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Transplanted food allergies, cavity-check hospital bills, and cancer-blocking houseplants
One lung, please (Hold the food allergy)
Is an organ transplant really worth the risk of developing a food allergy? Probably (er, definitely), but it still totally stinks. A 68-year-old woman suffered an allergic reaction to an innocent peanut butter and jelly sandwich earlier this year, after spending decades of eating peanut butter with no problem. Turns out, her lung transplant donor was allergic to peanuts and unfortunately passed that curse onto her. At least he wasn’t lactose intolerant – can you imagine suddenly being unable to eat cheese?!
Passing on allergies via transplant is extremely rare; there are only about five cases of transplanted peanut allergies. The use of tacrolimus, an immunosuppressive drug, can also increase the risk of contracting food allergies post transplant. Luckily, the woman in question was still in the hospital when she began experiencing symptoms of an allergy attack, and doctors were able to correctly identify and punish the offending sandwich.
A debt of ingratitude
Medical personnel generally don’t get involved in searches for illegal drugs, but physicians at St. Joseph’s Hospital Health Center in Syracuse, N.Y., found themselves in just such a position. Because the police had a court order. Because the suspect said that he’d hidden drugs … in his rectum.
An x-ray had shown no evidence of drugs, but physicians there performed a sigmoidoscopy on Torrence Jackson after a hospital lawyer said “that a search warrant required the doctors to use ‘any means’ to retrieve the drugs,” according to a recent Syracuse.com report of the incident, which took place on Oct. 16, 2017. The sigmoidoscopy confirmed the x-ray finding, or lack thereof, and drug charges against Mr. Jackson eventually were thrown out.
The health care system, however, did its part to put a cherry on top of the situation: The hospital billed Mr. Jackson $4,595.12 for the procedure, and then said it would turn the matter over to a debt collector when he refused to pay.
Cancer-blocking plants?
All hail the GMOs! Researchers from the University of Washington have used genetic modification on a houseplant to turn it into a lean, green, chloroform-eatin’ machine. These mad scientists modified devil’s ivy to pull chloroform (found in chlorinated water) and benzene (found in gasoline) from the air and use them for plant growth.
These compounds are often so small they can’t be caught by air filters but can still cause damage – exposure to chloroform and benzene has been linked to cancer. Now, you can lessen your risk of cancer and enjoy some nice greenery in your home. Researchers have also started working on a new genetic modification to remove formaldehyde compounds from the air. It looks like the future of health is all about plants!
It must be true – it’s in a study
There’s untested, widely accepted truth, and then there’s empirically tested truth demonstrated in a rigorous scientific trial. Untested, widely accepted truth in point: Compared with using a simple backpack, parachute use is more likely to prevent death or major traumatic injury when leaping from an aircraft. Of course, no one’s ever done a study to prove it. Because, duh. Also, institutional review boards. Also, lawyers.
Until now.
Robert Yeh, M.D., of Harvard Medical School, and his colleagues began recruiting for just such a research trial while flying commercially. Few seat mates took up their randomized-to-parachute-or-backpack offer. That forced Dr. Yeh to recruit randomized participants from among fellow academics. Twenty-three research-minded souls agreed to make the leap for scientific progress from either a biplane or a helicopter, thereby making the study “Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial” a BMJ-published reality.
The results? “Our groundbreaking study found no statistically significant difference in the primary outcome between the treatment and control arms.”
How can the scientific method explain such a skydiving miracle? Because each and every study participant leaped ... 2 feet. From a parked biplane or helicopter.
“Although we can confidently recommend that individuals jumping from small stationary aircraft on the ground do not require parachutes, individual judgment should be exercised when applying these findings at higher altitudes.” It’s also possible the study authors are suggesting individual judgment should have a parachute, not a backpack, when physicians dive into a study’s scientific methodology.
One lung, please (Hold the food allergy)
Is an organ transplant really worth the risk of developing a food allergy? Probably (er, definitely), but it still totally stinks. A 68-year-old woman suffered an allergic reaction to an innocent peanut butter and jelly sandwich earlier this year, after spending decades of eating peanut butter with no problem. Turns out, her lung transplant donor was allergic to peanuts and unfortunately passed that curse onto her. At least he wasn’t lactose intolerant – can you imagine suddenly being unable to eat cheese?!
Passing on allergies via transplant is extremely rare; there are only about five cases of transplanted peanut allergies. The use of tacrolimus, an immunosuppressive drug, can also increase the risk of contracting food allergies post transplant. Luckily, the woman in question was still in the hospital when she began experiencing symptoms of an allergy attack, and doctors were able to correctly identify and punish the offending sandwich.
A debt of ingratitude
Medical personnel generally don’t get involved in searches for illegal drugs, but physicians at St. Joseph’s Hospital Health Center in Syracuse, N.Y., found themselves in just such a position. Because the police had a court order. Because the suspect said that he’d hidden drugs … in his rectum.
An x-ray had shown no evidence of drugs, but physicians there performed a sigmoidoscopy on Torrence Jackson after a hospital lawyer said “that a search warrant required the doctors to use ‘any means’ to retrieve the drugs,” according to a recent Syracuse.com report of the incident, which took place on Oct. 16, 2017. The sigmoidoscopy confirmed the x-ray finding, or lack thereof, and drug charges against Mr. Jackson eventually were thrown out.
The health care system, however, did its part to put a cherry on top of the situation: The hospital billed Mr. Jackson $4,595.12 for the procedure, and then said it would turn the matter over to a debt collector when he refused to pay.
Cancer-blocking plants?
All hail the GMOs! Researchers from the University of Washington have used genetic modification on a houseplant to turn it into a lean, green, chloroform-eatin’ machine. These mad scientists modified devil’s ivy to pull chloroform (found in chlorinated water) and benzene (found in gasoline) from the air and use them for plant growth.
These compounds are often so small they can’t be caught by air filters but can still cause damage – exposure to chloroform and benzene has been linked to cancer. Now, you can lessen your risk of cancer and enjoy some nice greenery in your home. Researchers have also started working on a new genetic modification to remove formaldehyde compounds from the air. It looks like the future of health is all about plants!
It must be true – it’s in a study
There’s untested, widely accepted truth, and then there’s empirically tested truth demonstrated in a rigorous scientific trial. Untested, widely accepted truth in point: Compared with using a simple backpack, parachute use is more likely to prevent death or major traumatic injury when leaping from an aircraft. Of course, no one’s ever done a study to prove it. Because, duh. Also, institutional review boards. Also, lawyers.
Until now.
Robert Yeh, M.D., of Harvard Medical School, and his colleagues began recruiting for just such a research trial while flying commercially. Few seat mates took up their randomized-to-parachute-or-backpack offer. That forced Dr. Yeh to recruit randomized participants from among fellow academics. Twenty-three research-minded souls agreed to make the leap for scientific progress from either a biplane or a helicopter, thereby making the study “Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial” a BMJ-published reality.
The results? “Our groundbreaking study found no statistically significant difference in the primary outcome between the treatment and control arms.”
How can the scientific method explain such a skydiving miracle? Because each and every study participant leaped ... 2 feet. From a parked biplane or helicopter.
“Although we can confidently recommend that individuals jumping from small stationary aircraft on the ground do not require parachutes, individual judgment should be exercised when applying these findings at higher altitudes.” It’s also possible the study authors are suggesting individual judgment should have a parachute, not a backpack, when physicians dive into a study’s scientific methodology.
One lung, please (Hold the food allergy)
Is an organ transplant really worth the risk of developing a food allergy? Probably (er, definitely), but it still totally stinks. A 68-year-old woman suffered an allergic reaction to an innocent peanut butter and jelly sandwich earlier this year, after spending decades of eating peanut butter with no problem. Turns out, her lung transplant donor was allergic to peanuts and unfortunately passed that curse onto her. At least he wasn’t lactose intolerant – can you imagine suddenly being unable to eat cheese?!
Passing on allergies via transplant is extremely rare; there are only about five cases of transplanted peanut allergies. The use of tacrolimus, an immunosuppressive drug, can also increase the risk of contracting food allergies post transplant. Luckily, the woman in question was still in the hospital when she began experiencing symptoms of an allergy attack, and doctors were able to correctly identify and punish the offending sandwich.
A debt of ingratitude
Medical personnel generally don’t get involved in searches for illegal drugs, but physicians at St. Joseph’s Hospital Health Center in Syracuse, N.Y., found themselves in just such a position. Because the police had a court order. Because the suspect said that he’d hidden drugs … in his rectum.
An x-ray had shown no evidence of drugs, but physicians there performed a sigmoidoscopy on Torrence Jackson after a hospital lawyer said “that a search warrant required the doctors to use ‘any means’ to retrieve the drugs,” according to a recent Syracuse.com report of the incident, which took place on Oct. 16, 2017. The sigmoidoscopy confirmed the x-ray finding, or lack thereof, and drug charges against Mr. Jackson eventually were thrown out.
The health care system, however, did its part to put a cherry on top of the situation: The hospital billed Mr. Jackson $4,595.12 for the procedure, and then said it would turn the matter over to a debt collector when he refused to pay.
Cancer-blocking plants?
All hail the GMOs! Researchers from the University of Washington have used genetic modification on a houseplant to turn it into a lean, green, chloroform-eatin’ machine. These mad scientists modified devil’s ivy to pull chloroform (found in chlorinated water) and benzene (found in gasoline) from the air and use them for plant growth.
These compounds are often so small they can’t be caught by air filters but can still cause damage – exposure to chloroform and benzene has been linked to cancer. Now, you can lessen your risk of cancer and enjoy some nice greenery in your home. Researchers have also started working on a new genetic modification to remove formaldehyde compounds from the air. It looks like the future of health is all about plants!
It must be true – it’s in a study
There’s untested, widely accepted truth, and then there’s empirically tested truth demonstrated in a rigorous scientific trial. Untested, widely accepted truth in point: Compared with using a simple backpack, parachute use is more likely to prevent death or major traumatic injury when leaping from an aircraft. Of course, no one’s ever done a study to prove it. Because, duh. Also, institutional review boards. Also, lawyers.
Until now.
Robert Yeh, M.D., of Harvard Medical School, and his colleagues began recruiting for just such a research trial while flying commercially. Few seat mates took up their randomized-to-parachute-or-backpack offer. That forced Dr. Yeh to recruit randomized participants from among fellow academics. Twenty-three research-minded souls agreed to make the leap for scientific progress from either a biplane or a helicopter, thereby making the study “Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial” a BMJ-published reality.
The results? “Our groundbreaking study found no statistically significant difference in the primary outcome between the treatment and control arms.”
How can the scientific method explain such a skydiving miracle? Because each and every study participant leaped ... 2 feet. From a parked biplane or helicopter.
“Although we can confidently recommend that individuals jumping from small stationary aircraft on the ground do not require parachutes, individual judgment should be exercised when applying these findings at higher altitudes.” It’s also possible the study authors are suggesting individual judgment should have a parachute, not a backpack, when physicians dive into a study’s scientific methodology.
Studies support vedolizumab-calcineurin inhibitor combinations but not accelerated infliximab therapy for refractory UC
For patients with treatment-refractory ulcerative colitis, accelerated induction with infliximab did not appear to reduce the need for colectomy, while adding a calcineurin inhibitor to vedolizumab safely and effectively induced clinical remission in nearly half of patients, according to the results of two studies published in Clinical Gastroenterology and Hepatology.
The first study retrospectively evaluated 213 patients with acute severe ulcerative colitis who received infliximab rescue therapy at three gastroenterology centers between 2005 and 2017. Rates of subsequent colectomy were similar whether patients received infliximab (5 mg/kg) at weeks 0, 2, and 6, or were on an accelerated schedule (8% vs. 9%, respectively; adjusted odds ratio, 1.35; 95% confidence interval, 0.38-4.82).
However, among patients who received accelerated treatment, those who received a higher initial dose of infliximab (10 mg/kg) were less likely to subsequently undergo colectomy than those who started at 5 mg/kg and received “chaser” 5-mg or 10-mg doses before week 2, reported Niharika Nalagatla, MD, of Massachusetts General Hospital in Boston, with her associates. “While there was no statistically significant difference [between these groups], there were numerically lower rates of in-hospital and long-term colectomy in the 10 mg/kg group, with a trend toward statistical significance at 2 years [OR, 0.44; 95% CI, 0.18-1.12; P = .08],” they added.
They reported similar results from their systematic review and meta-analysis of seven studies of infliximab induction schedules in patients with acute severe ulcerative colitis. Accordingly, they called for prospective studies to identify which patients are most likely to benefit from accelerated infliximab therapy.
The second study, which was prospective, included 11 patients with treatment-refractory ulcerative colitis who initially received vedolizumab immunotherapy and then started on a calcineurin inhibitor (either tacrolimus or cyclosporine) during their first 12 months of treatment. Rates of steroid-free clinical remission (Harvey-Bradshaw index score less than 4 or short clinical colitis activity index score less than 2) were 55% at week 14 and 45% at week 52, reported Britt Christensen, MD, of the University of Chicago and the Royal Melbourne Hospital, with her associates.
Two of these patients were hospitalized for intravenous cyclosporine plus corticosteroid therapy because they failed to respond to 3 months of treatment with vedolizumab plus prednisolone (40 mg), the investigators noted. One patient did not respond and ultimately underwent colectomy, while the other tapered off cyclosporine after 51 days of treatment and remained in steroid-and calcineurin-free clinical remission at 12 months.
