Heidi Splete

Linked-color imaging (LCI) significantly increases the detection of adenomas in screening colonoscopies compared to white-light imaging (WLI) and blue-laser imaging (BLI)–bright, according to data from 205 adults who underwent screening colonoscopies.

LCI is a relatively new image-enhancement method designed to better identify adenomatous lesions by increasing the contrast of the mucosal surface, wrote Carlos E.O. dos Santos, MD, of Pontifícia Universidade Católica do Rio Grande do Sul in Porto Alegre, Brazil, and colleagues. Their report is in the Journal of Clinical Gastroenterology. With LCI, the lesions are more vascularized, and thus become reddish due to color contrast of hemoglobin present in capillary vessels, whereas the surrounding mucosa becomes whitish. Until this new study, the potential of LCI to detect adenomas compared with other imaging had not been evaluated.

The researchers randomized 205 patients with a total of 296 colorectal lesions to WLI, BLI-bright, or LCI; 70 patients were examined by WLI, 66 by BLI-bright, and 69 by LCI. The average age of the patients was 59 years, and 52% were women. The primary outcome measures were adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time.

A total of 251 adenomas were detected, with an overall ADR of 62%. The total number of adenomas detected by each method were 112 by LCI, 71 by WLI, and 68 by BLI-bright.

The ADR was significantly higher for patients in the LCI group compared with those in the WLI group (71% vs. 52.9%, P = .04). ADR for LCI was greater than the ADR for BLI-bright, but the difference was not significant (71% vs. 62.1%, P = .28). No significant differences in ADR were noted between the WLI and BLI-bright groups.

The mean number of adenomas identified per patient was 1.17 overall, but significantly higher in the LCI group compared to the WLI and BLI-bright groups (1.62, 1.01, and 1.03, respectively, P = .02). Mean withdrawal times were not significantly different among the three groups and ranged from approximately 10 to 11 minutes. An analysis of secondary outcomes showed no differences among the groups in terms of size and morphology of the adenomas, or in the detection of sessile serrated adenomas or polyps.

The researchers noted that the study findings were limited by several factors including the use of data from a single center with a high level of experience in image-enhanced endoscopy and by the relatively small sample size.

Nevertheless, concluded the researchers, “It is evident that better visibility of the mucosa is a key factor for the detection of neoplastic lesions,” and the results support the potential of LCI given the demonstrated superiority of LCI over WLI for colorectal adenoma detection and the mean number of adenomas detected per patient.

The researchers said that further single and multicenter randomized studies are needed to validate the results and to confirm whether one image-enhancement system is superior to the other for increasing the ADR.
 

Door is open for better detection tools

In an interview, Atsushi Sakuraba, MD, of the University of Chicago, who was not involved with the study, said that colonoscopy is considered the best method for colorectal cancer screening and prevention, but is associated with a certain risk of missing adenomas, so new methods and technologies to improve detection rate are needed. “Linked-color imaging provides an increased contrast of the mucosal surface and enhances the findings of adenomatous lesions in comparison to white-light endoscopy and has been shown to be effective in detecting adenomas, so the findings of the present study are not surprising,” said Dr. Sakuraba.

LCI provides clearer and brighter images by enhancing the differences in color contrast, and therefore does not cause the impaired visibility that can occur with narrow band imaging or BLI images, Dr. Sakuraba said. However, he noted, not all endoscopy centers carry the scopes equipped with LCI, which is a barrier to widespread use.

Dr. Sakuraba said that multicenter studies need to be undertaken to confirm the generalizability of the results of the present study.

“There is now convincing evidence that increasing adenoma detection rate is associated with fewer missed cancers and lower mortality from colorectal cancer,” said Ziad F. Gellad, MD, of Duke University, Durham, N.C., who was also not involved with the study. “As such, utilizing tools that enhance ADR may improve our ability to prevent colorectal cancer. ... Understanding the relative benefits and drawbacks of available tools and technologies in the market can help practicing gastroenterologists decide where to invest their time and resources to improve care.”

Dr. Gellad said he was not surprised by the enhanced detection using LCI, as the study is not the first to evaluate this technology. “However, I was surprised by how high the ADR was in the screening population (62%),” said Dr. Gellad, observing that this exceeds benchmarks set by the society. “We don’t have a full understanding of the demographic characteristics of this screening population. ... Nonetheless, I think this paper adds to accumulating data that current benchmarks may be too low.”

Dr. Gellad said he didn’t think the findings of the study are strong enough to change practice, but the results are a “valuable contribution to the literature and will empower future larger studies as well as meta-analyses.” He called for larger studies in nonspecialized centers to relate the findings from this small study to general practice.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Sakuraba disclosed collaborative research relationships with Fuji, the manufacturer of the imaging equipment used in the study. Dr. Gellad had no financial conflicts to disclose but serves on the editorial board of GI & Hepatology News.

Linked-color imaging (LCI) significantly increases the detection of adenomas in screening colonoscopies compared to white-light imaging (WLI) and blue-laser imaging (BLI)–bright, according to data from 205 adults who underwent screening colonoscopies.

LCI is a relatively new image-enhancement method designed to better identify adenomatous lesions by increasing the contrast of the mucosal surface, wrote Carlos E.O. dos Santos, MD, of Pontifícia Universidade Católica do Rio Grande do Sul in Porto Alegre, Brazil, and colleagues. Their report is in the Journal of Clinical Gastroenterology. With LCI, the lesions are more vascularized, and thus become reddish due to color contrast of hemoglobin present in capillary vessels, whereas the surrounding mucosa becomes whitish. Until this new study, the potential of LCI to detect adenomas compared with other imaging had not been evaluated.

The researchers randomized 205 patients with a total of 296 colorectal lesions to WLI, BLI-bright, or LCI; 70 patients were examined by WLI, 66 by BLI-bright, and 69 by LCI. The average age of the patients was 59 years, and 52% were women. The primary outcome measures were adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time.

A total of 251 adenomas were detected, with an overall ADR of 62%. The total number of adenomas detected by each method were 112 by LCI, 71 by WLI, and 68 by BLI-bright.

The ADR was significantly higher for patients in the LCI group compared with those in the WLI group (71% vs. 52.9%, P = .04). ADR for LCI was greater than the ADR for BLI-bright, but the difference was not significant (71% vs. 62.1%, P = .28). No significant differences in ADR were noted between the WLI and BLI-bright groups.

The mean number of adenomas identified per patient was 1.17 overall, but significantly higher in the LCI group compared to the WLI and BLI-bright groups (1.62, 1.01, and 1.03, respectively, P = .02). Mean withdrawal times were not significantly different among the three groups and ranged from approximately 10 to 11 minutes. An analysis of secondary outcomes showed no differences among the groups in terms of size and morphology of the adenomas, or in the detection of sessile serrated adenomas or polyps.

The researchers noted that the study findings were limited by several factors including the use of data from a single center with a high level of experience in image-enhanced endoscopy and by the relatively small sample size.

Nevertheless, concluded the researchers, “It is evident that better visibility of the mucosa is a key factor for the detection of neoplastic lesions,” and the results support the potential of LCI given the demonstrated superiority of LCI over WLI for colorectal adenoma detection and the mean number of adenomas detected per patient.

The researchers said that further single and multicenter randomized studies are needed to validate the results and to confirm whether one image-enhancement system is superior to the other for increasing the ADR.
 

Door is open for better detection tools

In an interview, Atsushi Sakuraba, MD, of the University of Chicago, who was not involved with the study, said that colonoscopy is considered the best method for colorectal cancer screening and prevention, but is associated with a certain risk of missing adenomas, so new methods and technologies to improve detection rate are needed. “Linked-color imaging provides an increased contrast of the mucosal surface and enhances the findings of adenomatous lesions in comparison to white-light endoscopy and has been shown to be effective in detecting adenomas, so the findings of the present study are not surprising,” said Dr. Sakuraba.

LCI provides clearer and brighter images by enhancing the differences in color contrast, and therefore does not cause the impaired visibility that can occur with narrow band imaging or BLI images, Dr. Sakuraba said. However, he noted, not all endoscopy centers carry the scopes equipped with LCI, which is a barrier to widespread use.

Dr. Sakuraba said that multicenter studies need to be undertaken to confirm the generalizability of the results of the present study.

“There is now convincing evidence that increasing adenoma detection rate is associated with fewer missed cancers and lower mortality from colorectal cancer,” said Ziad F. Gellad, MD, of Duke University, Durham, N.C., who was also not involved with the study. “As such, utilizing tools that enhance ADR may improve our ability to prevent colorectal cancer. ... Understanding the relative benefits and drawbacks of available tools and technologies in the market can help practicing gastroenterologists decide where to invest their time and resources to improve care.”

Dr. Gellad said he was not surprised by the enhanced detection using LCI, as the study is not the first to evaluate this technology. “However, I was surprised by how high the ADR was in the screening population (62%),” said Dr. Gellad, observing that this exceeds benchmarks set by the society. “We don’t have a full understanding of the demographic characteristics of this screening population. ... Nonetheless, I think this paper adds to accumulating data that current benchmarks may be too low.”

