a longitudinal study suggests.

Stockdevil/Thinkstock

“Our findings may have implications for surveillance and treatment of mental disorders after TBI,” wrote Murray B. Stein, MD, MPH, and his associates. The study was published Jan. 30 in JAMA Psychiatry.

The researchers looked at the risk factors for and prevalence of posttraumatic stress disorder (PTSD) and major depressive disorder among 1,155 patients. The patients were enrolled at 11 level 1 trauma centers across the United States after they were evaluated for mild TBI in emergency departments as part of a prospective study called Transforming Research and Clinical Knowledge in Traumatic Brain Injury, or TRACK-TBI. The comparison group was 230 patients with nonhead orthopedic trauma injuries, wrote Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego, and his associates.

They found that each additional year of education was associated with a significant 11% reduction in the risk of developing PTSD after mild TBI (P = .005). Also, black patients had a greater than fivefold higher risk of PTSD (P less than.001) than that of individuals who were not black.

Among patients with a history of mental illness and those who had experienced their injury as a result of assault or violence – as opposed to a motor vehicle accident or fall, for example – both had a greater than threefold higher risk of developing PTSD (odds ratio, 3.57 and 3.43 respectively). A prior TBI was nonsignificantly associated with an increased risk of developing PTSD.

Lower education duration, being black, or a history of mental illness also were all significantly associated with an increased risk of developing major depressive disorder after mild TBI.

However, duration of lost consciousness or posttraumatic amnesia, evidence of brain injury on CT, or hospitalization did not predict an increased risk of PTSD or major depression.

“Although MDD and PTSD are prevalent after TBI, little is known about which patients are at risk for developing them,” Dr. Stein and his associates wrote.

Noting that having a prior mental health problem was an “exceptionally strong” risk factor for PTSD and MDD after TBI, the authors said this could represent continuation or exacerbation of the prior mental health issue, or the triggering of a new episode in a person with a past history who had recovered.

“However, in either case this finding underscores the importance of clinicians being aware of the mental health history of their patients with [mild TBI], as this information is central to expectations regarding both short-term and long-term outcome,” they wrote.

Dr. Stein and his associates cited as a limitation their reliance on patient or family report. In addition, they said, the elevated risk for mental disorders among black individuals after mild TBI, which was independent of socioeconomic status or cause of injury, was not understood. “Unmeasured covariates may be part of the explanation; this is a topic needing further study,” they wrote.

The study was supported by the National Institutes of Health, the U.S. Department of Defense, Abbott Laboratories, and One Mind. Four authors declared consultancies, advisory board positions, speaking fees, and shares or stock options with the pharmaceutical and private industry. Two authors declared grants from the study sponsors.

SOURCE: Stein MB et al. JAMA Psychiatry. 2019. Jan 30. doi: 10.1001/jamapsychiatry.2018.4288.

Civilian patients with mild traumatic brain injury (TBI) who are black, have psychiatric history or lower education, or whose injury was caused by assault might be at greater risk of developing posttraumatic stress disorder or major depression, a longitudinal study suggests.

Stockdevil/Thinkstock

“Our findings may have implications for surveillance and treatment of mental disorders after TBI,” wrote Murray B. Stein, MD, MPH, and his associates. The study was published Jan. 30 in JAMA Psychiatry.

The researchers looked at the risk factors for and prevalence of posttraumatic stress disorder (PTSD) and major depressive disorder among 1,155 patients. The patients were enrolled at 11 level 1 trauma centers across the United States after they were evaluated for mild TBI in emergency departments as part of a prospective study called Transforming Research and Clinical Knowledge in Traumatic Brain Injury, or TRACK-TBI. The comparison group was 230 patients with nonhead orthopedic trauma injuries, wrote Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego, and his associates.

They found that each additional year of education was associated with a significant 11% reduction in the risk of developing PTSD after mild TBI (P = .005). Also, black patients had a greater than fivefold higher risk of PTSD (P less than.001) than that of individuals who were not black.

Among patients with a history of mental illness and those who had experienced their injury as a result of assault or violence – as opposed to a motor vehicle accident or fall, for example – both had a greater than threefold higher risk of developing PTSD (odds ratio, 3.57 and 3.43 respectively). A prior TBI was nonsignificantly associated with an increased risk of developing PTSD.

Lower education duration, being black, or a history of mental illness also were all significantly associated with an increased risk of developing major depressive disorder after mild TBI.

However, duration of lost consciousness or posttraumatic amnesia, evidence of brain injury on CT, or hospitalization did not predict an increased risk of PTSD or major depression.

“Although MDD and PTSD are prevalent after TBI, little is known about which patients are at risk for developing them,” Dr. Stein and his associates wrote.

Noting that having a prior mental health problem was an “exceptionally strong” risk factor for PTSD and MDD after TBI, the authors said this could represent continuation or exacerbation of the prior mental health issue, or the triggering of a new episode in a person with a past history who had recovered.

“However, in either case this finding underscores the importance of clinicians being aware of the mental health history of their patients with [mild TBI], as this information is central to expectations regarding both short-term and long-term outcome,” they wrote.

Dr. Stein and his associates cited as a limitation their reliance on patient or family report. In addition, they said, the elevated risk for mental disorders among black individuals after mild TBI, which was independent of socioeconomic status or cause of injury, was not understood. “Unmeasured covariates may be part of the explanation; this is a topic needing further study,” they wrote.

The study was supported by the National Institutes of Health, the U.S. Department of Defense, Abbott Laboratories, and One Mind. Four authors declared consultancies, advisory board positions, speaking fees, and shares or stock options with the pharmaceutical and private industry. Two authors declared grants from the study sponsors.

SOURCE: Stein MB et al. JAMA Psychiatry. 2019. Jan 30. doi: 10.1001/jamapsychiatry.2018.4288.