Serious adverse events were uncommon, reflecting the relatively good safety profile of vedolizumab. Combination antitumor necrosis factor and calcineurin inhibitor therapy has been linked to severe infections and deaths, and clinical trials of vedolizumab excluded patients with calcineurin inhibitor exposure. However, vedolizumab primarily targets the localized immune system of the gut, so adding an agent “with broad immune-suppressing effects would not [lead to greater] infective and other complications,” the investigators wrote. “Indeed, no significant toxicity was observed in our series, despite the fact that many patients were on quadruple immunosuppressive therapy, at least initially.”
Dr. Nalagatla reported receiving support from the National Institutes of Health and the Crohn’s & Colitis Foundation. She reported having no relevant conflicts of interest. One of her coinvestigators reported ties to AbbVie, Takeda, Gilead, Merck, and Pfizer. Dr. Christensen and her associates reported receiving support from the University of Chicago and the government of Australia. Dr. Christensen reported ties to Janssen, AbbVie, Takeda, and Pfizer, and four of her coinvestigators also reported ties to a number of pharmaceutical companies.
SOURCES: Nalagatla N et al. Clin Gastroenterol Hepatol. 2018 Jun 23. doi: 10.1016/j.cgh.2018.06.031; Christensen B et al. Clin Gastroenterol Hepatol. 2018 May 8. doi: 10.1016/j.cgh.2018.04.060.
We physicians are not known for our humility. However, acute severe ulcerative colitis (UC) can humble even the most confident inflammatory bowel disease specialist. The study by Nalagatla et al. did not show a difference of colectomy outcomes between accelerated versus standard infliximab induction. However, as the authors point out, their methodology was unable to address confounding by severity. Review of the baseline characteristics implies presence of confounding with numerically higher markers of inflammation in the accelerated infliximab group. The signal of lower, although not statistically significant, odds of colectomy in subgroup analyses of 10 mg/kg versus standard induction should encourage further investigation in 10-mg/kg induction dosing for acute severe UC.
These two studies continue to expand possibilities to manage acute severe UC and direct areas to focus future research.
Jason Ken Hou, MD, MS, is assistant professor of medicine-gastroenterology, director of the GI & Hepatology Fellowship Program, and director of research–IBD at Baylor College of Medicine, Houston, and staff physician of gastroenterology at Michael E. DeBakey VA Medical Center, Houston. He has financial ties to Janssen, AbbVie, and Pfizer.
We physicians are not known for our humility. However, acute severe ulcerative colitis (UC) can humble even the most confident inflammatory bowel disease specialist. The study by Nalagatla et al. did not show a difference of colectomy outcomes between accelerated versus standard infliximab induction. However, as the authors point out, their methodology was unable to address confounding by severity. Review of the baseline characteristics implies presence of confounding with numerically higher markers of inflammation in the accelerated infliximab group. The signal of lower, although not statistically significant, odds of colectomy in subgroup analyses of 10 mg/kg versus standard induction should encourage further investigation in 10-mg/kg induction dosing for acute severe UC.
These two studies continue to expand possibilities to manage acute severe UC and direct areas to focus future research.
Jason Ken Hou, MD, MS, is assistant professor of medicine-gastroenterology, director of the GI & Hepatology Fellowship Program, and director of research–IBD at Baylor College of Medicine, Houston, and staff physician of gastroenterology at Michael E. DeBakey VA Medical Center, Houston. He has financial ties to Janssen, AbbVie, and Pfizer.
We physicians are not known for our humility. However, acute severe ulcerative colitis (UC) can humble even the most confident inflammatory bowel disease specialist. The study by Nalagatla et al. did not show a difference of colectomy outcomes between accelerated versus standard infliximab induction. However, as the authors point out, their methodology was unable to address confounding by severity. Review of the baseline characteristics implies presence of confounding with numerically higher markers of inflammation in the accelerated infliximab group. The signal of lower, although not statistically significant, odds of colectomy in subgroup analyses of 10 mg/kg versus standard induction should encourage further investigation in 10-mg/kg induction dosing for acute severe UC.
These two studies continue to expand possibilities to manage acute severe UC and direct areas to focus future research.
Jason Ken Hou, MD, MS, is assistant professor of medicine-gastroenterology, director of the GI & Hepatology Fellowship Program, and director of research–IBD at Baylor College of Medicine, Houston, and staff physician of gastroenterology at Michael E. DeBakey VA Medical Center, Houston. He has financial ties to Janssen, AbbVie, and Pfizer.
For patients with treatment-refractory ulcerative colitis, accelerated induction with infliximab did not appear to reduce the need for colectomy, while adding a calcineurin inhibitor to vedolizumab safely and effectively induced clinical remission in nearly half of patients, according to the results of two studies published in Clinical Gastroenterology and Hepatology.
The first study retrospectively evaluated 213 patients with acute severe ulcerative colitis who received infliximab rescue therapy at three gastroenterology centers between 2005 and 2017. Rates of subsequent colectomy were similar whether patients received infliximab (5 mg/kg) at weeks 0, 2, and 6, or were on an accelerated schedule (8% vs. 9%, respectively; adjusted odds ratio, 1.35; 95% confidence interval, 0.38-4.82).
However, among patients who received accelerated treatment, those who received a higher initial dose of infliximab (10 mg/kg) were less likely to subsequently undergo colectomy than those who started at 5 mg/kg and received “chaser” 5-mg or 10-mg doses before week 2, reported Niharika Nalagatla, MD, of Massachusetts General Hospital in Boston, with her associates. “While there was no statistically significant difference [between these groups], there were numerically lower rates of in-hospital and long-term colectomy in the 10 mg/kg group, with a trend toward statistical significance at 2 years [OR, 0.44; 95% CI, 0.18-1.12; P = .08],” they added.
They reported similar results from their systematic review and meta-analysis of seven studies of infliximab induction schedules in patients with acute severe ulcerative colitis. Accordingly, they called for prospective studies to identify which patients are most likely to benefit from accelerated infliximab therapy.
The second study, which was prospective, included 11 patients with treatment-refractory ulcerative colitis who initially received vedolizumab immunotherapy and then started on a calcineurin inhibitor (either tacrolimus or cyclosporine) during their first 12 months of treatment. Rates of steroid-free clinical remission (Harvey-Bradshaw index score less than 4 or short clinical colitis activity index score less than 2) were 55% at week 14 and 45% at week 52, reported Britt Christensen, MD, of the University of Chicago and the Royal Melbourne Hospital, with her associates.
Two of these patients were hospitalized for intravenous cyclosporine plus corticosteroid therapy because they failed to respond to 3 months of treatment with vedolizumab plus prednisolone (40 mg), the investigators noted. One patient did not respond and ultimately underwent colectomy, while the other tapered off cyclosporine after 51 days of treatment and remained in steroid-and calcineurin-free clinical remission at 12 months.
Serious adverse events were uncommon, reflecting the relatively good safety profile of vedolizumab. Combination antitumor necrosis factor and calcineurin inhibitor therapy has been linked to severe infections and deaths, and clinical trials of vedolizumab excluded patients with calcineurin inhibitor exposure. However, vedolizumab primarily targets the localized immune system of the gut, so adding an agent “with broad immune-suppressing effects would not [lead to greater] infective and other complications,” the investigators wrote. “Indeed, no significant toxicity was observed in our series, despite the fact that many patients were on quadruple immunosuppressive therapy, at least initially.”
Dr. Nalagatla reported receiving support from the National Institutes of Health and the Crohn’s & Colitis Foundation. She reported having no relevant conflicts of interest. One of her coinvestigators reported ties to AbbVie, Takeda, Gilead, Merck, and Pfizer. Dr. Christensen and her associates reported receiving support from the University of Chicago and the government of Australia. Dr. Christensen reported ties to Janssen, AbbVie, Takeda, and Pfizer, and four of her coinvestigators also reported ties to a number of pharmaceutical companies.
SOURCES: Nalagatla N et al. Clin Gastroenterol Hepatol. 2018 Jun 23. doi: 10.1016/j.cgh.2018.06.031; Christensen B et al. Clin Gastroenterol Hepatol. 2018 May 8. doi: 10.1016/j.cgh.2018.04.060.
For patients with treatment-refractory ulcerative colitis, accelerated induction with infliximab did not appear to reduce the need for colectomy, while adding a calcineurin inhibitor to vedolizumab safely and effectively induced clinical remission in nearly half of patients, according to the results of two studies published in Clinical Gastroenterology and Hepatology.
The first study retrospectively evaluated 213 patients with acute severe ulcerative colitis who received infliximab rescue therapy at three gastroenterology centers between 2005 and 2017. Rates of subsequent colectomy were similar whether patients received infliximab (5 mg/kg) at weeks 0, 2, and 6, or were on an accelerated schedule (8% vs. 9%, respectively; adjusted odds ratio, 1.35; 95% confidence interval, 0.38-4.82).
However, among patients who received accelerated treatment, those who received a higher initial dose of infliximab (10 mg/kg) were less likely to subsequently undergo colectomy than those who started at 5 mg/kg and received “chaser” 5-mg or 10-mg doses before week 2, reported Niharika Nalagatla, MD, of Massachusetts General Hospital in Boston, with her associates. “While there was no statistically significant difference [between these groups], there were numerically lower rates of in-hospital and long-term colectomy in the 10 mg/kg group, with a trend toward statistical significance at 2 years [OR, 0.44; 95% CI, 0.18-1.12; P = .08],” they added.
They reported similar results from their systematic review and meta-analysis of seven studies of infliximab induction schedules in patients with acute severe ulcerative colitis. Accordingly, they called for prospective studies to identify which patients are most likely to benefit from accelerated infliximab therapy.
The second study, which was prospective, included 11 patients with treatment-refractory ulcerative colitis who initially received vedolizumab immunotherapy and then started on a calcineurin inhibitor (either tacrolimus or cyclosporine) during their first 12 months of treatment. Rates of steroid-free clinical remission (Harvey-Bradshaw index score less than 4 or short clinical colitis activity index score less than 2) were 55% at week 14 and 45% at week 52, reported Britt Christensen, MD, of the University of Chicago and the Royal Melbourne Hospital, with her associates.
Two of these patients were hospitalized for intravenous cyclosporine plus corticosteroid therapy because they failed to respond to 3 months of treatment with vedolizumab plus prednisolone (40 mg), the investigators noted. One patient did not respond and ultimately underwent colectomy, while the other tapered off cyclosporine after 51 days of treatment and remained in steroid-and calcineurin-free clinical remission at 12 months.
Serious adverse events were uncommon, reflecting the relatively good safety profile of vedolizumab. Combination antitumor necrosis factor and calcineurin inhibitor therapy has been linked to severe infections and deaths, and clinical trials of vedolizumab excluded patients with calcineurin inhibitor exposure. However, vedolizumab primarily targets the localized immune system of the gut, so adding an agent “with broad immune-suppressing effects would not [lead to greater] infective and other complications,” the investigators wrote. “Indeed, no significant toxicity was observed in our series, despite the fact that many patients were on quadruple immunosuppressive therapy, at least initially.”
Dr. Nalagatla reported receiving support from the National Institutes of Health and the Crohn’s & Colitis Foundation. She reported having no relevant conflicts of interest. One of her coinvestigators reported ties to AbbVie, Takeda, Gilead, Merck, and Pfizer. Dr. Christensen and her associates reported receiving support from the University of Chicago and the government of Australia. Dr. Christensen reported ties to Janssen, AbbVie, Takeda, and Pfizer, and four of her coinvestigators also reported ties to a number of pharmaceutical companies.
SOURCES: Nalagatla N et al. Clin Gastroenterol Hepatol. 2018 Jun 23. doi: 10.1016/j.cgh.2018.06.031; Christensen B et al. Clin Gastroenterol Hepatol. 2018 May 8. doi: 10.1016/j.cgh.2018.04.060.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: For patients with treatment-refractory ulcerative colitis, an accelerated schedule of infliximab did not appear to reduce the likelihood of colectomy, compared with a standard induction schedule; induction with vedolizumab plus a calcineurin inhibitor (cyclosporine or tacrolimus) induced clinical remission in nearly half of such patients.
Major finding: Rates of colectomy were similar whether patients received induction immunotherapy with infliximab (5 mg/kg) at weeks 0, 2, and 6, or were on an accelerated schedule (8% vs. 9%, respectively; adjusted odds ratio, 1.35; 95% confidence interval, 0.38-4.82). In a separate study, rates of steroid-free clinical remission were 55% at week 14 and 45% at week 52.
Study details: A retrospective study of 213 patients with acute severe steroid-refractory ulcerative colitis; a prospective observational study of 20 patients with ulcerative colitis or Crohn’s disease who received vedolizumab and a calcineurin inhibitor (cyclosporine or tacrolimus).
Disclosures: Dr. Nalagatla reported receiving support from the National Institutes of Health and the Crohn’s & Colitis Foundation. She reported having no relevant conflicts of interest. One of her coinvestigators reported ties to AbbVie, Takeda, Gilead, Merck, and Pfizer. Dr. Christensen and her associates reported receiving support from the University of Chicago and the government of Australia. Dr. Christensen reported ties to Janssen, AbbVie, Takeda, and Pfizer, and four of her coinvestigators also reported ties to a number of pharmaceutical companies.
Sources: Nalagatla N et al. Clin Gastroenterol Hepatol. 2018 Jun 23; Christensen B, et al. Clin Gastroenterol Hepatol. 2018 May 8.