Dr. Gellad said he didn’t think the findings of the study are strong enough to change practice, but the results are a “valuable contribution to the literature and will empower future larger studies as well as meta-analyses.” He called for larger studies in nonspecialized centers to relate the findings from this small study to general practice.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Sakuraba disclosed collaborative research relationships with Fuji, the manufacturer of the imaging equipment used in the study. Dr. Gellad had no financial conflicts to disclose but serves on the editorial board of GI & Hepatology News.

Linked-color imaging (LCI) significantly increases the detection of adenomas in screening colonoscopies compared to white-light imaging (WLI) and blue-laser imaging (BLI)–bright, according to data from 205 adults who underwent screening colonoscopies.

LCI is a relatively new image-enhancement method designed to better identify adenomatous lesions by increasing the contrast of the mucosal surface, wrote Carlos E.O. dos Santos, MD, of Pontifícia Universidade Católica do Rio Grande do Sul in Porto Alegre, Brazil, and colleagues. Their report is in the Journal of Clinical Gastroenterology. With LCI, the lesions are more vascularized, and thus become reddish due to color contrast of hemoglobin present in capillary vessels, whereas the surrounding mucosa becomes whitish. Until this new study, the potential of LCI to detect adenomas compared with other imaging had not been evaluated.

The researchers randomized 205 patients with a total of 296 colorectal lesions to WLI, BLI-bright, or LCI; 70 patients were examined by WLI, 66 by BLI-bright, and 69 by LCI. The average age of the patients was 59 years, and 52% were women. The primary outcome measures were adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time.

A total of 251 adenomas were detected, with an overall ADR of 62%. The total number of adenomas detected by each method were 112 by LCI, 71 by WLI, and 68 by BLI-bright.

The ADR was significantly higher for patients in the LCI group compared with those in the WLI group (71% vs. 52.9%, P = .04). ADR for LCI was greater than the ADR for BLI-bright, but the difference was not significant (71% vs. 62.1%, P = .28). No significant differences in ADR were noted between the WLI and BLI-bright groups.

The mean number of adenomas identified per patient was 1.17 overall, but significantly higher in the LCI group compared to the WLI and BLI-bright groups (1.62, 1.01, and 1.03, respectively, P = .02). Mean withdrawal times were not significantly different among the three groups and ranged from approximately 10 to 11 minutes. An analysis of secondary outcomes showed no differences among the groups in terms of size and morphology of the adenomas, or in the detection of sessile serrated adenomas or polyps.

The researchers noted that the study findings were limited by several factors including the use of data from a single center with a high level of experience in image-enhanced endoscopy and by the relatively small sample size.

Nevertheless, concluded the researchers, “It is evident that better visibility of the mucosa is a key factor for the detection of neoplastic lesions,” and the results support the potential of LCI given the demonstrated superiority of LCI over WLI for colorectal adenoma detection and the mean number of adenomas detected per patient.

The researchers said that further single and multicenter randomized studies are needed to validate the results and to confirm whether one image-enhancement system is superior to the other for increasing the ADR.
 

Door is open for better detection tools

In an interview, Atsushi Sakuraba, MD, of the University of Chicago, who was not involved with the study, said that colonoscopy is considered the best method for colorectal cancer screening and prevention, but is associated with a certain risk of missing adenomas, so new methods and technologies to improve detection rate are needed. “Linked-color imaging provides an increased contrast of the mucosal surface and enhances the findings of adenomatous lesions in comparison to white-light endoscopy and has been shown to be effective in detecting adenomas, so the findings of the present study are not surprising,” said Dr. Sakuraba.

LCI provides clearer and brighter images by enhancing the differences in color contrast, and therefore does not cause the impaired visibility that can occur with narrow band imaging or BLI images, Dr. Sakuraba said. However, he noted, not all endoscopy centers carry the scopes equipped with LCI, which is a barrier to widespread use.

Dr. Sakuraba said that multicenter studies need to be undertaken to confirm the generalizability of the results of the present study.

“There is now convincing evidence that increasing adenoma detection rate is associated with fewer missed cancers and lower mortality from colorectal cancer,” said Ziad F. Gellad, MD, of Duke University, Durham, N.C., who was also not involved with the study. “As such, utilizing tools that enhance ADR may improve our ability to prevent colorectal cancer. ... Understanding the relative benefits and drawbacks of available tools and technologies in the market can help practicing gastroenterologists decide where to invest their time and resources to improve care.”

Dr. Gellad said he was not surprised by the enhanced detection using LCI, as the study is not the first to evaluate this technology. “However, I was surprised by how high the ADR was in the screening population (62%),” said Dr. Gellad, observing that this exceeds benchmarks set by the society. “We don’t have a full understanding of the demographic characteristics of this screening population. ... Nonetheless, I think this paper adds to accumulating data that current benchmarks may be too low.”

Dr. Gellad said he didn’t think the findings of the study are strong enough to change practice, but the results are a “valuable contribution to the literature and will empower future larger studies as well as meta-analyses.” He called for larger studies in nonspecialized centers to relate the findings from this small study to general practice.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Sakuraba disclosed collaborative research relationships with Fuji, the manufacturer of the imaging equipment used in the study. Dr. Gellad had no financial conflicts to disclose but serves on the editorial board of GI & Hepatology News.

The American College of Obstetricians and Gynecologists (ACOG), took a prominent stand in the battle over abortion legislation by filing an amicus brief to the United States Supreme Court in the case of Dobbs v. Jackson Women’s Health Organization, according to a statement from ACOG issued on Sept. 21.

The case, filed by Thomas E. Dobbs, MD, state health officer of the Mississippi Department of Health, and others, appeals the decision by the U.S. Court of Appeals for the Fifth Circuit to throw out Mississippi’s law banning abortion after 15 weeks of pregnancy.*

ACOG’s amicus brief, which was signed by 24 additional medical organizations, including the American Medical Association, “represents an unprecedented level of support from a diverse group of physicians, nurses, and other health care professionals, which demonstrates the concrete medical consensus of opposition to abortion restriction legislation such as the law at the heart of Dobbs v. Jackson,” according to the ACOG statement.

The brief explains how the ban goes against not only the ability of health professionals to provide safe and essential care, but also goes against scientific evidence and medical ethics. “By preventing clinicians from providing patients with necessary medical care, the ban represents gross interference in the patient-clinician relationship,” according to the ACOG brief. 

Potential implications if the ban is upheld include health risks to pregnant women at or near 15 weeks’ gestation, who might be forced to travel out of state, attempt self-induced abortion, or carry a pregnancy to term, according to the brief.

“Each of these outcomes increases the likelihood of negative consequences to a woman’s physical and psychological health that could be avoided if care were available,” according to the brief.

The brief also emphasizes that the ban will have a disproportionate effect on women who are already at risk for being medically underserved and who make up a majority of women seeking abortion: women of color, women in rural areas, and women with limited financial resources.

“This law is an example of harmful legislative interference into the practice of medicine,” said ACOG President J. Martin Tucker, MD, FACOG, on behalf of ACOG, in the statement.

“The outcome of this case could overturn decades of legal precedent that safeguards safe, legal abortion before viability, and the consequences of this case have national implications,” said Maureen G. Phipps, MD, MPH, CEO of ACOG, in an interview, as reported by ACOG press person Kate Connors.

“If the court does not strike down this law, clinicians in states across the country may face similar restrictions in their ability to provide necessary, evidence-based medical care,” Dr. Phipps explained. “If states are allowed to create new laws that further restrict abortion access, patients and families across the country will suffer,” she said.

“We hope that the Supreme Court will respond to the arguments of our brief and to the remarkable medical consensus represented by 25 organization signing the brief,” Dr. Phipps said. “We will continue educating and working through the judicial system in support of our patients’ access to evidence-based care and in opposition to legislative interference in the practice of medicine,” she emphasized.

Other medical organizations that signed the brief in support of the case against the Mississippi abortion ban included the American Academy of Pediatrics, the American Association of Family Physicians, the American College of Nurse Midwives, the American College of Physicians, the American Psychological Association, the American Society for Reproductive Medicine, the Association of Women’s Health, Obstetric and Neonatal Nurses, the American Medical Women’s Association, the Council of University Chairs of Obstetrics and Gynecology, the National Association of Nurse Practitioners in Women’s Health, the North American Society for Pediatric and Adolescent Gynecology, the Society of OB/GYN Hospitalists, and the Society of Family Planning.

*This story was updated on 10/7/2021.

The American College of Obstetricians and Gynecologists (ACOG), took a prominent stand in the battle over abortion legislation by filing an amicus brief to the United States Supreme Court in the case of Dobbs v. Jackson Women’s Health Organization, according to a statement from ACOG issued on Sept. 21.