Study supports swallowed topical steroids as maintenance for eosinophilic esophagitis
For adults with eosinophilic esophagitis, maintenance treatment with swallowed topical steroids was associated with significantly higher remission rates when compared with “steroid holidays” in a single-center retrospective observational study presented in the February issue of Clinical Gastroenterology and Hepatology.
At a median follow-up time of 5 years, the rate of complete (including clinical, endoscopic, and histologic) remission was 16.1% when patients were receiving swallowed topical steroids but only 1.3% when they were not on these or other maintenance therapies (that is, on “drug holidays”), reported Thomas Greuter, MD, of University Hospital Zürich and the Mayo Clinic in Rochester, Minn., and his associates. Swallowed topical steroids also were associated with significantly higher rates of each individual endpoint (P less than .001). Swallowed topical steroid therapy did not appear to cause dysplasia or mucosal atrophy, although esophageal candidiasis was confirmed in 2.7% of visits when patients were on treatment. “Given the good safety profile of low-dose swallowed topical steroid therapy, we advocate for prolonged treatment. Dose-finding trials are needed to achieve higher remission rates,” the investigators wrote in Clinical Gastroenterology and Hepatology.
Several studies have confirmed the efficacy of short-term swallowed topical steroids for treating eosinophilic esophagitis, but only one small randomized trial has evaluated longer-term treatment, and participants were followed for only 1 year. Dr. Greuter and his associates therefore analyzed retrospective data from 229 adults in Switzerland who received swallowed topical steroids for eosinophilic esophagitis between 2000 and 2014. Induction therapy consisted of 1 mg swallowed topical steroids twice daily, allowing 2-4 weeks for a clinical response. Patients then received infinite maintenance therapy with 0.25 mg swallowed topical steroids twice daily. Patients tended to be male and diagnosed in their late 30s. Endoscopy commonly showed corrugated rings, white exudates, edema, and furrows, and 35% of patients had strictures. Peak eosinophil count typically was 25 cells per high-power frame.
Among 819 follow-up visits, 336 (41%) occurred when patients were on maintenance swallowed topical steroid therapy. The median duration of maintenance therapy prior to a follow-up visit was 347 days (interquartile range, 90-750 days) or 677 doses (IQR, 280-1413 doses). The rate of clinical remission was 31% when patients were on maintenance treatment but only 4.5% when they were not (P less than .001). Respective rates of endoscopic and histologic remission were 48.8% versus 17.8% (P less than .001) and 44.8% versus 10.1% (P less than .001). After accounting for numerous demographic and clinical variables, the only significant predictors of clinical remission were treatment with swallowed topical steroids (odds ratio, 16.98; 95% confidence interval, 6.69-43.09) and a negative family history of esophageal eosinophilia (OR, 4.02; 95% CI, 1.41-11.47).
This study excluded patients whose eosinophilic esophagitis had responded to proton pump inhibitor therapy. Also, the maintenance dose of swallowed topical steroid dose (0.25 mg twice daily) probably was too low to achieve efficacious drug levels in the esophageal mucosa, which could explain the high proportion of treatment-refractory cases, according to the researchers. Evaluating a higher maintenance dose “would be of particular interest in the future,” they added.
The Swiss National Science Foundation provided partial funding. Dr. Greuter disclosed a travel grant from Falk Pharma GmbH and Vifor and an unrestricted research grant from Novartis.
SOURCE: Greuter T et al. Clin Gastroenterol Hepatol. 2018 Jun 11.
For adults with eosinophilic esophagitis, maintenance treatment with swallowed topical steroids was associated with significantly higher remission rates when compared with “steroid holidays” in a single-center retrospective observational study presented in the February issue of Clinical Gastroenterology and Hepatology.
At a median follow-up time of 5 years, the rate of complete (including clinical, endoscopic, and histologic) remission was 16.1% when patients were receiving swallowed topical steroids but only 1.3% when they were not on these or other maintenance therapies (that is, on “drug holidays”), reported Thomas Greuter, MD, of University Hospital Zürich and the Mayo Clinic in Rochester, Minn., and his associates. Swallowed topical steroids also were associated with significantly higher rates of each individual endpoint (P less than .001). Swallowed topical steroid therapy did not appear to cause dysplasia or mucosal atrophy, although esophageal candidiasis was confirmed in 2.7% of visits when patients were on treatment. “Given the good safety profile of low-dose swallowed topical steroid therapy, we advocate for prolonged treatment. Dose-finding trials are needed to achieve higher remission rates,” the investigators wrote in Clinical Gastroenterology and Hepatology.
Several studies have confirmed the efficacy of short-term swallowed topical steroids for treating eosinophilic esophagitis, but only one small randomized trial has evaluated longer-term treatment, and participants were followed for only 1 year. Dr. Greuter and his associates therefore analyzed retrospective data from 229 adults in Switzerland who received swallowed topical steroids for eosinophilic esophagitis between 2000 and 2014. Induction therapy consisted of 1 mg swallowed topical steroids twice daily, allowing 2-4 weeks for a clinical response. Patients then received infinite maintenance therapy with 0.25 mg swallowed topical steroids twice daily. Patients tended to be male and diagnosed in their late 30s. Endoscopy commonly showed corrugated rings, white exudates, edema, and furrows, and 35% of patients had strictures. Peak eosinophil count typically was 25 cells per high-power frame.
Among 819 follow-up visits, 336 (41%) occurred when patients were on maintenance swallowed topical steroid therapy. The median duration of maintenance therapy prior to a follow-up visit was 347 days (interquartile range, 90-750 days) or 677 doses (IQR, 280-1413 doses). The rate of clinical remission was 31% when patients were on maintenance treatment but only 4.5% when they were not (P less than .001). Respective rates of endoscopic and histologic remission were 48.8% versus 17.8% (P less than .001) and 44.8% versus 10.1% (P less than .001). After accounting for numerous demographic and clinical variables, the only significant predictors of clinical remission were treatment with swallowed topical steroids (odds ratio, 16.98; 95% confidence interval, 6.69-43.09) and a negative family history of esophageal eosinophilia (OR, 4.02; 95% CI, 1.41-11.47).
This study excluded patients whose eosinophilic esophagitis had responded to proton pump inhibitor therapy. Also, the maintenance dose of swallowed topical steroid dose (0.25 mg twice daily) probably was too low to achieve efficacious drug levels in the esophageal mucosa, which could explain the high proportion of treatment-refractory cases, according to the researchers. Evaluating a higher maintenance dose “would be of particular interest in the future,” they added.
The Swiss National Science Foundation provided partial funding. Dr. Greuter disclosed a travel grant from Falk Pharma GmbH and Vifor and an unrestricted research grant from Novartis.
SOURCE: Greuter T et al. Clin Gastroenterol Hepatol. 2018 Jun 11.
For adults with eosinophilic esophagitis, maintenance treatment with swallowed topical steroids was associated with significantly higher remission rates when compared with “steroid holidays” in a single-center retrospective observational study presented in the February issue of Clinical Gastroenterology and Hepatology.
At a median follow-up time of 5 years, the rate of complete (including clinical, endoscopic, and histologic) remission was 16.1% when patients were receiving swallowed topical steroids but only 1.3% when they were not on these or other maintenance therapies (that is, on “drug holidays”), reported Thomas Greuter, MD, of University Hospital Zürich and the Mayo Clinic in Rochester, Minn., and his associates. Swallowed topical steroids also were associated with significantly higher rates of each individual endpoint (P less than .001). Swallowed topical steroid therapy did not appear to cause dysplasia or mucosal atrophy, although esophageal candidiasis was confirmed in 2.7% of visits when patients were on treatment. “Given the good safety profile of low-dose swallowed topical steroid therapy, we advocate for prolonged treatment. Dose-finding trials are needed to achieve higher remission rates,” the investigators wrote in Clinical Gastroenterology and Hepatology.
Several studies have confirmed the efficacy of short-term swallowed topical steroids for treating eosinophilic esophagitis, but only one small randomized trial has evaluated longer-term treatment, and participants were followed for only 1 year. Dr. Greuter and his associates therefore analyzed retrospective data from 229 adults in Switzerland who received swallowed topical steroids for eosinophilic esophagitis between 2000 and 2014. Induction therapy consisted of 1 mg swallowed topical steroids twice daily, allowing 2-4 weeks for a clinical response. Patients then received infinite maintenance therapy with 0.25 mg swallowed topical steroids twice daily. Patients tended to be male and diagnosed in their late 30s. Endoscopy commonly showed corrugated rings, white exudates, edema, and furrows, and 35% of patients had strictures. Peak eosinophil count typically was 25 cells per high-power frame.
Among 819 follow-up visits, 336 (41%) occurred when patients were on maintenance swallowed topical steroid therapy. The median duration of maintenance therapy prior to a follow-up visit was 347 days (interquartile range, 90-750 days) or 677 doses (IQR, 280-1413 doses). The rate of clinical remission was 31% when patients were on maintenance treatment but only 4.5% when they were not (P less than .001). Respective rates of endoscopic and histologic remission were 48.8% versus 17.8% (P less than .001) and 44.8% versus 10.1% (P less than .001). After accounting for numerous demographic and clinical variables, the only significant predictors of clinical remission were treatment with swallowed topical steroids (odds ratio, 16.98; 95% confidence interval, 6.69-43.09) and a negative family history of esophageal eosinophilia (OR, 4.02; 95% CI, 1.41-11.47).
This study excluded patients whose eosinophilic esophagitis had responded to proton pump inhibitor therapy. Also, the maintenance dose of swallowed topical steroid dose (0.25 mg twice daily) probably was too low to achieve efficacious drug levels in the esophageal mucosa, which could explain the high proportion of treatment-refractory cases, according to the researchers. Evaluating a higher maintenance dose “would be of particular interest in the future,” they added.
The Swiss National Science Foundation provided partial funding. Dr. Greuter disclosed a travel grant from Falk Pharma GmbH and Vifor and an unrestricted research grant from Novartis.
SOURCE: Greuter T et al. Clin Gastroenterol Hepatol. 2018 Jun 11.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: Swallowed topical steroids appear to increase remission rates among adults with eosinophilic esophagitis.
Major finding: After a median of 5 years of follow-up, rates of clinical remission were 16.1% and 1.3%, respectively (P less than .001).
Study details: Retrospective cohort study of 229 adults with eosinophilic esophagitis.
Disclosures: The Swiss National Science Foundation provided partial funding. Dr. Greuter disclosed a travel grant from Falk Pharma GmbH and Vifor and an unrestricted research grant from Novartis.
Source: Greuter T et al. Clin Gastroenterol Hepatol. 2018 Jun 11.
Lenalidomide maintenance improves MCL survival after ASCT
SAN DIEGO – For patients 65 years or younger with mantle cell lymphoma (MCL) who have undergone autologous stem cell transplantation (ASCT), maintenance therapy with lenalidomide (Revlimid) can significantly improve progression-free survival (PFS), suggest results of the phase, 3 randomized MCL0208 trial.
After a median follow-up of 39 months, the 3-year PFS in an intention-to-treat analysis was 80% for patients treated with ASCT and lenalidomide maintenance, compared with 64% for patients treated with ASCT alone, reported Marco Ladetto, MD, of Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo in Alessandria, Italy.
“Lenalidomide maintenance after autologous stem cell transplant has substantial clinical activity in mantle cell lymphoma in terms of progression-free survival,” he said at the annual meeting of the American Society of Hematology. “Follow-up is still too short for meaningful overall survival considerations.”
Dr. Ladetto and his colleagues at centers in Italy and Portugal enrolled patients aged 18-65 years with previously untreated MCL stage III or IV, or stage II with bulky disease (5 cm or greater), and good performance status.
The patients first underwent induction with three cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, and prednisone), which was followed by treatment with rituximab plus high-dose cyclophosphamide and two cycles of rituximab with high-dose cytarabine. Stem cells were collected after the first course of the latter regimen.
The patients then underwent conditioning with BEAM (carmustine, etoposide, cytarabine, melphalan) and ASCT.
Following ASCT, patients with complete or partial remissions were randomized either to maintenance therapy with lenalidomide 15 mg for 21 of 28 days for each cycle or to observation.
Of the 303 patients initially enrolled, 248 went on to ASCT, and 205 went on to randomization – 104 assigned to maintenance and 101 assigned to observation.
A total of 52 patients completed 2 years of maintenance: Of the rest, 2 patients died from toxicities (thrombotic thrombocytopenic purpura and pneumonia), 7 had disease progression, 41 dropped out for nonprogression reasons, and 2 patients were still in maintenance at the time of the data cutoff. In this arm, 6 of 8 patients with partial responses converted to complete responses by the end of maintenance. More than a quarter of patients (28%) received less than 25% of the planned lenalidomide dose.
In the observation arm, 1 patient died from pneumonia, 20 had disease progression, 3 were lost to follow-up, 6 were still under observation, and 71 completed observation. In this arm, 1 of 4 patients with a partial response converted to a complete response at the end of the observation period.
Despite suboptimal dosing in a large proportion of patients, the PFS primary endpoint showed significant benefit for lenalidomide, with an unstratified hazard ratio of 0.52 (P = .015) and a stratified HR of 0.51 (P = .013).
At a median follow-up of 39 months from randomization, 3-year overall survival (OS) rates were 93% with lenalidomide and 86% with observation, a difference that was not statistically significant.
Grade 3 or 4 hematologic toxicities occurred in 63% of patients in the lenalidomide arm, compared with 11% in the observation arm. The respective rates of granulocytopenia were 59% vs. 10%. Nonhematological grade 3 toxicity was comparable in the two arms except for grade 3 or 4 infections, which were more common with lenalidomide. Seven patients in the lenalidomide arm and three patients in the observation arm developed second cancers.
Dr. Ladetto noted that difficulties in delivering the planned dose of lenalidomide may have been caused by an already-stressed hematopoietic compartment; he commented that the question of the relative benefit of a fixed lenalidomide schedule or an until-progression approach still needs to be answered.
Additionally, the induction schedule used in the trial, while feasible, is not superior to “less cumbersome and possibly less toxic regimens,” he said.
The study was supported by the Italian Lymphoma Foundation (Fondazione Italiana Linfomi) with the European Mantle Cell Lymphoma Network. Dr. Ladetto reported honoraria from Roche, Celgene, Acerta, Janssen, AbbVie, and Sandoz, as well as off-label use of lenalidomide.
SOURCE: Ladetto M et al. ASH 2018, Abstract 401.
SAN DIEGO – For patients 65 years or younger with mantle cell lymphoma (MCL) who have undergone autologous stem cell transplantation (ASCT), maintenance therapy with lenalidomide (Revlimid) can significantly improve progression-free survival (PFS), suggest results of the phase, 3 randomized MCL0208 trial.
After a median follow-up of 39 months, the 3-year PFS in an intention-to-treat analysis was 80% for patients treated with ASCT and lenalidomide maintenance, compared with 64% for patients treated with ASCT alone, reported Marco Ladetto, MD, of Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo in Alessandria, Italy.
“Lenalidomide maintenance after autologous stem cell transplant has substantial clinical activity in mantle cell lymphoma in terms of progression-free survival,” he said at the annual meeting of the American Society of Hematology. “Follow-up is still too short for meaningful overall survival considerations.”
Dr. Ladetto and his colleagues at centers in Italy and Portugal enrolled patients aged 18-65 years with previously untreated MCL stage III or IV, or stage II with bulky disease (5 cm or greater), and good performance status.
The patients first underwent induction with three cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, and prednisone), which was followed by treatment with rituximab plus high-dose cyclophosphamide and two cycles of rituximab with high-dose cytarabine. Stem cells were collected after the first course of the latter regimen.
The patients then underwent conditioning with BEAM (carmustine, etoposide, cytarabine, melphalan) and ASCT.
Following ASCT, patients with complete or partial remissions were randomized either to maintenance therapy with lenalidomide 15 mg for 21 of 28 days for each cycle or to observation.
Of the 303 patients initially enrolled, 248 went on to ASCT, and 205 went on to randomization – 104 assigned to maintenance and 101 assigned to observation.
A total of 52 patients completed 2 years of maintenance: Of the rest, 2 patients died from toxicities (thrombotic thrombocytopenic purpura and pneumonia), 7 had disease progression, 41 dropped out for nonprogression reasons, and 2 patients were still in maintenance at the time of the data cutoff. In this arm, 6 of 8 patients with partial responses converted to complete responses by the end of maintenance. More than a quarter of patients (28%) received less than 25% of the planned lenalidomide dose.
In the observation arm, 1 patient died from pneumonia, 20 had disease progression, 3 were lost to follow-up, 6 were still under observation, and 71 completed observation. In this arm, 1 of 4 patients with a partial response converted to a complete response at the end of the observation period.
Despite suboptimal dosing in a large proportion of patients, the PFS primary endpoint showed significant benefit for lenalidomide, with an unstratified hazard ratio of 0.52 (P = .015) and a stratified HR of 0.51 (P = .013).
At a median follow-up of 39 months from randomization, 3-year overall survival (OS) rates were 93% with lenalidomide and 86% with observation, a difference that was not statistically significant.
Grade 3 or 4 hematologic toxicities occurred in 63% of patients in the lenalidomide arm, compared with 11% in the observation arm. The respective rates of granulocytopenia were 59% vs. 10%. Nonhematological grade 3 toxicity was comparable in the two arms except for grade 3 or 4 infections, which were more common with lenalidomide. Seven patients in the lenalidomide arm and three patients in the observation arm developed second cancers.
Dr. Ladetto noted that difficulties in delivering the planned dose of lenalidomide may have been caused by an already-stressed hematopoietic compartment; he commented that the question of the relative benefit of a fixed lenalidomide schedule or an until-progression approach still needs to be answered.
Additionally, the induction schedule used in the trial, while feasible, is not superior to “less cumbersome and possibly less toxic regimens,” he said.
The study was supported by the Italian Lymphoma Foundation (Fondazione Italiana Linfomi) with the European Mantle Cell Lymphoma Network. Dr. Ladetto reported honoraria from Roche, Celgene, Acerta, Janssen, AbbVie, and Sandoz, as well as off-label use of lenalidomide.
SOURCE: Ladetto M et al. ASH 2018, Abstract 401.
SAN DIEGO – For patients 65 years or younger with mantle cell lymphoma (MCL) who have undergone autologous stem cell transplantation (ASCT), maintenance therapy with lenalidomide (Revlimid) can significantly improve progression-free survival (PFS), suggest results of the phase, 3 randomized MCL0208 trial.
After a median follow-up of 39 months, the 3-year PFS in an intention-to-treat analysis was 80% for patients treated with ASCT and lenalidomide maintenance, compared with 64% for patients treated with ASCT alone, reported Marco Ladetto, MD, of Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo in Alessandria, Italy.
“Lenalidomide maintenance after autologous stem cell transplant has substantial clinical activity in mantle cell lymphoma in terms of progression-free survival,” he said at the annual meeting of the American Society of Hematology. “Follow-up is still too short for meaningful overall survival considerations.”
Dr. Ladetto and his colleagues at centers in Italy and Portugal enrolled patients aged 18-65 years with previously untreated MCL stage III or IV, or stage II with bulky disease (5 cm or greater), and good performance status.
The patients first underwent induction with three cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, and prednisone), which was followed by treatment with rituximab plus high-dose cyclophosphamide and two cycles of rituximab with high-dose cytarabine. Stem cells were collected after the first course of the latter regimen.
The patients then underwent conditioning with BEAM (carmustine, etoposide, cytarabine, melphalan) and ASCT.
Following ASCT, patients with complete or partial remissions were randomized either to maintenance therapy with lenalidomide 15 mg for 21 of 28 days for each cycle or to observation.
Of the 303 patients initially enrolled, 248 went on to ASCT, and 205 went on to randomization – 104 assigned to maintenance and 101 assigned to observation.
A total of 52 patients completed 2 years of maintenance: Of the rest, 2 patients died from toxicities (thrombotic thrombocytopenic purpura and pneumonia), 7 had disease progression, 41 dropped out for nonprogression reasons, and 2 patients were still in maintenance at the time of the data cutoff. In this arm, 6 of 8 patients with partial responses converted to complete responses by the end of maintenance. More than a quarter of patients (28%) received less than 25% of the planned lenalidomide dose.
In the observation arm, 1 patient died from pneumonia, 20 had disease progression, 3 were lost to follow-up, 6 were still under observation, and 71 completed observation. In this arm, 1 of 4 patients with a partial response converted to a complete response at the end of the observation period.
Despite suboptimal dosing in a large proportion of patients, the PFS primary endpoint showed significant benefit for lenalidomide, with an unstratified hazard ratio of 0.52 (P = .015) and a stratified HR of 0.51 (P = .013).
At a median follow-up of 39 months from randomization, 3-year overall survival (OS) rates were 93% with lenalidomide and 86% with observation, a difference that was not statistically significant.
Grade 3 or 4 hematologic toxicities occurred in 63% of patients in the lenalidomide arm, compared with 11% in the observation arm. The respective rates of granulocytopenia were 59% vs. 10%. Nonhematological grade 3 toxicity was comparable in the two arms except for grade 3 or 4 infections, which were more common with lenalidomide. Seven patients in the lenalidomide arm and three patients in the observation arm developed second cancers.
Dr. Ladetto noted that difficulties in delivering the planned dose of lenalidomide may have been caused by an already-stressed hematopoietic compartment; he commented that the question of the relative benefit of a fixed lenalidomide schedule or an until-progression approach still needs to be answered.
Additionally, the induction schedule used in the trial, while feasible, is not superior to “less cumbersome and possibly less toxic regimens,” he said.
The study was supported by the Italian Lymphoma Foundation (Fondazione Italiana Linfomi) with the European Mantle Cell Lymphoma Network. Dr. Ladetto reported honoraria from Roche, Celgene, Acerta, Janssen, AbbVie, and Sandoz, as well as off-label use of lenalidomide.
SOURCE: Ladetto M et al. ASH 2018, Abstract 401.
REPORTING FROM ASH 2018
Key clinical point:
Major finding: The 3-year PFS rate was 80% for patients on lenalidomide maintenance, compared with 64% for patients on observation alone.
Study details: An open-label, randomized, phase 3 trial with 205 patients randomized to lenalidomide or observation.
Disclosures: The study was supported by the Italian Lymphoma Foundation (Fondazione Italiana Linfomi) with the European Mantle Cell Lymphoma Network. Dr. Ladetto reported honoraria from Roche, Celgene, Acerta, Janssen, AbbVie, and Sandoz, as well as off-label use of lenalidomide.
Source: Ladetto M et al. ASH 2018, Abstract 401.
Some patients leave a scar on you
Every surgeon has experienced the anguish of an adverse outcome. The elective aneurysm that dies on the table, the asymptomatic carotid patient that has a stroke in the recovery room, the cosmetic varicose vein case that has a pulmonary embolus. Driving home alone, we tell ourselves that we did our “best,” but lingering in the dark shadows of our minds are the nagging questions: What should I have done differently? Am I really a safe surgeon? Should I quit and get a job with “industry”? What if I get sued? How should I deal with the family? Will I get fired?
Our houses are dark when we arrive home. We sit alone in living rooms silently mulling over the events of the day. Our spouses have seen this before and will offer sincere consolation, but will never really know how it feels. So we do what surgeons are trained to do – we suck it up and hide our feelings. As the Brits say: “Keep calm and carry on!”
A few years ago, I operated on a young woman with suspected median arcuate ligament syndrome. She had experienced temporary improvement after laparoscopic release of the median arcuate ligament at an outside hospital, but her symptoms returned after a few months.
Initially, I attempted to place a stent in the celiac artery from the groin but failed to establish a stable access sheath. Rather than choosing a brachial approach, I recommended open repair. The next day in the operating room, I was surprised to find a distinct blue tint to the adventitia of the celiac and hepatic arteries typical of dissection. After opening the common hepatic artery, I discovered that the dissection continued well into the bifurcation of the proper hepatic artery, forcing me to clamp the gastroduodenal artery, the primary collateral pathway to the liver. Within minutes, the liver turned a nauseating purple black.
I urgently constructed an aorto-hepatic bypass with vein using 8-0 suture to try to tack the dissection flap into place distally. I tried to ignore the dire appearance of the liver as I worked, but I was fearful that my distal anastomosis would be inadequate. When I took off the clamps, the liver improved slightly but remained bruised. The finding of a Doppler signal distal to my anastomosis gave me some hope but I remained fearful about the viability of the liver.
Postop, I found her husband in the waiting room with two small children. I explained the potentially catastrophic circumstances and prepared him for the possibility that she might need a liver transplant! He was stunned and angry but mostly silent. Her liver function tests (LFTs) deteriorated over the next 3 days, leaving me depressed, anxious, and sleepless. I hated making rounds on her. Her husband was invariably lying on a couch in her room, pictures of her children taped to her headboard. I reached out to hepatology and transplant surgery hoping for some encouragement. My partners patted me on the back and reminded me that they’d all been in similar binds. I swore to myself that I’d never do another operation on a patient with median arcuate ligament syndrome.
On the morning of the fourth postop day, her LFTs miraculously reversed course and she made an uneventful recovery. But I was scarred. To this day, when I see the diagnosis of median arcuate ligament syndrome on a chart in the office, I shudder. I remember the color of her liver – like the deep blackness of the abyss.
Some patients leave a scar on you. But how we, as surgeons, deal with adversity is largely unknown. Each of us has to discover through trial and error the most effective way to respond to unwanted outcomes. We model ourselves after our teachers, mentors, and chief residents. Some of us have enlightened, sympathetic partners to turn to for consolation, advice, and “competent critique.” But others may be isolated in solo practice or in shared-expense practice models where “partners” may actually be competitors.
Some of the same traits that make us effective surgeons – autonomy, courage, and leadership – also make us particularly unlikely to seek outside counsel. We fear that acknowledging our humanity will be perceived as a sign of weakness. While it has become common practice in most hospitals to have programs for so-called “second victims” – for example, emergency workers, nurses, and others caring for victims of the Boston Marathon bombing – it is uncommon for surgeons to take advantage of these resources. Surgeons tend to rely on each other, like soldiers in battle, for advice, consolation, and improvement. Professionals call it “peer support” and it forms the basis of some successful peer-to-peer rehabilitation programs.
Over the next few months, we hope to initiate a dialogue among members of the SVS community about how we can learn to best care for each other. Few of us have any formal training in how to ask for or provide assistance. We hope that you will share your stories, techniques, and best practices.
Who do you turn to for advice in times of adversity? A spouse, trusted senior partner, a mentor, a defense lawyer, a priest, a bottle? How do you respond to your partners facing adversity? How do you recognize in yourself, or your colleagues, that an adverse outcome has affected your ability to deliver safe, compassionate care? How do you listen for telltale signs that substance abuse, depression, or suicidal ideation have entered the equation? And what should you do next?