The case, filed by Thomas E. Dobbs, MD, state health officer of the Mississippi Department of Health, and others, appeals the decision by the U.S. Court of Appeals for the Fifth Circuit to throw out Mississippi’s law banning abortion after 15 weeks of pregnancy.*

ACOG’s amicus brief, which was signed by 24 additional medical organizations, including the American Medical Association, “represents an unprecedented level of support from a diverse group of physicians, nurses, and other health care professionals, which demonstrates the concrete medical consensus of opposition to abortion restriction legislation such as the law at the heart of Dobbs v. Jackson,” according to the ACOG statement.

The brief explains how the ban goes against not only the ability of health professionals to provide safe and essential care, but also goes against scientific evidence and medical ethics. “By preventing clinicians from providing patients with necessary medical care, the ban represents gross interference in the patient-clinician relationship,” according to the ACOG brief. 

Potential implications if the ban is upheld include health risks to pregnant women at or near 15 weeks’ gestation, who might be forced to travel out of state, attempt self-induced abortion, or carry a pregnancy to term, according to the brief.

“Each of these outcomes increases the likelihood of negative consequences to a woman’s physical and psychological health that could be avoided if care were available,” according to the brief.

The brief also emphasizes that the ban will have a disproportionate effect on women who are already at risk for being medically underserved and who make up a majority of women seeking abortion: women of color, women in rural areas, and women with limited financial resources.

“This law is an example of harmful legislative interference into the practice of medicine,” said ACOG President J. Martin Tucker, MD, FACOG, on behalf of ACOG, in the statement.

“The outcome of this case could overturn decades of legal precedent that safeguards safe, legal abortion before viability, and the consequences of this case have national implications,” said Maureen G. Phipps, MD, MPH, CEO of ACOG, in an interview, as reported by ACOG press person Kate Connors.

“If the court does not strike down this law, clinicians in states across the country may face similar restrictions in their ability to provide necessary, evidence-based medical care,” Dr. Phipps explained. “If states are allowed to create new laws that further restrict abortion access, patients and families across the country will suffer,” she said.

“We hope that the Supreme Court will respond to the arguments of our brief and to the remarkable medical consensus represented by 25 organization signing the brief,” Dr. Phipps said. “We will continue educating and working through the judicial system in support of our patients’ access to evidence-based care and in opposition to legislative interference in the practice of medicine,” she emphasized.

Other medical organizations that signed the brief in support of the case against the Mississippi abortion ban included the American Academy of Pediatrics, the American Association of Family Physicians, the American College of Nurse Midwives, the American College of Physicians, the American Psychological Association, the American Society for Reproductive Medicine, the Association of Women’s Health, Obstetric and Neonatal Nurses, the American Medical Women’s Association, the Council of University Chairs of Obstetrics and Gynecology, the National Association of Nurse Practitioners in Women’s Health, the North American Society for Pediatric and Adolescent Gynecology, the Society of OB/GYN Hospitalists, and the Society of Family Planning.

*This story was updated on 10/7/2021.

The American College of Obstetricians and Gynecologists (ACOG), took a prominent stand in the battle over abortion legislation by filing an amicus brief to the United States Supreme Court in the case of Dobbs v. Jackson Women’s Health Organization, according to a statement from ACOG issued on Sept. 21.

The case, filed by Thomas E. Dobbs, MD, state health officer of the Mississippi Department of Health, and others, appeals the decision by the U.S. Court of Appeals for the Fifth Circuit to throw out Mississippi’s law banning abortion after 15 weeks of pregnancy.*

ACOG’s amicus brief, which was signed by 24 additional medical organizations, including the American Medical Association, “represents an unprecedented level of support from a diverse group of physicians, nurses, and other health care professionals, which demonstrates the concrete medical consensus of opposition to abortion restriction legislation such as the law at the heart of Dobbs v. Jackson,” according to the ACOG statement.

The brief explains how the ban goes against not only the ability of health professionals to provide safe and essential care, but also goes against scientific evidence and medical ethics. “By preventing clinicians from providing patients with necessary medical care, the ban represents gross interference in the patient-clinician relationship,” according to the ACOG brief. 

Potential implications if the ban is upheld include health risks to pregnant women at or near 15 weeks’ gestation, who might be forced to travel out of state, attempt self-induced abortion, or carry a pregnancy to term, according to the brief.

“Each of these outcomes increases the likelihood of negative consequences to a woman’s physical and psychological health that could be avoided if care were available,” according to the brief.

The brief also emphasizes that the ban will have a disproportionate effect on women who are already at risk for being medically underserved and who make up a majority of women seeking abortion: women of color, women in rural areas, and women with limited financial resources.

“This law is an example of harmful legislative interference into the practice of medicine,” said ACOG President J. Martin Tucker, MD, FACOG, on behalf of ACOG, in the statement.

“The outcome of this case could overturn decades of legal precedent that safeguards safe, legal abortion before viability, and the consequences of this case have national implications,” said Maureen G. Phipps, MD, MPH, CEO of ACOG, in an interview, as reported by ACOG press person Kate Connors.

“If the court does not strike down this law, clinicians in states across the country may face similar restrictions in their ability to provide necessary, evidence-based medical care,” Dr. Phipps explained. “If states are allowed to create new laws that further restrict abortion access, patients and families across the country will suffer,” she said.

“We hope that the Supreme Court will respond to the arguments of our brief and to the remarkable medical consensus represented by 25 organization signing the brief,” Dr. Phipps said. “We will continue educating and working through the judicial system in support of our patients’ access to evidence-based care and in opposition to legislative interference in the practice of medicine,” she emphasized.

Other medical organizations that signed the brief in support of the case against the Mississippi abortion ban included the American Academy of Pediatrics, the American Association of Family Physicians, the American College of Nurse Midwives, the American College of Physicians, the American Psychological Association, the American Society for Reproductive Medicine, the Association of Women’s Health, Obstetric and Neonatal Nurses, the American Medical Women’s Association, the Council of University Chairs of Obstetrics and Gynecology, the National Association of Nurse Practitioners in Women’s Health, the North American Society for Pediatric and Adolescent Gynecology, the Society of OB/GYN Hospitalists, and the Society of Family Planning.

*This story was updated on 10/7/2021.

Among women with a history of gestational diabetes, alcohol intake of half a drink to one drink daily was associated with a 55% lower risk for subsequent type 2 diabetes, based on data from approximately 4,700 women in the Nurses’ Health Study II cohort.

However, the findings must be considered in the context of other risks and benefits of alcohol consumption before making statements or clinical recommendations, wrote Stefanie N. Hinkle, PhD, of the National Institutes of Health, Bethesda, Md., and colleagues.

Women with a history of gestational diabetes remain at increased risk for developing type 2 diabetes, so modifiable diet and lifestyle factors deserve further study, the researchers noted. Previous research has shown an association between light to moderate alcohol consumption and reduced risk of type 2 diabetes among women in the general population, but data on a similar risk reduction for women with a history of gestational diabetes are lacking, they added.

In a study published in JAMA Network Open, the researchers reviewed data from 4,740 women enrolled in the Nurses’ Health Study II who reported a history of gestational diabetes. These women were followed from Jan. 1, 1991, to Dec. 31, 2017, as part of the Diabetes & Women’s Health Study; dietary intake, including alcohol intake, was assessed every 4 years via validated food frequency questionnaires.

The average age at baseline was 38 years, and the median follow-up time was 24 years, yielding a total of 78,328 person-years of follow-up. Alcohol consumption was divided into four categories: none; 0.1 g/day to 4.9 g/day; 5.0 to 14.9 g/day, and 15.0 g/day or higher.

A total of 897 incident cases of type 2 diabetes were reported during the study period. After adjustment for multiple dietary and lifestyle variables, including diet and physical activity, only alcohol consumption of 5.0-14.9 g/day (approximately half a drink to one drink) was associated with a significantly decreased risk for incident type 2 diabetes (hazard ratio, 0.45) compared with women who reported no alcohol consumption.

On further adjustment for body mass index, women who reported alcohol consumption in the 5.0-14.9 g/day range had a 41% lower risk for developing incident type 2 diabetes (HR, 0.59); alcohol consumption in the other ranges remained unassociated with type 2 diabetes risk, although the researchers noted that these estimates were attenuated.

The median daily intake for women who consumed alcohol was 2.3 g/day, approximately one drink per week. Beer was the most frequently consumed type of alcohol.

When the researchers analyzed the data by alcohol type, notably, “only beer consumption of 1 or more servings a week was associated with a lower risk for type 2 diabetes,” although previous studies have suggested a stronger association in diabetes risk reduction with wine consumption vs. beer, the researchers noted.

The study findings were the potential for confounding factors not included in the adjustment, potential underreporting of alcohol intake, and potential screening bias toward women who were more health conscious, the researchers noted. Other limitations were lack of generalizability given that most of the study participants were white women, and a lack of data on binge drinking and whether alcohol was consumed with meals, they added. The study strengths included the prospective design, large size, long-term follow-up, and use of validated questionnaires, they said.