I’m sure that, like me, most of you are burned out on burnout. And while I don’t diminish the importance of personal resilience, I also think that we as surgeons can learn to be better caregivers for each other. That we can learn from others how to ask the right questions, and how to be more attentive listeners. Vascular surgery is undoubtedly an immensely rewarding career, but it can bring with it very intense personal challenges. Through the resources of the SVS, we hope to raise awareness of the importance of peer support, to provide a forum to share our stories, and to develop programs that will assist each of us in acquiring the tools and skills to be better partners. Your comments are encouraged.
John F Eidt, MD, is a vascular surgeon at Baylor Scott & White Heart and Vascular Hospital, Dallas.
Every surgeon has experienced the anguish of an adverse outcome. The elective aneurysm that dies on the table, the asymptomatic carotid patient that has a stroke in the recovery room, the cosmetic varicose vein case that has a pulmonary embolus. Driving home alone, we tell ourselves that we did our “best,” but lingering in the dark shadows of our minds are the nagging questions: What should I have done differently? Am I really a safe surgeon? Should I quit and get a job with “industry”? What if I get sued? How should I deal with the family? Will I get fired?
Our houses are dark when we arrive home. We sit alone in living rooms silently mulling over the events of the day. Our spouses have seen this before and will offer sincere consolation, but will never really know how it feels. So we do what surgeons are trained to do – we suck it up and hide our feelings. As the Brits say: “Keep calm and carry on!”
A few years ago, I operated on a young woman with suspected median arcuate ligament syndrome. She had experienced temporary improvement after laparoscopic release of the median arcuate ligament at an outside hospital, but her symptoms returned after a few months.
Initially, I attempted to place a stent in the celiac artery from the groin but failed to establish a stable access sheath. Rather than choosing a brachial approach, I recommended open repair. The next day in the operating room, I was surprised to find a distinct blue tint to the adventitia of the celiac and hepatic arteries typical of dissection. After opening the common hepatic artery, I discovered that the dissection continued well into the bifurcation of the proper hepatic artery, forcing me to clamp the gastroduodenal artery, the primary collateral pathway to the liver. Within minutes, the liver turned a nauseating purple black.
I urgently constructed an aorto-hepatic bypass with vein using 8-0 suture to try to tack the dissection flap into place distally. I tried to ignore the dire appearance of the liver as I worked, but I was fearful that my distal anastomosis would be inadequate. When I took off the clamps, the liver improved slightly but remained bruised. The finding of a Doppler signal distal to my anastomosis gave me some hope but I remained fearful about the viability of the liver.
Postop, I found her husband in the waiting room with two small children. I explained the potentially catastrophic circumstances and prepared him for the possibility that she might need a liver transplant! He was stunned and angry but mostly silent. Her liver function tests (LFTs) deteriorated over the next 3 days, leaving me depressed, anxious, and sleepless. I hated making rounds on her. Her husband was invariably lying on a couch in her room, pictures of her children taped to her headboard. I reached out to hepatology and transplant surgery hoping for some encouragement. My partners patted me on the back and reminded me that they’d all been in similar binds. I swore to myself that I’d never do another operation on a patient with median arcuate ligament syndrome.
On the morning of the fourth postop day, her LFTs miraculously reversed course and she made an uneventful recovery. But I was scarred. To this day, when I see the diagnosis of median arcuate ligament syndrome on a chart in the office, I shudder. I remember the color of her liver – like the deep blackness of the abyss.
Some patients leave a scar on you. But how we, as surgeons, deal with adversity is largely unknown. Each of us has to discover through trial and error the most effective way to respond to unwanted outcomes. We model ourselves after our teachers, mentors, and chief residents. Some of us have enlightened, sympathetic partners to turn to for consolation, advice, and “competent critique.” But others may be isolated in solo practice or in shared-expense practice models where “partners” may actually be competitors.
Some of the same traits that make us effective surgeons – autonomy, courage, and leadership – also make us particularly unlikely to seek outside counsel. We fear that acknowledging our humanity will be perceived as a sign of weakness. While it has become common practice in most hospitals to have programs for so-called “second victims” – for example, emergency workers, nurses, and others caring for victims of the Boston Marathon bombing – it is uncommon for surgeons to take advantage of these resources. Surgeons tend to rely on each other, like soldiers in battle, for advice, consolation, and improvement. Professionals call it “peer support” and it forms the basis of some successful peer-to-peer rehabilitation programs.
Over the next few months, we hope to initiate a dialogue among members of the SVS community about how we can learn to best care for each other. Few of us have any formal training in how to ask for or provide assistance. We hope that you will share your stories, techniques, and best practices.
Who do you turn to for advice in times of adversity? A spouse, trusted senior partner, a mentor, a defense lawyer, a priest, a bottle? How do you respond to your partners facing adversity? How do you recognize in yourself, or your colleagues, that an adverse outcome has affected your ability to deliver safe, compassionate care? How do you listen for telltale signs that substance abuse, depression, or suicidal ideation have entered the equation? And what should you do next?
I’m sure that, like me, most of you are burned out on burnout. And while I don’t diminish the importance of personal resilience, I also think that we as surgeons can learn to be better caregivers for each other. That we can learn from others how to ask the right questions, and how to be more attentive listeners. Vascular surgery is undoubtedly an immensely rewarding career, but it can bring with it very intense personal challenges. Through the resources of the SVS, we hope to raise awareness of the importance of peer support, to provide a forum to share our stories, and to develop programs that will assist each of us in acquiring the tools and skills to be better partners. Your comments are encouraged.
John F Eidt, MD, is a vascular surgeon at Baylor Scott & White Heart and Vascular Hospital, Dallas.
Every surgeon has experienced the anguish of an adverse outcome. The elective aneurysm that dies on the table, the asymptomatic carotid patient that has a stroke in the recovery room, the cosmetic varicose vein case that has a pulmonary embolus. Driving home alone, we tell ourselves that we did our “best,” but lingering in the dark shadows of our minds are the nagging questions: What should I have done differently? Am I really a safe surgeon? Should I quit and get a job with “industry”? What if I get sued? How should I deal with the family? Will I get fired?
Our houses are dark when we arrive home. We sit alone in living rooms silently mulling over the events of the day. Our spouses have seen this before and will offer sincere consolation, but will never really know how it feels. So we do what surgeons are trained to do – we suck it up and hide our feelings. As the Brits say: “Keep calm and carry on!”
A few years ago, I operated on a young woman with suspected median arcuate ligament syndrome. She had experienced temporary improvement after laparoscopic release of the median arcuate ligament at an outside hospital, but her symptoms returned after a few months.
Initially, I attempted to place a stent in the celiac artery from the groin but failed to establish a stable access sheath. Rather than choosing a brachial approach, I recommended open repair. The next day in the operating room, I was surprised to find a distinct blue tint to the adventitia of the celiac and hepatic arteries typical of dissection. After opening the common hepatic artery, I discovered that the dissection continued well into the bifurcation of the proper hepatic artery, forcing me to clamp the gastroduodenal artery, the primary collateral pathway to the liver. Within minutes, the liver turned a nauseating purple black.
I urgently constructed an aorto-hepatic bypass with vein using 8-0 suture to try to tack the dissection flap into place distally. I tried to ignore the dire appearance of the liver as I worked, but I was fearful that my distal anastomosis would be inadequate. When I took off the clamps, the liver improved slightly but remained bruised. The finding of a Doppler signal distal to my anastomosis gave me some hope but I remained fearful about the viability of the liver.
Postop, I found her husband in the waiting room with two small children. I explained the potentially catastrophic circumstances and prepared him for the possibility that she might need a liver transplant! He was stunned and angry but mostly silent. Her liver function tests (LFTs) deteriorated over the next 3 days, leaving me depressed, anxious, and sleepless. I hated making rounds on her. Her husband was invariably lying on a couch in her room, pictures of her children taped to her headboard. I reached out to hepatology and transplant surgery hoping for some encouragement. My partners patted me on the back and reminded me that they’d all been in similar binds. I swore to myself that I’d never do another operation on a patient with median arcuate ligament syndrome.
On the morning of the fourth postop day, her LFTs miraculously reversed course and she made an uneventful recovery. But I was scarred. To this day, when I see the diagnosis of median arcuate ligament syndrome on a chart in the office, I shudder. I remember the color of her liver – like the deep blackness of the abyss.
Some patients leave a scar on you. But how we, as surgeons, deal with adversity is largely unknown. Each of us has to discover through trial and error the most effective way to respond to unwanted outcomes. We model ourselves after our teachers, mentors, and chief residents. Some of us have enlightened, sympathetic partners to turn to for consolation, advice, and “competent critique.” But others may be isolated in solo practice or in shared-expense practice models where “partners” may actually be competitors.
Some of the same traits that make us effective surgeons – autonomy, courage, and leadership – also make us particularly unlikely to seek outside counsel. We fear that acknowledging our humanity will be perceived as a sign of weakness. While it has become common practice in most hospitals to have programs for so-called “second victims” – for example, emergency workers, nurses, and others caring for victims of the Boston Marathon bombing – it is uncommon for surgeons to take advantage of these resources. Surgeons tend to rely on each other, like soldiers in battle, for advice, consolation, and improvement. Professionals call it “peer support” and it forms the basis of some successful peer-to-peer rehabilitation programs.
Over the next few months, we hope to initiate a dialogue among members of the SVS community about how we can learn to best care for each other. Few of us have any formal training in how to ask for or provide assistance. We hope that you will share your stories, techniques, and best practices.
Who do you turn to for advice in times of adversity? A spouse, trusted senior partner, a mentor, a defense lawyer, a priest, a bottle? How do you respond to your partners facing adversity? How do you recognize in yourself, or your colleagues, that an adverse outcome has affected your ability to deliver safe, compassionate care? How do you listen for telltale signs that substance abuse, depression, or suicidal ideation have entered the equation? And what should you do next?
I’m sure that, like me, most of you are burned out on burnout. And while I don’t diminish the importance of personal resilience, I also think that we as surgeons can learn to be better caregivers for each other. That we can learn from others how to ask the right questions, and how to be more attentive listeners. Vascular surgery is undoubtedly an immensely rewarding career, but it can bring with it very intense personal challenges. Through the resources of the SVS, we hope to raise awareness of the importance of peer support, to provide a forum to share our stories, and to develop programs that will assist each of us in acquiring the tools and skills to be better partners. Your comments are encouraged.
John F Eidt, MD, is a vascular surgeon at Baylor Scott & White Heart and Vascular Hospital, Dallas.
Digital Revolution: Dermatology Is on the Edge
The Digital Revolution has invaded the House of Medicine, which is not really news since the invasion has been long-standing, but it seems to be generating more interest and concern in recent months. The American Medical Association recently created the Digital Health Implementation Playbook to lend guidance in developing technologies that are fundamentally altering the manner in which patients interact with health care providers.1 The playbook lays out specific steps for developing and implementing digital health technologies such as remote patient monitoring devices. The goal of the playbook is to make certain that such devices are accurate, reliable, and validated as valuable additions to high-quality patient care.1
In the February 2018 issue of Cutis, Masud et al2 evaluated 44 patient-directed mobile applications (apps) for dermatologic conditions and developed a schematic for evaluating their value in providing valid usable information for patients. They found that most of the apps failed to live up to their purported usefulness in patient education.2 I am certain we have all seen numerous examples on the Internet, many times brought to us by patients, of fallacious and inaccurate information about the diagnosis and treatment of dermatologic conditions that are actually harmful to the care of our patients.
A more upsetting trend in recent years is the proliferation of open-access journals. Although such digital journals can result in more rapid dissemination of valid scientific information, many of them do not follow a true peer-review process. So-called predatory journals from for-profit unethical publishers are increasing at an alarming rate.3
Furthermore, there is a need to present data more accurately and in formats that provide more meaningful interpretation, according to a recent Letter From the Editor in the Journal of the American Academy of Dermatology.4 Elston4 wrote: “Be honest about your data and the limitations of the study design.” He cautioned further about the proper use of statistical analysis.
As dermatologists, how do we make certain that the Digital Revolution results in better care of our patients? The answer, of course, is in education of the practitioner and our young colleagues in training. Although most Cutis readers still access the print version of our journal, more and more readers are accessing our digital format. Online we are able to offer readers the peer-reviewed content you have known to trust and rely on to improve your care of patients as well as other educational tools. Furthermore, we can provide readers access to additional charts and tables pertaining to research published in the print journal.
In January 2019 the Cutis website will merge with Dermatology News, our sister news publication, to become MDedge Dermatology (www.mdedge.com/dermatology). This site will be your new one-stop destination for timely news and clinical content you can trust from both publications. This interactive site is designed to help clinicians quickly find the information they need to improve the treatment and care of patients with conditions affecting the hair, skin, and nails. You will have free access to digital resources such as procedural videos, podcasts, image quizzes, board review, and resident resources, as well as an archive of Cutis content dating back to 2000.
As we at Cutis broaden our digital footprint, we look forward to providing our readers with a larger volume of clinically relevant content in more easily accessed formats while maintaining our commitment to valid trustworthy information. In the coming months we look forward to joining with you in this new digital endeavor, and as always, we appreciate the input of our readers during this process.
1. AMA announces playbook to successfully adopt digital health [press release]. Boston, MA: American Medical Association; October 16, 2018. https://www.ama-assn.org/press-center/press-releases/ama-announces-playbook-successfully-adopt-digital-health. Accessed December 14, 2018.
2. Masud A, Shafi S, Rao BK. Mobile medical apps for patient education: a graded review of available dermatology apps. Cutis. 2018;101:141-144.
3. Shahrivar N, Grant-Kels JM, Payette MJ. Predatory journals: how to recognize and avoid the threat of involvement with these unethical “publishers.” J Am Acad Dermatol. 2016;75:658-659.
4. Elston DM. Presentation of data. J Am Acad Dermatol. 2019;80:55.
The Digital Revolution has invaded the House of Medicine, which is not really news since the invasion has been long-standing, but it seems to be generating more interest and concern in recent months. The American Medical Association recently created the Digital Health Implementation Playbook to lend guidance in developing technologies that are fundamentally altering the manner in which patients interact with health care providers.1 The playbook lays out specific steps for developing and implementing digital health technologies such as remote patient monitoring devices. The goal of the playbook is to make certain that such devices are accurate, reliable, and validated as valuable additions to high-quality patient care.1
In the February 2018 issue of Cutis, Masud et al2 evaluated 44 patient-directed mobile applications (apps) for dermatologic conditions and developed a schematic for evaluating their value in providing valid usable information for patients. They found that most of the apps failed to live up to their purported usefulness in patient education.2 I am certain we have all seen numerous examples on the Internet, many times brought to us by patients, of fallacious and inaccurate information about the diagnosis and treatment of dermatologic conditions that are actually harmful to the care of our patients.
A more upsetting trend in recent years is the proliferation of open-access journals. Although such digital journals can result in more rapid dissemination of valid scientific information, many of them do not follow a true peer-review process. So-called predatory journals from for-profit unethical publishers are increasing at an alarming rate.3
Furthermore, there is a need to present data more accurately and in formats that provide more meaningful interpretation, according to a recent Letter From the Editor in the Journal of the American Academy of Dermatology.4 Elston4 wrote: “Be honest about your data and the limitations of the study design.” He cautioned further about the proper use of statistical analysis.
As dermatologists, how do we make certain that the Digital Revolution results in better care of our patients? The answer, of course, is in education of the practitioner and our young colleagues in training. Although most Cutis readers still access the print version of our journal, more and more readers are accessing our digital format. Online we are able to offer readers the peer-reviewed content you have known to trust and rely on to improve your care of patients as well as other educational tools. Furthermore, we can provide readers access to additional charts and tables pertaining to research published in the print journal.
In January 2019 the Cutis website will merge with Dermatology News, our sister news publication, to become MDedge Dermatology (www.mdedge.com/dermatology). This site will be your new one-stop destination for timely news and clinical content you can trust from both publications. This interactive site is designed to help clinicians quickly find the information they need to improve the treatment and care of patients with conditions affecting the hair, skin, and nails. You will have free access to digital resources such as procedural videos, podcasts, image quizzes, board review, and resident resources, as well as an archive of Cutis content dating back to 2000.
As we at Cutis broaden our digital footprint, we look forward to providing our readers with a larger volume of clinically relevant content in more easily accessed formats while maintaining our commitment to valid trustworthy information. In the coming months we look forward to joining with you in this new digital endeavor, and as always, we appreciate the input of our readers during this process.
The Digital Revolution has invaded the House of Medicine, which is not really news since the invasion has been long-standing, but it seems to be generating more interest and concern in recent months. The American Medical Association recently created the Digital Health Implementation Playbook to lend guidance in developing technologies that are fundamentally altering the manner in which patients interact with health care providers.1 The playbook lays out specific steps for developing and implementing digital health technologies such as remote patient monitoring devices. The goal of the playbook is to make certain that such devices are accurate, reliable, and validated as valuable additions to high-quality patient care.1
In the February 2018 issue of Cutis, Masud et al2 evaluated 44 patient-directed mobile applications (apps) for dermatologic conditions and developed a schematic for evaluating their value in providing valid usable information for patients. They found that most of the apps failed to live up to their purported usefulness in patient education.2 I am certain we have all seen numerous examples on the Internet, many times brought to us by patients, of fallacious and inaccurate information about the diagnosis and treatment of dermatologic conditions that are actually harmful to the care of our patients.
A more upsetting trend in recent years is the proliferation of open-access journals. Although such digital journals can result in more rapid dissemination of valid scientific information, many of them do not follow a true peer-review process. So-called predatory journals from for-profit unethical publishers are increasing at an alarming rate.3
Furthermore, there is a need to present data more accurately and in formats that provide more meaningful interpretation, according to a recent Letter From the Editor in the Journal of the American Academy of Dermatology.4 Elston4 wrote: “Be honest about your data and the limitations of the study design.” He cautioned further about the proper use of statistical analysis.
As dermatologists, how do we make certain that the Digital Revolution results in better care of our patients? The answer, of course, is in education of the practitioner and our young colleagues in training. Although most Cutis readers still access the print version of our journal, more and more readers are accessing our digital format. Online we are able to offer readers the peer-reviewed content you have known to trust and rely on to improve your care of patients as well as other educational tools. Furthermore, we can provide readers access to additional charts and tables pertaining to research published in the print journal.
In January 2019 the Cutis website will merge with Dermatology News, our sister news publication, to become MDedge Dermatology (www.mdedge.com/dermatology). This site will be your new one-stop destination for timely news and clinical content you can trust from both publications. This interactive site is designed to help clinicians quickly find the information they need to improve the treatment and care of patients with conditions affecting the hair, skin, and nails. You will have free access to digital resources such as procedural videos, podcasts, image quizzes, board review, and resident resources, as well as an archive of Cutis content dating back to 2000.
As we at Cutis broaden our digital footprint, we look forward to providing our readers with a larger volume of clinically relevant content in more easily accessed formats while maintaining our commitment to valid trustworthy information. In the coming months we look forward to joining with you in this new digital endeavor, and as always, we appreciate the input of our readers during this process.
1. AMA announces playbook to successfully adopt digital health [press release]. Boston, MA: American Medical Association; October 16, 2018. https://www.ama-assn.org/press-center/press-releases/ama-announces-playbook-successfully-adopt-digital-health. Accessed December 14, 2018.
2. Masud A, Shafi S, Rao BK. Mobile medical apps for patient education: a graded review of available dermatology apps. Cutis. 2018;101:141-144.
3. Shahrivar N, Grant-Kels JM, Payette MJ. Predatory journals: how to recognize and avoid the threat of involvement with these unethical “publishers.” J Am Acad Dermatol. 2016;75:658-659.
4. Elston DM. Presentation of data. J Am Acad Dermatol. 2019;80:55.
1. AMA announces playbook to successfully adopt digital health [press release]. Boston, MA: American Medical Association; October 16, 2018. https://www.ama-assn.org/press-center/press-releases/ama-announces-playbook-successfully-adopt-digital-health. Accessed December 14, 2018.
2. Masud A, Shafi S, Rao BK. Mobile medical apps for patient education: a graded review of available dermatology apps. Cutis. 2018;101:141-144.
3. Shahrivar N, Grant-Kels JM, Payette MJ. Predatory journals: how to recognize and avoid the threat of involvement with these unethical “publishers.” J Am Acad Dermatol. 2016;75:658-659.
4. Elston DM. Presentation of data. J Am Acad Dermatol. 2019;80:55.
Aspirin, omega-3 PUFA fail to reduce adenoma detection rate in high-risk patients
Taking aspirin or an omega-3 polyunsaturated fatty acid daily did not reduce the colorectal adenoma detection rate among high-risk patients in a randomized, placebo-controlled trial, though both drugs showed potential chemopreventive effects.
There was no evidence that aspirin, eicosapentaenoic acid (EPA), or the two agents combined had any effect on the adenoma detection rate, reported Mark A. Hull, PhD, of the Institute of Biomedical and Clinical Sciences at the University of Leeds (England), and his coinvestigators.
However, both agents decreased the mean number of adenomas per participants, and showed subtype- and location-specific reductions in adenomas that were consistent with previous studies, according to the investigators.
“Existing data on colorectal cancer risk reduction by aspirin suggest that the decrease in colorectal adenoma recurrence that we report for both agents is likely to translate into a clinically meaningful decrease in long-term colorectal cancer risk,” Dr. Hull and his coauthors said in the report, which appears in the Lancet.
Their randomized, double-blind, multicenter trial, known as the seAFOod Polyp Prevention trial, included participants aged 55-73 years with high-risk adenoma features at screening colonoscopy. A total of 709 participants were enrolled between November 2011 and June 2016.
Adenoma detection rate, the primary endpoint, was 62% overall, and similarly, 63% in the EPA group, 61% in the aspirin group, 61% in the EPA plus aspirin group, and 61% for placebo. There was no evidence that either drug had any effect on this endpoint, according to investigators, who reported risk ratios of 0.98 (95% confidence interval, 0.87-1.12) for EPA and 0.99 (95% CI, 0.87-1.12) for aspirin.
However, aspirin reduced the mean total number of adenomas per participant versus placebo (incidence rate ratio, 0.78; 95% CI, 0.68-0.90), as well as the number of adenomas in the right colon (IRR, 0.73; 95% CI, 0.61-0.88).
While EPA by contrast did not conclusively reduce the mean total number of adenomas per participant, it did reduce the number of adenomas in the left colon, with an IRR of 0.75 (95% CI, 0.60-0.94).
Both aspirin and EPA were generally well tolerated, according to Dr. Hall and his colleagues, though the number of gastrointestinal adverse events was higher in the EPA-alone group, at 146 events, versus 85, 86, and 68 events in the placebo, aspirin, and EPA plus aspirin groups, respectively.
To optimize use of aspirin and EPA for prevention of colorectal adenomas, the approach might need to be tailored to the individual patient, Dr. Hall and his coauthors wrote.
“A key objective of future work will be to apply precision medicine principles to establish which individuals might gain most from chemoprevention with one or both agents, based on baseline colorectal adenoma characteristics alone or together with other mucosal biomarkers,” they added.
Trial funding came from the U.K. Medical Research Council and the National Institute for Health Research. Medicine and placebo were provided without charge by SLA Pharma and Bayer. Dr. Hull provided disclosures related to SLA Pharma, Bayer, and Thetis Pharmaceuticals.
SOURCE: Hull MA et al. Lancet. 2018 Nov 19. doi: 10.1016/S0140-6736(18)31775-6.
The authors of this study suggest that daily aspirin or eicosapentaenoic acid (EPA) could lead to meaningful clinical benefit, as reflected by reductions in mean number of adenomas per participant, Evelien Dekker, MD, and Michal F. Kaminski, MD, PhD, noted in a commentary.
However, neither drug had a significant effect on the study’s primary endpoint and the effect of reducing the mean number of adenomas per participant is unknown in terms of reducing colorectal cancer risk, Dr. Dekker and Dr. Kaminski wrote. “Both measures are surrogates of colorectal cancer incidence and mortality, which should be considered ultimate endpoints for chemoprevention trials.”
Even if aspirin or EPA clearly reduced risk of colorectal cancer in high-risk patients, it’s “questionable” whether patients would be willing to take daily medication to prevent a cancer or precursor lesion at some point in the far future, they wrote, pointing to the low inclusion rate of the study, which amounted to three patients per center per year.
“Compliance to taking the medications daily in the long run might be relatively low,” Dr. Dekker and Dr. Kaminski wrote, noting a high rate of gastrointestinal adverse events in patients randomized to EPA. Moreover, analysis would need to be conducted to determine whether daily aspirin or EPA is more cost-effective than regular surveillance colonoscopy would need to be evaluated.
“The road to a paradigm shift to taking chemoprevention medications instead of, or alongside, surveillance colonoscopies is still long,” they concluded.
The commentary by Dr. Dekker and Dr. Kaminski appears in the Lancet. Dr. Dekker is with the department of gastroenterology and hepatology at Amsterdam University Medical Centres. Dr. Kaminski is with the department of gastroenterological oncology and department of cancer prevention at the Maria Sklodowska-Curie Institute–Oncology Center, Warsaw. The authors reported disclosures related to Olympus, FujiFilm, Tillots, AlfaSigma, and Norgine.
The authors of this study suggest that daily aspirin or eicosapentaenoic acid (EPA) could lead to meaningful clinical benefit, as reflected by reductions in mean number of adenomas per participant, Evelien Dekker, MD, and Michal F. Kaminski, MD, PhD, noted in a commentary.
However, neither drug had a significant effect on the study’s primary endpoint and the effect of reducing the mean number of adenomas per participant is unknown in terms of reducing colorectal cancer risk, Dr. Dekker and Dr. Kaminski wrote. “Both measures are surrogates of colorectal cancer incidence and mortality, which should be considered ultimate endpoints for chemoprevention trials.”
Even if aspirin or EPA clearly reduced risk of colorectal cancer in high-risk patients, it’s “questionable” whether patients would be willing to take daily medication to prevent a cancer or precursor lesion at some point in the far future, they wrote, pointing to the low inclusion rate of the study, which amounted to three patients per center per year.
“Compliance to taking the medications daily in the long run might be relatively low,” Dr. Dekker and Dr. Kaminski wrote, noting a high rate of gastrointestinal adverse events in patients randomized to EPA. Moreover, analysis would need to be conducted to determine whether daily aspirin or EPA is more cost-effective than regular surveillance colonoscopy would need to be evaluated.
“The road to a paradigm shift to taking chemoprevention medications instead of, or alongside, surveillance colonoscopies is still long,” they concluded.