The researchers cautioned that the results should not be interpreted without considering other health outcomes. “Consistent with the 2020 Dietary Guidelines for Americans, which recommend that adults who do not consume alcohol do not initiate drinking, it may not be prudent for those with a history of gestational diabetes who do not consume alcohol to initiate drinking alcohol solely to reduce their risk for type 2 diabetes,” they emphasized.
 

Risk/benefit ratio for alcohol includes many factors

“There is a relative paucity of data regarding women’s long-term health as it may relate to pregnancy and pregnancy outcomes,” Angela Bianco, MD, of Mount Sinai Hospital, New York, said in an interview.

Dr. Bianco said she was surprised by some of the study findings.

“Generally speaking, I consider alcohol to be of little to no nutritional value, and to have a high sugar content/glycemic index,” she said. “However, a reduced incidence of adult-onset diabetes has been observed among moderate drinkers in other large prospective studies as well,” she noted. “In contrast, some studies have shown an increased risk of diabetes among a proportion of subjects in the top alcohol consumption category, while other studies have found no association. Possible inconsistencies may be due to differences in drinking patterns and the types of beverages consumed,” Dr. Bianco explained.

A key point for clinicians to keep in mind is that “the study may be flawed based on the different criteria used to make a diagnosis of history of gestational diabetes, the fact that they excluded patients that did not return the questionnaires, and the fact that respondents may not have answered correctly due to recall bias” or other reasons, Dr. Bianco said. “Additionally, those who responded obviously had access to health care, which in and of itself is a confounder,” she noted.

Another key point is that “the effect of alcohol being consumed with or without a meal was not examined,” said Dr. Bianco. “Alcohol concentration is reduced if consumed with meals. Alcohol can lead to hypoglycemia (from reduced gluconeogenesis) during fasting states, but after meals (postprandial states) it can result in lower glucose disposal and higher blood glucose levels,” she said. “The available literature suggests that alcohol may improve insulin sensitivity and reduce resistance, but there is likely a U-shaped association between alcohol consumption and the risk of diabetes,” Dr. Bianco noted. “There is likely a delicate balance between benefits and risks of alcohol intake. The inherent benefit/risk ratio must take into account with other potential comorbidities including BMI, activity level, stress, and preexisting conditions,” she said.

“Additional long-term studies engaging patients with diverse ethnic and socioeconomic backgrounds with detailed information regarding the role of nutrition, alcohol intake, tobacco and drug use, environmental exposures, and medical comorbidities need to be performed,” Dr. Bianco concluded.

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of General Medical Sciences, and the National Institute of Diabetes and Digestive and Kidney Diseases; the Nurses’ Health Study II was supported by the National Institutes of Health. Lead author Dr. Hinkle and coauthor Cuilin Zhang, MD, are employees of the U.S. federal government. The researchers and Dr. Bianco had no financial conflicts to disclose.

Among women with a history of gestational diabetes, alcohol intake of half a drink to one drink daily was associated with a 55% lower risk for subsequent type 2 diabetes, based on data from approximately 4,700 women in the Nurses’ Health Study II cohort.

However, the findings must be considered in the context of other risks and benefits of alcohol consumption before making statements or clinical recommendations, wrote Stefanie N. Hinkle, PhD, of the National Institutes of Health, Bethesda, Md., and colleagues.

Women with a history of gestational diabetes remain at increased risk for developing type 2 diabetes, so modifiable diet and lifestyle factors deserve further study, the researchers noted. Previous research has shown an association between light to moderate alcohol consumption and reduced risk of type 2 diabetes among women in the general population, but data on a similar risk reduction for women with a history of gestational diabetes are lacking, they added.

In a study published in JAMA Network Open, the researchers reviewed data from 4,740 women enrolled in the Nurses’ Health Study II who reported a history of gestational diabetes. These women were followed from Jan. 1, 1991, to Dec. 31, 2017, as part of the Diabetes & Women’s Health Study; dietary intake, including alcohol intake, was assessed every 4 years via validated food frequency questionnaires.

The average age at baseline was 38 years, and the median follow-up time was 24 years, yielding a total of 78,328 person-years of follow-up. Alcohol consumption was divided into four categories: none; 0.1 g/day to 4.9 g/day; 5.0 to 14.9 g/day, and 15.0 g/day or higher.

A total of 897 incident cases of type 2 diabetes were reported during the study period. After adjustment for multiple dietary and lifestyle variables, including diet and physical activity, only alcohol consumption of 5.0-14.9 g/day (approximately half a drink to one drink) was associated with a significantly decreased risk for incident type 2 diabetes (hazard ratio, 0.45) compared with women who reported no alcohol consumption.

On further adjustment for body mass index, women who reported alcohol consumption in the 5.0-14.9 g/day range had a 41% lower risk for developing incident type 2 diabetes (HR, 0.59); alcohol consumption in the other ranges remained unassociated with type 2 diabetes risk, although the researchers noted that these estimates were attenuated.

The median daily intake for women who consumed alcohol was 2.3 g/day, approximately one drink per week. Beer was the most frequently consumed type of alcohol.

When the researchers analyzed the data by alcohol type, notably, “only beer consumption of 1 or more servings a week was associated with a lower risk for type 2 diabetes,” although previous studies have suggested a stronger association in diabetes risk reduction with wine consumption vs. beer, the researchers noted.

The study findings were the potential for confounding factors not included in the adjustment, potential underreporting of alcohol intake, and potential screening bias toward women who were more health conscious, the researchers noted. Other limitations were lack of generalizability given that most of the study participants were white women, and a lack of data on binge drinking and whether alcohol was consumed with meals, they added. The study strengths included the prospective design, large size, long-term follow-up, and use of validated questionnaires, they said.

The researchers cautioned that the results should not be interpreted without considering other health outcomes. “Consistent with the 2020 Dietary Guidelines for Americans, which recommend that adults who do not consume alcohol do not initiate drinking, it may not be prudent for those with a history of gestational diabetes who do not consume alcohol to initiate drinking alcohol solely to reduce their risk for type 2 diabetes,” they emphasized.
 

Risk/benefit ratio for alcohol includes many factors

“There is a relative paucity of data regarding women’s long-term health as it may relate to pregnancy and pregnancy outcomes,” Angela Bianco, MD, of Mount Sinai Hospital, New York, said in an interview.

Dr. Bianco said she was surprised by some of the study findings.

“Generally speaking, I consider alcohol to be of little to no nutritional value, and to have a high sugar content/glycemic index,” she said. “However, a reduced incidence of adult-onset diabetes has been observed among moderate drinkers in other large prospective studies as well,” she noted. “In contrast, some studies have shown an increased risk of diabetes among a proportion of subjects in the top alcohol consumption category, while other studies have found no association. Possible inconsistencies may be due to differences in drinking patterns and the types of beverages consumed,” Dr. Bianco explained.

A key point for clinicians to keep in mind is that “the study may be flawed based on the different criteria used to make a diagnosis of history of gestational diabetes, the fact that they excluded patients that did not return the questionnaires, and the fact that respondents may not have answered correctly due to recall bias” or other reasons, Dr. Bianco said. “Additionally, those who responded obviously had access to health care, which in and of itself is a confounder,” she noted.

Another key point is that “the effect of alcohol being consumed with or without a meal was not examined,” said Dr. Bianco. “Alcohol concentration is reduced if consumed with meals. Alcohol can lead to hypoglycemia (from reduced gluconeogenesis) during fasting states, but after meals (postprandial states) it can result in lower glucose disposal and higher blood glucose levels,” she said. “The available literature suggests that alcohol may improve insulin sensitivity and reduce resistance, but there is likely a U-shaped association between alcohol consumption and the risk of diabetes,” Dr. Bianco noted. “There is likely a delicate balance between benefits and risks of alcohol intake. The inherent benefit/risk ratio must take into account with other potential comorbidities including BMI, activity level, stress, and preexisting conditions,” she said.

“Additional long-term studies engaging patients with diverse ethnic and socioeconomic backgrounds with detailed information regarding the role of nutrition, alcohol intake, tobacco and drug use, environmental exposures, and medical comorbidities need to be performed,” Dr. Bianco concluded.

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of General Medical Sciences, and the National Institute of Diabetes and Digestive and Kidney Diseases; the Nurses’ Health Study II was supported by the National Institutes of Health. Lead author Dr. Hinkle and coauthor Cuilin Zhang, MD, are employees of the U.S. federal government. The researchers and Dr. Bianco had no financial conflicts to disclose.

Among women with a history of gestational diabetes, alcohol intake of half a drink to one drink daily was associated with a 55% lower risk for subsequent type 2 diabetes, based on data from approximately 4,700 women in the Nurses’ Health Study II cohort.

However, the findings must be considered in the context of other risks and benefits of alcohol consumption before making statements or clinical recommendations, wrote Stefanie N. Hinkle, PhD, of the National Institutes of Health, Bethesda, Md., and colleagues.

Women with a history of gestational diabetes remain at increased risk for developing type 2 diabetes, so modifiable diet and lifestyle factors deserve further study, the researchers noted. Previous research has shown an association between light to moderate alcohol consumption and reduced risk of type 2 diabetes among women in the general population, but data on a similar risk reduction for women with a history of gestational diabetes are lacking, they added.

In a study published in JAMA Network Open, the researchers reviewed data from 4,740 women enrolled in the Nurses’ Health Study II who reported a history of gestational diabetes. These women were followed from Jan. 1, 1991, to Dec. 31, 2017, as part of the Diabetes & Women’s Health Study; dietary intake, including alcohol intake, was assessed every 4 years via validated food frequency questionnaires.

The average age at baseline was 38 years, and the median follow-up time was 24 years, yielding a total of 78,328 person-years of follow-up. Alcohol consumption was divided into four categories: none; 0.1 g/day to 4.9 g/day; 5.0 to 14.9 g/day, and 15.0 g/day or higher.

A total of 897 incident cases of type 2 diabetes were reported during the study period. After adjustment for multiple dietary and lifestyle variables, including diet and physical activity, only alcohol consumption of 5.0-14.9 g/day (approximately half a drink to one drink) was associated with a significantly decreased risk for incident type 2 diabetes (hazard ratio, 0.45) compared with women who reported no alcohol consumption.

On further adjustment for body mass index, women who reported alcohol consumption in the 5.0-14.9 g/day range had a 41% lower risk for developing incident type 2 diabetes (HR, 0.59); alcohol consumption in the other ranges remained unassociated with type 2 diabetes risk, although the researchers noted that these estimates were attenuated.

The median daily intake for women who consumed alcohol was 2.3 g/day, approximately one drink per week. Beer was the most frequently consumed type of alcohol.

When the researchers analyzed the data by alcohol type, notably, “only beer consumption of 1 or more servings a week was associated with a lower risk for type 2 diabetes,” although previous studies have suggested a stronger association in diabetes risk reduction with wine consumption vs. beer, the researchers noted.

The study findings were the potential for confounding factors not included in the adjustment, potential underreporting of alcohol intake, and potential screening bias toward women who were more health conscious, the researchers noted. Other limitations were lack of generalizability given that most of the study participants were white women, and a lack of data on binge drinking and whether alcohol was consumed with meals, they added. The study strengths included the prospective design, large size, long-term follow-up, and use of validated questionnaires, they said.

The researchers cautioned that the results should not be interpreted without considering other health outcomes. “Consistent with the 2020 Dietary Guidelines for Americans, which recommend that adults who do not consume alcohol do not initiate drinking, it may not be prudent for those with a history of gestational diabetes who do not consume alcohol to initiate drinking alcohol solely to reduce their risk for type 2 diabetes,” they emphasized.
 

Risk/benefit ratio for alcohol includes many factors

“There is a relative paucity of data regarding women’s long-term health as it may relate to pregnancy and pregnancy outcomes,” Angela Bianco, MD, of Mount Sinai Hospital, New York, said in an interview.

Dr. Bianco said she was surprised by some of the study findings.

“Generally speaking, I consider alcohol to be of little to no nutritional value, and to have a high sugar content/glycemic index,” she said. “However, a reduced incidence of adult-onset diabetes has been observed among moderate drinkers in other large prospective studies as well,” she noted. “In contrast, some studies have shown an increased risk of diabetes among a proportion of subjects in the top alcohol consumption category, while other studies have found no association. Possible inconsistencies may be due to differences in drinking patterns and the types of beverages consumed,” Dr. Bianco explained.

A key point for clinicians to keep in mind is that “the study may be flawed based on the different criteria used to make a diagnosis of history of gestational diabetes, the fact that they excluded patients that did not return the questionnaires, and the fact that respondents may not have answered correctly due to recall bias” or other reasons, Dr. Bianco said. “Additionally, those who responded obviously had access to health care, which in and of itself is a confounder,” she noted.

Another key point is that “the effect of alcohol being consumed with or without a meal was not examined,” said Dr. Bianco. “Alcohol concentration is reduced if consumed with meals. Alcohol can lead to hypoglycemia (from reduced gluconeogenesis) during fasting states, but after meals (postprandial states) it can result in lower glucose disposal and higher blood glucose levels,” she said. “The available literature suggests that alcohol may improve insulin sensitivity and reduce resistance, but there is likely a U-shaped association between alcohol consumption and the risk of diabetes,” Dr. Bianco noted. “There is likely a delicate balance between benefits and risks of alcohol intake. The inherent benefit/risk ratio must take into account with other potential comorbidities including BMI, activity level, stress, and preexisting conditions,” she said.

“Additional long-term studies engaging patients with diverse ethnic and socioeconomic backgrounds with detailed information regarding the role of nutrition, alcohol intake, tobacco and drug use, environmental exposures, and medical comorbidities need to be performed,” Dr. Bianco concluded.

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of General Medical Sciences, and the National Institute of Diabetes and Digestive and Kidney Diseases; the Nurses’ Health Study II was supported by the National Institutes of Health. Lead author Dr. Hinkle and coauthor Cuilin Zhang, MD, are employees of the U.S. federal government. The researchers and Dr. Bianco had no financial conflicts to disclose.

The use of gonadotropin-releasing hormone agonists has a negative effect on bone mass in transgender youth, according to data from 172 individuals.

The onset of puberty and pubertal hormones contributes to the development of bone mass and body composition in adolescence, wrote Behdad Navabi, MD, and colleagues at Children’s Hospital of Eastern Ontario, Canada. Although the safety and efficacy of gonadotropin-releasing hormone agonists (GnRHa) has been described in short-term studies of youth with gender dysphoria, concerns persist about suppression of bone mass accrual from extended use of GnRHas in this population, they noted.

In a study published in Pediatrics, the researchers reviewed data from 172 youth younger than 18 years of age who were treated with GNRHa and underwent at least one baseline dual-energy radiograph absorptiometry (DXA) measurement between January 2006 and April 2017 at a single center. The standard treatment protocol started with three doses of 7.5 mg leuprolide acetate, given intramuscularly every 4 weeks, followed by 11.25 mg intramuscularly every 12 weeks after puberty suppression was confirmed both clinically and biochemically. Areal bone mineral density (aBMD) measurement z scores were based on birth-assigned sex, age, and ethnicity, and assessed at baseline and every 12 months. In addition, volumetric bone mineral density was calculated as bone mineral apparent density (BMAD) at the lower spine, and the z score based on age-matched, birth-assigned gender BMAD.

Overall, 55.2% of the youth were vitamin D deficient or insufficient at baseline, but 87.3% were sufficient by the time of a third follow-up visit after treatment with 1,000-2,000 IU of vitamin D daily; no cases of vitamin D toxicity were reported.

At baseline, transgender females had lower z scores for the LS aBMD and BMAD compared to transgender males, reflecting a difference seen in previous studies of transgender youth and adult females, the researchers noted.

The researchers analyzed pre- and posttreatment DXA data in a subgroup of 36 transgender females and 80 transgender males to identify any changes associated with GnRHa. The average time between the DXA scans was 407 days. In this population, aBMD z scores at the lower lumbar spine (LS), left total hip (LTH), and total body less head (TBLH) decreased significantly from baseline in transgender males and females.

Among transgender males, LS bone mineral apparent density (BMAD) z scores also decreased significantly from baseline, but no such change occurred among transgender females. The most significant decrease in z scores occurred in the LS aBMD and BMAD of transgender males, with changes that reflect findings from previous studies and may be explained by decreased estrogen, the researchers wrote.

In terms of body composition, no significant changes occurred in body mass index z score from baseline to follow-up in transgender males or females, the researchers noted, and changes in both gynoid and android fat percentages were consistent with the individuals’ affirmed genders. No vertebral fractures were detected.

However, GnRHa was significantly associated with a decrease in total body fat percentage and a decrease in lean body mass (LBM) in transgender females.

The study findings were limited by several factors, including the lack of consistent baseline physical activity records, and limited analysis at follow-up of the possible role of physical activity in bone health and body composition, the researchers noted. However, the results were strengthened by the relatively large study population with baseline assessments, and by the pre- and posttreatment analysis, they added.

“Evidence on GnRHa-associated changes in body composition and BMD will help health care professionals involved in the care of youth with GD [gender dysphoria] to counsel appropriately and optimize their bone health,” the researchers said. “Given the absence of vertebral fractures detected in those with significant decreases in their LS z scores, the significance of BMD effects of GnRHa in transgender youth needs further study, as well as whether future spine radiographs are needed on the basis of BMD trajectory,” they concluded.
 

Balance bone health concerns with potential benefits

The effect of estrogen and testosterone on bone geometry in puberty varies, and the increase in the use of GnRHa as part of a multidisciplinary gender transition plan makes research on the skeletal impact of this therapy in transgender youth a top priority, Laura K. Bachrach, MD, of Stanford (Calif.) University, and Catherine M. Gordon of Harvard Medical School, Boston, wrote in an accompanying editorial.