The commentary by Dr. Dekker and Dr. Kaminski appears in the Lancet. Dr. Dekker is with the department of gastroenterology and hepatology at Amsterdam University Medical Centres. Dr. Kaminski is with the department of gastroenterological oncology and department of cancer prevention at the Maria Sklodowska-Curie Institute–Oncology Center, Warsaw. The authors reported disclosures related to Olympus, FujiFilm, Tillots, AlfaSigma, and Norgine.
The authors of this study suggest that daily aspirin or eicosapentaenoic acid (EPA) could lead to meaningful clinical benefit, as reflected by reductions in mean number of adenomas per participant, Evelien Dekker, MD, and Michal F. Kaminski, MD, PhD, noted in a commentary.
However, neither drug had a significant effect on the study’s primary endpoint and the effect of reducing the mean number of adenomas per participant is unknown in terms of reducing colorectal cancer risk, Dr. Dekker and Dr. Kaminski wrote. “Both measures are surrogates of colorectal cancer incidence and mortality, which should be considered ultimate endpoints for chemoprevention trials.”
Even if aspirin or EPA clearly reduced risk of colorectal cancer in high-risk patients, it’s “questionable” whether patients would be willing to take daily medication to prevent a cancer or precursor lesion at some point in the far future, they wrote, pointing to the low inclusion rate of the study, which amounted to three patients per center per year.
“Compliance to taking the medications daily in the long run might be relatively low,” Dr. Dekker and Dr. Kaminski wrote, noting a high rate of gastrointestinal adverse events in patients randomized to EPA. Moreover, analysis would need to be conducted to determine whether daily aspirin or EPA is more cost-effective than regular surveillance colonoscopy would need to be evaluated.
“The road to a paradigm shift to taking chemoprevention medications instead of, or alongside, surveillance colonoscopies is still long,” they concluded.
The commentary by Dr. Dekker and Dr. Kaminski appears in the Lancet. Dr. Dekker is with the department of gastroenterology and hepatology at Amsterdam University Medical Centres. Dr. Kaminski is with the department of gastroenterological oncology and department of cancer prevention at the Maria Sklodowska-Curie Institute–Oncology Center, Warsaw. The authors reported disclosures related to Olympus, FujiFilm, Tillots, AlfaSigma, and Norgine.
Taking aspirin or an omega-3 polyunsaturated fatty acid daily did not reduce the colorectal adenoma detection rate among high-risk patients in a randomized, placebo-controlled trial, though both drugs showed potential chemopreventive effects.
There was no evidence that aspirin, eicosapentaenoic acid (EPA), or the two agents combined had any effect on the adenoma detection rate, reported Mark A. Hull, PhD, of the Institute of Biomedical and Clinical Sciences at the University of Leeds (England), and his coinvestigators.
However, both agents decreased the mean number of adenomas per participants, and showed subtype- and location-specific reductions in adenomas that were consistent with previous studies, according to the investigators.
“Existing data on colorectal cancer risk reduction by aspirin suggest that the decrease in colorectal adenoma recurrence that we report for both agents is likely to translate into a clinically meaningful decrease in long-term colorectal cancer risk,” Dr. Hull and his coauthors said in the report, which appears in the Lancet.
Their randomized, double-blind, multicenter trial, known as the seAFOod Polyp Prevention trial, included participants aged 55-73 years with high-risk adenoma features at screening colonoscopy. A total of 709 participants were enrolled between November 2011 and June 2016.
Adenoma detection rate, the primary endpoint, was 62% overall, and similarly, 63% in the EPA group, 61% in the aspirin group, 61% in the EPA plus aspirin group, and 61% for placebo. There was no evidence that either drug had any effect on this endpoint, according to investigators, who reported risk ratios of 0.98 (95% confidence interval, 0.87-1.12) for EPA and 0.99 (95% CI, 0.87-1.12) for aspirin.
However, aspirin reduced the mean total number of adenomas per participant versus placebo (incidence rate ratio, 0.78; 95% CI, 0.68-0.90), as well as the number of adenomas in the right colon (IRR, 0.73; 95% CI, 0.61-0.88).
While EPA by contrast did not conclusively reduce the mean total number of adenomas per participant, it did reduce the number of adenomas in the left colon, with an IRR of 0.75 (95% CI, 0.60-0.94).
Both aspirin and EPA were generally well tolerated, according to Dr. Hall and his colleagues, though the number of gastrointestinal adverse events was higher in the EPA-alone group, at 146 events, versus 85, 86, and 68 events in the placebo, aspirin, and EPA plus aspirin groups, respectively.
To optimize use of aspirin and EPA for prevention of colorectal adenomas, the approach might need to be tailored to the individual patient, Dr. Hall and his coauthors wrote.
“A key objective of future work will be to apply precision medicine principles to establish which individuals might gain most from chemoprevention with one or both agents, based on baseline colorectal adenoma characteristics alone or together with other mucosal biomarkers,” they added.
Trial funding came from the U.K. Medical Research Council and the National Institute for Health Research. Medicine and placebo were provided without charge by SLA Pharma and Bayer. Dr. Hull provided disclosures related to SLA Pharma, Bayer, and Thetis Pharmaceuticals.
SOURCE: Hull MA et al. Lancet. 2018 Nov 19. doi: 10.1016/S0140-6736(18)31775-6.
Taking aspirin or an omega-3 polyunsaturated fatty acid daily did not reduce the colorectal adenoma detection rate among high-risk patients in a randomized, placebo-controlled trial, though both drugs showed potential chemopreventive effects.
There was no evidence that aspirin, eicosapentaenoic acid (EPA), or the two agents combined had any effect on the adenoma detection rate, reported Mark A. Hull, PhD, of the Institute of Biomedical and Clinical Sciences at the University of Leeds (England), and his coinvestigators.
However, both agents decreased the mean number of adenomas per participants, and showed subtype- and location-specific reductions in adenomas that were consistent with previous studies, according to the investigators.
“Existing data on colorectal cancer risk reduction by aspirin suggest that the decrease in colorectal adenoma recurrence that we report for both agents is likely to translate into a clinically meaningful decrease in long-term colorectal cancer risk,” Dr. Hull and his coauthors said in the report, which appears in the Lancet.
Their randomized, double-blind, multicenter trial, known as the seAFOod Polyp Prevention trial, included participants aged 55-73 years with high-risk adenoma features at screening colonoscopy. A total of 709 participants were enrolled between November 2011 and June 2016.
Adenoma detection rate, the primary endpoint, was 62% overall, and similarly, 63% in the EPA group, 61% in the aspirin group, 61% in the EPA plus aspirin group, and 61% for placebo. There was no evidence that either drug had any effect on this endpoint, according to investigators, who reported risk ratios of 0.98 (95% confidence interval, 0.87-1.12) for EPA and 0.99 (95% CI, 0.87-1.12) for aspirin.
However, aspirin reduced the mean total number of adenomas per participant versus placebo (incidence rate ratio, 0.78; 95% CI, 0.68-0.90), as well as the number of adenomas in the right colon (IRR, 0.73; 95% CI, 0.61-0.88).
While EPA by contrast did not conclusively reduce the mean total number of adenomas per participant, it did reduce the number of adenomas in the left colon, with an IRR of 0.75 (95% CI, 0.60-0.94).
Both aspirin and EPA were generally well tolerated, according to Dr. Hall and his colleagues, though the number of gastrointestinal adverse events was higher in the EPA-alone group, at 146 events, versus 85, 86, and 68 events in the placebo, aspirin, and EPA plus aspirin groups, respectively.
To optimize use of aspirin and EPA for prevention of colorectal adenomas, the approach might need to be tailored to the individual patient, Dr. Hall and his coauthors wrote.
“A key objective of future work will be to apply precision medicine principles to establish which individuals might gain most from chemoprevention with one or both agents, based on baseline colorectal adenoma characteristics alone or together with other mucosal biomarkers,” they added.
Trial funding came from the U.K. Medical Research Council and the National Institute for Health Research. Medicine and placebo were provided without charge by SLA Pharma and Bayer. Dr. Hull provided disclosures related to SLA Pharma, Bayer, and Thetis Pharmaceuticals.
SOURCE: Hull MA et al. Lancet. 2018 Nov 19. doi: 10.1016/S0140-6736(18)31775-6.
FROM THE LANCET
Key clinical point: Daily aspirin or eicosapentaenoic acid did not reduce the colorectal adenoma detection rate among high-risk patients, though both drugs had other apparent chemopreventive effects.
Major finding: Aspirin reduced the mean total number of adenomas per participant versus placebo (incidence rate ratio, 0.78; 95% confidence interval, 0.68-0.90), as well as the number of adenomas in the right colon (IRR, 0.73; 95% CI, 0.61-0.88). Eicosapentaenoic acid reduced the number of adenomas in the left colon (IRR, 0.75; 95% CI, 0.60-0.94).
Study details: A randomized, double-blind, multicenter trial including 709 participants aged 55-73 years with high-risk adenoma features at screening colonoscopy.
Disclosures: Trial funding came from the U.K. Medical Research Council and the National Institute for Health Research. Medicine and placebo were provided without charge by SLA Pharma and Bayer. Dr. Hull provided disclosures related to SLA Pharma, Bayer, and Thetis Pharmaceuticals.
Source: Hull MA et al. Lancet. 2018 Nov 19. doi: 10.1016/S0140-6736(18)31775-6.
Reflections on women in surgery
As I reflect upon the past year, 2018 has certainly made a mark for addressing burnout among medical professionals, enforcing wellness, and targeting implicit and explicit gender bias in medicine and surgery.
Looking back, I entered surgery with a dream to change the culture of surgery. I knew I didn’t fit the traditional mold of an aggressive or arrogant surgeon. But I thought that my empathetic, open, and compassionate ways may spark a change in paradigm for that traditional surgical ideology. However, what I encountered as I made my way on this long, ever-winding journey was a system, culture, and tradition that beats you down, and what I thought were my strengths were quickly turned into weaknesses. As I grew and matured, this loss of identity in a culture of depersonalization surrounded by gender bias, for me, was a perfect recipe leading straight to burnout. However, this was an impetus for change, to be that voice and spark for a cultural transformation of surgery and for the women who work in the specialty.
More women are entering medical and surgical specialties. However, despite the advances made there are still clear gender-based disparities influencing overall wellness and work satisfaction. For instance, a study by Meyerson et al. demonstrated that female residents receive less operating room autonomy than male ones. I see it daily within my own curriculum and in observing other female residents in other surgical specialties. Furthermore, female residents are less often introduced by their physician titles, compared with their male counterparts, are often confused as nonphysicians, and are perceived as being less competent. This influences, to no small extent, overall confidence. It’s discouraging and disheartening to have worked so hard and yet still be treated in a sexist paradigm. And to top it all off, female physicians face a motherhood penalty.
In a recent study by Magudia et al., out of 12 top medical institutions that provided maternity leave, only 8 did so for residents with a grant total of 6.6 weeks on average. Furthermore, women with children or women who plan to have children have constrained career opportunities and are less likely to get full professorship or leadership positions. Anecdotally, a surgeon in passing semijokingly told me that if I were to take a specific academic vascular position, I may have to sign an agreement not to get pregnant ... probably not the job for me.
It’s appalling that, in this day and age, these explicit beliefs still exist, but what scares me more are all the implicit unconscious biases that affect all women not only in surgery but in medicine as well.
Looking back, 2018 is a year of beginning difficult conversations about physician and surgeon wellness, burnout, and gender bias. What’s obvious is that there is a hell of a lot of work to do. But change is slowly starting. We are now recognizing what the issues are, and the next step is to take action. It’s difficult to steer big ships, but there is an active community investing in strategies to improve the cultural scope of surgery and supporting and valuing women and what they have to offer.
References
Magudia K et al. JAMA. 2018;320(22):2372-4.
Meyerson SL et al. J Surg Educ. 2017;74(6):e111-18.
Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.
As I reflect upon the past year, 2018 has certainly made a mark for addressing burnout among medical professionals, enforcing wellness, and targeting implicit and explicit gender bias in medicine and surgery.
Looking back, I entered surgery with a dream to change the culture of surgery. I knew I didn’t fit the traditional mold of an aggressive or arrogant surgeon. But I thought that my empathetic, open, and compassionate ways may spark a change in paradigm for that traditional surgical ideology. However, what I encountered as I made my way on this long, ever-winding journey was a system, culture, and tradition that beats you down, and what I thought were my strengths were quickly turned into weaknesses. As I grew and matured, this loss of identity in a culture of depersonalization surrounded by gender bias, for me, was a perfect recipe leading straight to burnout. However, this was an impetus for change, to be that voice and spark for a cultural transformation of surgery and for the women who work in the specialty.
More women are entering medical and surgical specialties. However, despite the advances made there are still clear gender-based disparities influencing overall wellness and work satisfaction. For instance, a study by Meyerson et al. demonstrated that female residents receive less operating room autonomy than male ones. I see it daily within my own curriculum and in observing other female residents in other surgical specialties. Furthermore, female residents are less often introduced by their physician titles, compared with their male counterparts, are often confused as nonphysicians, and are perceived as being less competent. This influences, to no small extent, overall confidence. It’s discouraging and disheartening to have worked so hard and yet still be treated in a sexist paradigm. And to top it all off, female physicians face a motherhood penalty.