The decrease in areal bone mineral density and in bone mineral apparent density (BMAD) z scores in the current study is not unexpected, but the key question is how much bone density recovers once the suppression therapy ends and transgender sex steroid use begins, they said. “Follow-up studies of young adults treated with GnRHa for precocious puberty in childhood are reassuring,” they wrote. “It is premature, however, to extrapolate from these findings to transgender youth,” because the impact of gender-affirming sex steroid therapy on the skeleton at older ages and stages of maturity are unclear, they emphasized.

In the absence of definitive answers, the editorial authors advised clinicians treating youth with gender dysphoria to provide a balanced view of the risks and benefits of hormone therapy, and encourage adequate intake of dietary vitamin D and calcium, along with weight-bearing physical activity, to promote general bone health. “Transgender teenagers and their parents should be reassured that some recovery from decreases in aBMD during pubertal suppression with GnRHa is likely,” the authors noted. Bone health should be monitored throughout all stages of treatment in transgender youth, but concerns about transient bone loss should not discourage gender transition therapy, they emphasized. “In this patient group, providing a pause in pubertal development offers a life-changing and, for some, a life-saving intervention,” they concluded.
 

Comparison to cisgender controls would add value

“This study is important because one of the major side effects of GnRH agonists is decreased bone density, especially the longer that patients are on them,” M. Brett Cooper, MD, of UT Southwestern Medical Center, said in an interview. The findings add to existing data to underscore the importance of screening for low bone density and low vitamin D levels, Dr. Cooper added.

Dr. Cooper said that he was not surprised by the study findings. “I think that this study supported what clinicians already knew, which is that GnRH agonists do potentially cause a decline in bone mineral density and thus, you need to support these patients as best you can with calcium, vitamin D, and weight-bearing exercise,” he noted.

Dr. Cooper emphasized two main take-home points from the study. “First, clinicians who prescribe GnRH agonists need to ensure that they are checking bone density and vitamin D measurements, and then optimizing these appropriately,” he said. “Second, when a bone density is found to be low or a vitamin level is low, clinicians need to ensure that they are monitored and treated appropriately.” Clinicians need to use these data when deciding when to start gender-affirming hormones so their patients have the best chance to recover bone density, he added.

“I think one confounding factor on this study is the ranges they used for vitamin D deficiency,” Dr. Cooper noted. “This study was done in Canada, and the scale used was in nmol/L, while most labs in the U.S. use ng/mL,” he said. “Most pediatric and adolescent societies in the United States use < 20 ng/mL as an indicator of vitamin D deficient and between 20 and 29 ng/mL as insufficient,” he explained, citing the position statement on recommended vitamin D intake for adolescents published by The Society for Adolescent Health and Medicine. In this study, the results converted to < 12 ng/mL as deficient and between 12 and 20 ng/mL as insufficient, respectively, on the U.S. scale, said Dr. Cooper.

“Therefore, I can see that there are cases where someone may have been labeled vitamin D insufficient in this study using their range, whereas in the U.S. these patients would be labeled as vitamin D deficient and treated with higher-dose supplementation,” he said. In addition, individuals with levels between 20 ng/mL and 29 ng/mL in the U.S. would still be treated with vitamin D supplementation, “whereas in their study those individuals would have been labeled as normal,” he noted.

As for future research, it would be useful to study whether bone mass in transgender young people differs from age- and gender-matched controls who are not gender diverse (cisgender), Dr. Cooper added. “It may be possible that the youth in this study are not different from their peers and maybe the GnRH agonist is not the culprit,” he said.

The study received no outside funding. The researchers, editorial authors, and Dr. Cooper had no financial conflicts to disclose.

The use of gonadotropin-releasing hormone agonists has a negative effect on bone mass in transgender youth, according to data from 172 individuals.

The onset of puberty and pubertal hormones contributes to the development of bone mass and body composition in adolescence, wrote Behdad Navabi, MD, and colleagues at Children’s Hospital of Eastern Ontario, Canada. Although the safety and efficacy of gonadotropin-releasing hormone agonists (GnRHa) has been described in short-term studies of youth with gender dysphoria, concerns persist about suppression of bone mass accrual from extended use of GnRHas in this population, they noted.

In a study published in Pediatrics, the researchers reviewed data from 172 youth younger than 18 years of age who were treated with GNRHa and underwent at least one baseline dual-energy radiograph absorptiometry (DXA) measurement between January 2006 and April 2017 at a single center. The standard treatment protocol started with three doses of 7.5 mg leuprolide acetate, given intramuscularly every 4 weeks, followed by 11.25 mg intramuscularly every 12 weeks after puberty suppression was confirmed both clinically and biochemically. Areal bone mineral density (aBMD) measurement z scores were based on birth-assigned sex, age, and ethnicity, and assessed at baseline and every 12 months. In addition, volumetric bone mineral density was calculated as bone mineral apparent density (BMAD) at the lower spine, and the z score based on age-matched, birth-assigned gender BMAD.

Overall, 55.2% of the youth were vitamin D deficient or insufficient at baseline, but 87.3% were sufficient by the time of a third follow-up visit after treatment with 1,000-2,000 IU of vitamin D daily; no cases of vitamin D toxicity were reported.

At baseline, transgender females had lower z scores for the LS aBMD and BMAD compared to transgender males, reflecting a difference seen in previous studies of transgender youth and adult females, the researchers noted.

The researchers analyzed pre- and posttreatment DXA data in a subgroup of 36 transgender females and 80 transgender males to identify any changes associated with GnRHa. The average time between the DXA scans was 407 days. In this population, aBMD z scores at the lower lumbar spine (LS), left total hip (LTH), and total body less head (TBLH) decreased significantly from baseline in transgender males and females.

Among transgender males, LS bone mineral apparent density (BMAD) z scores also decreased significantly from baseline, but no such change occurred among transgender females. The most significant decrease in z scores occurred in the LS aBMD and BMAD of transgender males, with changes that reflect findings from previous studies and may be explained by decreased estrogen, the researchers wrote.

In terms of body composition, no significant changes occurred in body mass index z score from baseline to follow-up in transgender males or females, the researchers noted, and changes in both gynoid and android fat percentages were consistent with the individuals’ affirmed genders. No vertebral fractures were detected.

However, GnRHa was significantly associated with a decrease in total body fat percentage and a decrease in lean body mass (LBM) in transgender females.

The study findings were limited by several factors, including the lack of consistent baseline physical activity records, and limited analysis at follow-up of the possible role of physical activity in bone health and body composition, the researchers noted. However, the results were strengthened by the relatively large study population with baseline assessments, and by the pre- and posttreatment analysis, they added.

“Evidence on GnRHa-associated changes in body composition and BMD will help health care professionals involved in the care of youth with GD [gender dysphoria] to counsel appropriately and optimize their bone health,” the researchers said. “Given the absence of vertebral fractures detected in those with significant decreases in their LS z scores, the significance of BMD effects of GnRHa in transgender youth needs further study, as well as whether future spine radiographs are needed on the basis of BMD trajectory,” they concluded.
 

Balance bone health concerns with potential benefits

The effect of estrogen and testosterone on bone geometry in puberty varies, and the increase in the use of GnRHa as part of a multidisciplinary gender transition plan makes research on the skeletal impact of this therapy in transgender youth a top priority, Laura K. Bachrach, MD, of Stanford (Calif.) University, and Catherine M. Gordon of Harvard Medical School, Boston, wrote in an accompanying editorial.

The decrease in areal bone mineral density and in bone mineral apparent density (BMAD) z scores in the current study is not unexpected, but the key question is how much bone density recovers once the suppression therapy ends and transgender sex steroid use begins, they said. “Follow-up studies of young adults treated with GnRHa for precocious puberty in childhood are reassuring,” they wrote. “It is premature, however, to extrapolate from these findings to transgender youth,” because the impact of gender-affirming sex steroid therapy on the skeleton at older ages and stages of maturity are unclear, they emphasized.

In the absence of definitive answers, the editorial authors advised clinicians treating youth with gender dysphoria to provide a balanced view of the risks and benefits of hormone therapy, and encourage adequate intake of dietary vitamin D and calcium, along with weight-bearing physical activity, to promote general bone health. “Transgender teenagers and their parents should be reassured that some recovery from decreases in aBMD during pubertal suppression with GnRHa is likely,” the authors noted. Bone health should be monitored throughout all stages of treatment in transgender youth, but concerns about transient bone loss should not discourage gender transition therapy, they emphasized. “In this patient group, providing a pause in pubertal development offers a life-changing and, for some, a life-saving intervention,” they concluded.
 

Comparison to cisgender controls would add value

“This study is important because one of the major side effects of GnRH agonists is decreased bone density, especially the longer that patients are on them,” M. Brett Cooper, MD, of UT Southwestern Medical Center, said in an interview. The findings add to existing data to underscore the importance of screening for low bone density and low vitamin D levels, Dr. Cooper added.

Dr. Cooper said that he was not surprised by the study findings. “I think that this study supported what clinicians already knew, which is that GnRH agonists do potentially cause a decline in bone mineral density and thus, you need to support these patients as best you can with calcium, vitamin D, and weight-bearing exercise,” he noted.

Dr. Cooper emphasized two main take-home points from the study. “First, clinicians who prescribe GnRH agonists need to ensure that they are checking bone density and vitamin D measurements, and then optimizing these appropriately,” he said. “Second, when a bone density is found to be low or a vitamin level is low, clinicians need to ensure that they are monitored and treated appropriately.” Clinicians need to use these data when deciding when to start gender-affirming hormones so their patients have the best chance to recover bone density, he added.

“I think one confounding factor on this study is the ranges they used for vitamin D deficiency,” Dr. Cooper noted. “This study was done in Canada, and the scale used was in nmol/L, while most labs in the U.S. use ng/mL,” he said. “Most pediatric and adolescent societies in the United States use < 20 ng/mL as an indicator of vitamin D deficient and between 20 and 29 ng/mL as insufficient,” he explained, citing the position statement on recommended vitamin D intake for adolescents published by The Society for Adolescent Health and Medicine. In this study, the results converted to < 12 ng/mL as deficient and between 12 and 20 ng/mL as insufficient, respectively, on the U.S. scale, said Dr. Cooper.

“Therefore, I can see that there are cases where someone may have been labeled vitamin D insufficient in this study using their range, whereas in the U.S. these patients would be labeled as vitamin D deficient and treated with higher-dose supplementation,” he said. In addition, individuals with levels between 20 ng/mL and 29 ng/mL in the U.S. would still be treated with vitamin D supplementation, “whereas in their study those individuals would have been labeled as normal,” he noted.

As for future research, it would be useful to study whether bone mass in transgender young people differs from age- and gender-matched controls who are not gender diverse (cisgender), Dr. Cooper added. “It may be possible that the youth in this study are not different from their peers and maybe the GnRH agonist is not the culprit,” he said.

The study received no outside funding. The researchers, editorial authors, and Dr. Cooper had no financial conflicts to disclose.

The use of gonadotropin-releasing hormone agonists has a negative effect on bone mass in transgender youth, according to data from 172 individuals.

The onset of puberty and pubertal hormones contributes to the development of bone mass and body composition in adolescence, wrote Behdad Navabi, MD, and colleagues at Children’s Hospital of Eastern Ontario, Canada. Although the safety and efficacy of gonadotropin-releasing hormone agonists (GnRHa) has been described in short-term studies of youth with gender dysphoria, concerns persist about suppression of bone mass accrual from extended use of GnRHas in this population, they noted.

In a study published in Pediatrics, the researchers reviewed data from 172 youth younger than 18 years of age who were treated with GNRHa and underwent at least one baseline dual-energy radiograph absorptiometry (DXA) measurement between January 2006 and April 2017 at a single center. The standard treatment protocol started with three doses of 7.5 mg leuprolide acetate, given intramuscularly every 4 weeks, followed by 11.25 mg intramuscularly every 12 weeks after puberty suppression was confirmed both clinically and biochemically. Areal bone mineral density (aBMD) measurement z scores were based on birth-assigned sex, age, and ethnicity, and assessed at baseline and every 12 months. In addition, volumetric bone mineral density was calculated as bone mineral apparent density (BMAD) at the lower spine, and the z score based on age-matched, birth-assigned gender BMAD.

Overall, 55.2% of the youth were vitamin D deficient or insufficient at baseline, but 87.3% were sufficient by the time of a third follow-up visit after treatment with 1,000-2,000 IU of vitamin D daily; no cases of vitamin D toxicity were reported.

At baseline, transgender females had lower z scores for the LS aBMD and BMAD compared to transgender males, reflecting a difference seen in previous studies of transgender youth and adult females, the researchers noted.

The researchers analyzed pre- and posttreatment DXA data in a subgroup of 36 transgender females and 80 transgender males to identify any changes associated with GnRHa. The average time between the DXA scans was 407 days. In this population, aBMD z scores at the lower lumbar spine (LS), left total hip (LTH), and total body less head (TBLH) decreased significantly from baseline in transgender males and females.

Among transgender males, LS bone mineral apparent density (BMAD) z scores also decreased significantly from baseline, but no such change occurred among transgender females. The most significant decrease in z scores occurred in the LS aBMD and BMAD of transgender males, with changes that reflect findings from previous studies and may be explained by decreased estrogen, the researchers wrote.

In terms of body composition, no significant changes occurred in body mass index z score from baseline to follow-up in transgender males or females, the researchers noted, and changes in both gynoid and android fat percentages were consistent with the individuals’ affirmed genders. No vertebral fractures were detected.

However, GnRHa was significantly associated with a decrease in total body fat percentage and a decrease in lean body mass (LBM) in transgender females.

The study findings were limited by several factors, including the lack of consistent baseline physical activity records, and limited analysis at follow-up of the possible role of physical activity in bone health and body composition, the researchers noted. However, the results were strengthened by the relatively large study population with baseline assessments, and by the pre- and posttreatment analysis, they added.

“Evidence on GnRHa-associated changes in body composition and BMD will help health care professionals involved in the care of youth with GD [gender dysphoria] to counsel appropriately and optimize their bone health,” the researchers said. “Given the absence of vertebral fractures detected in those with significant decreases in their LS z scores, the significance of BMD effects of GnRHa in transgender youth needs further study, as well as whether future spine radiographs are needed on the basis of BMD trajectory,” they concluded.
 

Balance bone health concerns with potential benefits

The effect of estrogen and testosterone on bone geometry in puberty varies, and the increase in the use of GnRHa as part of a multidisciplinary gender transition plan makes research on the skeletal impact of this therapy in transgender youth a top priority, Laura K. Bachrach, MD, of Stanford (Calif.) University, and Catherine M. Gordon of Harvard Medical School, Boston, wrote in an accompanying editorial.

The decrease in areal bone mineral density and in bone mineral apparent density (BMAD) z scores in the current study is not unexpected, but the key question is how much bone density recovers once the suppression therapy ends and transgender sex steroid use begins, they said. “Follow-up studies of young adults treated with GnRHa for precocious puberty in childhood are reassuring,” they wrote. “It is premature, however, to extrapolate from these findings to transgender youth,” because the impact of gender-affirming sex steroid therapy on the skeleton at older ages and stages of maturity are unclear, they emphasized.

In the absence of definitive answers, the editorial authors advised clinicians treating youth with gender dysphoria to provide a balanced view of the risks and benefits of hormone therapy, and encourage adequate intake of dietary vitamin D and calcium, along with weight-bearing physical activity, to promote general bone health. “Transgender teenagers and their parents should be reassured that some recovery from decreases in aBMD during pubertal suppression with GnRHa is likely,” the authors noted. Bone health should be monitored throughout all stages of treatment in transgender youth, but concerns about transient bone loss should not discourage gender transition therapy, they emphasized. “In this patient group, providing a pause in pubertal development offers a life-changing and, for some, a life-saving intervention,” they concluded.
 

Comparison to cisgender controls would add value

“This study is important because one of the major side effects of GnRH agonists is decreased bone density, especially the longer that patients are on them,” M. Brett Cooper, MD, of UT Southwestern Medical Center, said in an interview. The findings add to existing data to underscore the importance of screening for low bone density and low vitamin D levels, Dr. Cooper added.

Dr. Cooper said that he was not surprised by the study findings. “I think that this study supported what clinicians already knew, which is that GnRH agonists do potentially cause a decline in bone mineral density and thus, you need to support these patients as best you can with calcium, vitamin D, and weight-bearing exercise,” he noted.

Dr. Cooper emphasized two main take-home points from the study. “First, clinicians who prescribe GnRH agonists need to ensure that they are checking bone density and vitamin D measurements, and then optimizing these appropriately,” he said. “Second, when a bone density is found to be low or a vitamin level is low, clinicians need to ensure that they are monitored and treated appropriately.” Clinicians need to use these data when deciding when to start gender-affirming hormones so their patients have the best chance to recover bone density, he added.

“I think one confounding factor on this study is the ranges they used for vitamin D deficiency,” Dr. Cooper noted. “This study was done in Canada, and the scale used was in nmol/L, while most labs in the U.S. use ng/mL,” he said. “Most pediatric and adolescent societies in the United States use < 20 ng/mL as an indicator of vitamin D deficient and between 20 and 29 ng/mL as insufficient,” he explained, citing the position statement on recommended vitamin D intake for adolescents published by The Society for Adolescent Health and Medicine. In this study, the results converted to < 12 ng/mL as deficient and between 12 and 20 ng/mL as insufficient, respectively, on the U.S. scale, said Dr. Cooper.

“Therefore, I can see that there are cases where someone may have been labeled vitamin D insufficient in this study using their range, whereas in the U.S. these patients would be labeled as vitamin D deficient and treated with higher-dose supplementation,” he said. In addition, individuals with levels between 20 ng/mL and 29 ng/mL in the U.S. would still be treated with vitamin D supplementation, “whereas in their study those individuals would have been labeled as normal,” he noted.