In a recent study by Magudia et al., out of 12 top medical institutions that provided maternity leave, only 8 did so for residents with a grant total of 6.6 weeks on average. Furthermore, women with children or women who plan to have children have constrained career opportunities and are less likely to get full professorship or leadership positions. Anecdotally, a surgeon in passing semijokingly told me that if I were to take a specific academic vascular position, I may have to sign an agreement not to get pregnant ... probably not the job for me.
It’s appalling that, in this day and age, these explicit beliefs still exist, but what scares me more are all the implicit unconscious biases that affect all women not only in surgery but in medicine as well.
Looking back, 2018 is a year of beginning difficult conversations about physician and surgeon wellness, burnout, and gender bias. What’s obvious is that there is a hell of a lot of work to do. But change is slowly starting. We are now recognizing what the issues are, and the next step is to take action. It’s difficult to steer big ships, but there is an active community investing in strategies to improve the cultural scope of surgery and supporting and valuing women and what they have to offer.
References
Magudia K et al. JAMA. 2018;320(22):2372-4.
Meyerson SL et al. J Surg Educ. 2017;74(6):e111-18.
Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.
As I reflect upon the past year, 2018 has certainly made a mark for addressing burnout among medical professionals, enforcing wellness, and targeting implicit and explicit gender bias in medicine and surgery.
Looking back, I entered surgery with a dream to change the culture of surgery. I knew I didn’t fit the traditional mold of an aggressive or arrogant surgeon. But I thought that my empathetic, open, and compassionate ways may spark a change in paradigm for that traditional surgical ideology. However, what I encountered as I made my way on this long, ever-winding journey was a system, culture, and tradition that beats you down, and what I thought were my strengths were quickly turned into weaknesses. As I grew and matured, this loss of identity in a culture of depersonalization surrounded by gender bias, for me, was a perfect recipe leading straight to burnout. However, this was an impetus for change, to be that voice and spark for a cultural transformation of surgery and for the women who work in the specialty.
More women are entering medical and surgical specialties. However, despite the advances made there are still clear gender-based disparities influencing overall wellness and work satisfaction. For instance, a study by Meyerson et al. demonstrated that female residents receive less operating room autonomy than male ones. I see it daily within my own curriculum and in observing other female residents in other surgical specialties. Furthermore, female residents are less often introduced by their physician titles, compared with their male counterparts, are often confused as nonphysicians, and are perceived as being less competent. This influences, to no small extent, overall confidence. It’s discouraging and disheartening to have worked so hard and yet still be treated in a sexist paradigm. And to top it all off, female physicians face a motherhood penalty.
In a recent study by Magudia et al., out of 12 top medical institutions that provided maternity leave, only 8 did so for residents with a grant total of 6.6 weeks on average. Furthermore, women with children or women who plan to have children have constrained career opportunities and are less likely to get full professorship or leadership positions. Anecdotally, a surgeon in passing semijokingly told me that if I were to take a specific academic vascular position, I may have to sign an agreement not to get pregnant ... probably not the job for me.
It’s appalling that, in this day and age, these explicit beliefs still exist, but what scares me more are all the implicit unconscious biases that affect all women not only in surgery but in medicine as well.
Looking back, 2018 is a year of beginning difficult conversations about physician and surgeon wellness, burnout, and gender bias. What’s obvious is that there is a hell of a lot of work to do. But change is slowly starting. We are now recognizing what the issues are, and the next step is to take action. It’s difficult to steer big ships, but there is an active community investing in strategies to improve the cultural scope of surgery and supporting and valuing women and what they have to offer.
References
Magudia K et al. JAMA. 2018;320(22):2372-4.
Meyerson SL et al. J Surg Educ. 2017;74(6):e111-18.
Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.
Rheumatologists see little value in MOC
Among the 515 rheumatologists responding to the survey, 74.8% “did not think there is significant additional value in MOC, beyond what is already achieved from Continuing Medical Education,” Amr Sawalha, MD, and Patrick Coit, both of the University of Michigan, Ann Arbor, wrote in Arthritis Care & Research. The survey was sent to 3,107 rheumatologists in the United States.
The survey also found that 63.5% of respondents “did not believe board recertification and MOC are valuable in terms of improving patients’ care,” although 65.6% did perceive that staying current with new knowledge was a positive effect of participating in the MOC process, Dr. Sawalha and Mr. Coit wrote.
On the flip side, requiring MOC was perceived to be a contributor to physician burnout by 77.7% of respondents and to early retirements by 67.4% of respondents.
“If participation in MOC indeed does not have a significant value on improving patient care in rheumatology, as indicated by the perception of practicing rheumatologists, and if it remains a requirement to practice for at least over a third of rheumatologists in the United States, then an argument can be made that elimination of MOC might be a way to sustain and improve the rheumatology workforce without compromising quality,” Dr. Sawalha and Mr. Coit wrote. “To our knowledge, there have not been any studies to show that rheumatologists participating in MOC activities provide better care.”
Another aspect that the survey revealed is the rheumatologists’ perception of certifying organizations.
“A striking finding from our study is the indication that there seems to be a lack of trust in [the] board-certifying organization and their motives among practicing rheumatologists in the United States,” the authors wrote. “When asked to rank in order what is thought to be the reason for creating MOC programs, financial well-being of board-certifying organizations was the highest ranked answer. Improving patient care, which is the motive claimed by board-certifying organizations, was the least likely ranked answer.”
Indeed, about 60% of respondents believe alternative organizations, such as the American College of Rheumatology, should be administering or overseeing the board certification process for rheumatologists.
“Regardless of what the motive might be, these results suggest that practicing physicians, and in this case rheumatologists, do not trust board-certifying organizations,” Dr. Sawalha and Mr. Coit wrote. “Therefore, we suggest that these organizations revisit their relationship with practicing physicians and facilitate true collaboration with physicians to determine the best way to assess and ensure physician competence and knowledge.”
The authors declared that they have no financial conflicts of interest.
SOURCE: Sawalha A and Coit P. Arthritis Care Res. 2018 Dec 20. doi: 10.1002/acr.23823
The fact that survey respondents say with almost identical affirmation that MOC helps them stay current on medical knowledge and is redundant with CME suggests that rheumatologists favor continuing to learn about their profession throughout the life of their career but want that learning in an environment they have more control over.
Given the expansion of technology, physicians have access at their fingertips to information, which questions the need for exams that require memorization of details.
New ways are needed to help physicians maintain certification in ways that take advantage of current information technology in a manner that can be more customizable to their practice rather than a one-size-fits-all examination.
David Karp, MD, PhD , is chief of the division of rheumatic diseases at the University of Texas Southwestern Medical Center, Dallas. His comments are paraphrased from an editorial accompanying the survey report (Arthritis Care Res. 2018 Dec 20. doi: 10.1002/acr.23822 ). He had no relevant disclosures.
The fact that survey respondents say with almost identical affirmation that MOC helps them stay current on medical knowledge and is redundant with CME suggests that rheumatologists favor continuing to learn about their profession throughout the life of their career but want that learning in an environment they have more control over.
Given the expansion of technology, physicians have access at their fingertips to information, which questions the need for exams that require memorization of details.
New ways are needed to help physicians maintain certification in ways that take advantage of current information technology in a manner that can be more customizable to their practice rather than a one-size-fits-all examination.
David Karp, MD, PhD , is chief of the division of rheumatic diseases at the University of Texas Southwestern Medical Center, Dallas. His comments are paraphrased from an editorial accompanying the survey report (Arthritis Care Res. 2018 Dec 20. doi: 10.1002/acr.23822 ). He had no relevant disclosures.
The fact that survey respondents say with almost identical affirmation that MOC helps them stay current on medical knowledge and is redundant with CME suggests that rheumatologists favor continuing to learn about their profession throughout the life of their career but want that learning in an environment they have more control over.
Given the expansion of technology, physicians have access at their fingertips to information, which questions the need for exams that require memorization of details.
New ways are needed to help physicians maintain certification in ways that take advantage of current information technology in a manner that can be more customizable to their practice rather than a one-size-fits-all examination.
David Karp, MD, PhD , is chief of the division of rheumatic diseases at the University of Texas Southwestern Medical Center, Dallas. His comments are paraphrased from an editorial accompanying the survey report (Arthritis Care Res. 2018 Dec 20. doi: 10.1002/acr.23822 ). He had no relevant disclosures.
Among the 515 rheumatologists responding to the survey, 74.8% “did not think there is significant additional value in MOC, beyond what is already achieved from Continuing Medical Education,” Amr Sawalha, MD, and Patrick Coit, both of the University of Michigan, Ann Arbor, wrote in Arthritis Care & Research. The survey was sent to 3,107 rheumatologists in the United States.
The survey also found that 63.5% of respondents “did not believe board recertification and MOC are valuable in terms of improving patients’ care,” although 65.6% did perceive that staying current with new knowledge was a positive effect of participating in the MOC process, Dr. Sawalha and Mr. Coit wrote.
On the flip side, requiring MOC was perceived to be a contributor to physician burnout by 77.7% of respondents and to early retirements by 67.4% of respondents.
“If participation in MOC indeed does not have a significant value on improving patient care in rheumatology, as indicated by the perception of practicing rheumatologists, and if it remains a requirement to practice for at least over a third of rheumatologists in the United States, then an argument can be made that elimination of MOC might be a way to sustain and improve the rheumatology workforce without compromising quality,” Dr. Sawalha and Mr. Coit wrote. “To our knowledge, there have not been any studies to show that rheumatologists participating in MOC activities provide better care.”
Another aspect that the survey revealed is the rheumatologists’ perception of certifying organizations.
“A striking finding from our study is the indication that there seems to be a lack of trust in [the] board-certifying organization and their motives among practicing rheumatologists in the United States,” the authors wrote. “When asked to rank in order what is thought to be the reason for creating MOC programs, financial well-being of board-certifying organizations was the highest ranked answer. Improving patient care, which is the motive claimed by board-certifying organizations, was the least likely ranked answer.”
Indeed, about 60% of respondents believe alternative organizations, such as the American College of Rheumatology, should be administering or overseeing the board certification process for rheumatologists.
“Regardless of what the motive might be, these results suggest that practicing physicians, and in this case rheumatologists, do not trust board-certifying organizations,” Dr. Sawalha and Mr. Coit wrote. “Therefore, we suggest that these organizations revisit their relationship with practicing physicians and facilitate true collaboration with physicians to determine the best way to assess and ensure physician competence and knowledge.”
The authors declared that they have no financial conflicts of interest.
SOURCE: Sawalha A and Coit P. Arthritis Care Res. 2018 Dec 20. doi: 10.1002/acr.23823
Among the 515 rheumatologists responding to the survey, 74.8% “did not think there is significant additional value in MOC, beyond what is already achieved from Continuing Medical Education,” Amr Sawalha, MD, and Patrick Coit, both of the University of Michigan, Ann Arbor, wrote in Arthritis Care & Research. The survey was sent to 3,107 rheumatologists in the United States.
The survey also found that 63.5% of respondents “did not believe board recertification and MOC are valuable in terms of improving patients’ care,” although 65.6% did perceive that staying current with new knowledge was a positive effect of participating in the MOC process, Dr. Sawalha and Mr. Coit wrote.
On the flip side, requiring MOC was perceived to be a contributor to physician burnout by 77.7% of respondents and to early retirements by 67.4% of respondents.
“If participation in MOC indeed does not have a significant value on improving patient care in rheumatology, as indicated by the perception of practicing rheumatologists, and if it remains a requirement to practice for at least over a third of rheumatologists in the United States, then an argument can be made that elimination of MOC might be a way to sustain and improve the rheumatology workforce without compromising quality,” Dr. Sawalha and Mr. Coit wrote. “To our knowledge, there have not been any studies to show that rheumatologists participating in MOC activities provide better care.”
Another aspect that the survey revealed is the rheumatologists’ perception of certifying organizations.
“A striking finding from our study is the indication that there seems to be a lack of trust in [the] board-certifying organization and their motives among practicing rheumatologists in the United States,” the authors wrote. “When asked to rank in order what is thought to be the reason for creating MOC programs, financial well-being of board-certifying organizations was the highest ranked answer. Improving patient care, which is the motive claimed by board-certifying organizations, was the least likely ranked answer.”
Indeed, about 60% of respondents believe alternative organizations, such as the American College of Rheumatology, should be administering or overseeing the board certification process for rheumatologists.
“Regardless of what the motive might be, these results suggest that practicing physicians, and in this case rheumatologists, do not trust board-certifying organizations,” Dr. Sawalha and Mr. Coit wrote. “Therefore, we suggest that these organizations revisit their relationship with practicing physicians and facilitate true collaboration with physicians to determine the best way to assess and ensure physician competence and knowledge.”
The authors declared that they have no financial conflicts of interest.
SOURCE: Sawalha A and Coit P. Arthritis Care Res. 2018 Dec 20. doi: 10.1002/acr.23823
FROM ARTHRITIS CARE & RESEARCH
Key clinical point: Nearly 75% of respondents saw little value in MOC beyond what’s achieved with Continuing Medical Education.
Major finding: Nearly two-thirds of respondents did not believe MOC is valuable in improving patients’ care.
Study details: A survey was sent to 3,107 rheumatologists in the United States to ascertain the perceived value and impact of MOC on rheumatology practice and patient care. There were 515 responses received.
Disclosures: The study authors declared that they have no financial conflicts of interest.
Source: Sawalha A and Coit P. Arthritis Care Res. 2018 Dec 20. doi: 10.1002/acr.23823
Martin Buber, deep learning, and the still soft voice beyond the screen
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).