As for future research, it would be useful to study whether bone mass in transgender young people differs from age- and gender-matched controls who are not gender diverse (cisgender), Dr. Cooper added. “It may be possible that the youth in this study are not different from their peers and maybe the GnRH agonist is not the culprit,” he said.

The study received no outside funding. The researchers, editorial authors, and Dr. Cooper had no financial conflicts to disclose.

The Society of Hospital Medicine’s annual Chapter Excellence Exemplary Awards have additional meaning this year, in the wake of the persistent challenges faced by the medical profession as a result of the COVID-19 pandemic.

SHM Hampton Roads chapter

“The Chapter Excellence Award program is an annual rewards program to recognize outstanding work conducted by chapters to carry out the SHM mission locally,” Lisa Kroll, associate director of membership at SHM, said in an interview.

The Chapter Excellence Award program is composed of Status Awards (Platinum, Gold, Silver, and Bronze) and Exemplary Awards. “Chapters that receive these awards have demonstrated growth, sustenance, and innovation within their chapter activities,” Ms. Kroll said.

For 2020, the Houston Chapter received the Outstanding Chapter of the Year Award, the Hampton Roads (Va.) Chapter received the Resiliency Award, and Amith Skandhan, MD, SFHM, of the Wiregrass Chapter in Alabama, received the Most Engaged Chapter Leader Award.

“SHM members are assigned to a chapter based on their geographical location and are provided opportunities for education and networking through in-person and virtual events, volunteering in a chapter leadership position, and connecting with local hospitalists through the chapter’s community in HMX, SHM’s online engagement platform,” Ms. Kroll said.

The Houston Chapter received the Outstanding Chapter of the Year Award because it “exemplified high performance during 2020,” Ms. Kroll said. “During a particularly challenging year for everyone, the chapter was able to rethink how they could make the largest impact for members and expand their audience with the use of virtual meetings, provide incentives for participants, and expand their leadership team.”

“The Houston Chapter has been successful in establishing a Houston-wide Resident Interest Group to better involve and provide SHM resources to the residents within the four local internal medicine residency programs who are interested in hospital medicine,” Ms. Kroll said. “Additionally, the chapter created its first curriculum to assist residents in knowing more about hospital medicine and how to approach the job search. The Houston Chapter has provided sources of support, both emotionally and professionally, and incorporated comedians and musicians into their web meetings to provide a much-needed break from medical content.”

The Resiliency Award is a new SHM award category that goes to one chapter that has gone “above and beyond” to showcase their ability to withstand and rise above hardships, as well as to successfully adapt and position the chapter for long term sustainability and success, according to Ms. Kroll. “The Hampton Roads Chapter received this award for the 2020 year. Some of the chapter’s accomplishments included initiating a provider well-being series.”

Ms. Kroll noted that the Hampton Roads Chapter thrived by trying new approaches and ideas to bring hospitalists together across a wide region, such as by utilizing the virtual format to provide more specialized outreach to providers and recognize hospitalists’ contributions to the broader community.

The Most Engaged Chapter Leader Award was given to Alabama-based hospitalist Dr. Skandhan, who “has demonstrated how he goes above and beyond to grow and sustain the Wiregrass Chapter of SHM and continues to carry out the SHM mission,” Ms. Kroll said.

Dr. Skandhan’s accomplishments in 2020 include inviting four Alabama state representatives and three Alabama state senators to participate in a case discussion with Wiregrass Chapter leaders; creating and moderating a weekly check-in platform for the Alabama state hospital-medicine program directors’ forum through the Wiregrass Chapter – a project that enabled him to encourage the sharing of information between hospital medicine program directors; and working with the other Wiregrass Chapter leaders to launch a poster competition on Twitter with more than 80 posters presented. 
 

Hampton Roads Chapter embraces virtual connections

“I believe chapters are one of the best answers to the question: ‘What’s the value of joining SHM?’” Thomas Miller, MD, FHM, leader of the Hampton Roads Chapter, said in an interview.

“Sharing ideas and experiences with other hospitalist teams in a region, coordinating efforts to improve care, and the personal connection with others in your field are very important for hospitalists,” he emphasized. “Chapters are uniquely positioned to do just that. Recognizing individual chapters is a great way to highlight these benefits and to promote new ideas – which other chapters can incorporate into their future plans.”

The Hampton Roads Chapter demonstrated its resilience in many ways during the challenging year of 2020, Dr. Miller said.

“We love our in-person meetings,” he emphasized. “When 2020 took that away from us, we tried to make the most of the situation by embracing the reduced overhead of the virtual format to offer more specialized outreach programs, such as ‘Cultural Context Matters: How Race and Culture Impact Health Outcomes’ and ‘Critical Care: Impact of Immigration Policy on U.S. Healthcare.’ ” The critical care and immigration program “was a great outreach to our many international physicians who have faced special struggles during COVID; it not only highlighted these issues to other hospitalists, but to the broader community, since it was a joint meeting with our local World Affairs Council,” he added.

Dr. Miller also was impressed with the resilience of other chapter members, “such as our vice president, Dr. Gwen Williams, who put together a provider well-being series, ‘Hospitalist Well Being & Support in Times of Crisis.’ ” He expressed further appreciation for the multiple chapter members who supported the chapter’s virtual resident abstract/poster competition.

“Despite the limitations imposed by 2020, we have used unique approaches that have held together a strong core group while broadening outreach to new providers in our region through programs like those described,” said Dr. Miller. “At the same time, we have promoted hospital medicine to the broader community through a joint program, increased social media presence, and achieved cover articles in Hampton Roads Physician about hospital medicine and a ‘Heroes of COVID’ story featuring chapter members. We also continued our effort to add value by providing ready access to the newly state-mandated CME with ‘Opiate Prescribing in the 21st Century.’

“In a time when even family and close friends struggled to maintain connection, we found ways to offer that to our hospitalist teams, at the same time experimenting with new tools that we can put to use long after COVID is gone,” Dr. Miller added.
 

Houston Chapter supports residents, provides levity

“As a medical community, we hope that the award recognition brings more attention to the issues for which our chapter advocates,” Jeffrey W. Chen, MD, of the Houston Chapter and a hospitalist at Memorial Hermann Hospital Texas Medical Center, said in an interview.

“We hope that it encourages more residents to pursue hospital medicine, and encourages early career hospitalists to get plugged in to the incredible opportunities our chapter offers,” he said. “We are so incredibly honored that the Society of Hospital Medicine has recognized the decade of work that has gone on to get to where we are now. We started with one officer, and we have worked so hard to grow and expand over the years so we can help support our fellow hospitalists across the city and state. 

“We are excited about what our chapter has been able to achieve,” said Dr. Chen. “We united the four internal medicine residencies around Houston and created a Houston-wide Hospitalist Interest Group to support residents, providing them the resources they need to be successful in pursuing a career in hospital medicine. We also are proud of the support we provided this year to our early career hospitalists, helping them navigate the transitions and stay up to date in topics relevant to hospital medicine. We held our biggest abstract competition yet, and held a virtual research showcase to celebrate the incredible clinical advancements still happening during the midst of the pandemic.

“It was certainly a tough and challenging year for all chapters, but despite us not being able to hold the in-person dinners that our members love so much, we were proud that we were able to have such a big year,” said Dr. Chen. “We were thankful for the physicians who led our COVID-19 talks, which provided an opportunity for hospitalists across Houston to collaborate and share ideas on which treatments and therapies were working well for their patients. During such a difficult year, we also hosted our first wellness events, including a comedian and band to bring some light during tough times.”
 

Strong leader propels team efforts

“The Chapter Exemplary Awards Program is important because it encourages higher performance while increasing membership engagement and retaining talent,” said Dr. Skandhan, of Southeast Health Medical Center in Dothan, Ala., and winner of the Most Engaged Chapter Leader award. “Being recognized as the most engaged chapter leader is an honor, especially given the national and international presence of SHM.

“Success is achieved through the help and support of your peers and mentors, and I am fortunate to have found them through this organization,” said Dr. Skandhan. “This award brings attention to the fantastic work done by the engaged membership and leadership of the Wiregrass Chapter. This recognition makes me proud to be part of a team that prides itself on improving the quality health and wellbeing of the patients, providers, and public through innovation and collaboration; this is a testament to their work.”

Dr. Skandhan’s activities as a chapter leader included visiting health care facilities in the rural Southeastern United States. “I slowly began to learn how small towns and their economies tied into a health system, how invested the health care providers were towards their communities, and how health care disparities existed between the rural and urban populations,” he explained. “When the COVID-19 pandemic hit, I worried about these hospitals and their providers. COVID-19 was a new disease with limited understanding of the virus, treatment options, and prevention protocols.” To help smaller hospitals, the Wiregrass Chapter created a weekly check-in for hospital medicine program directors in the state of Alabama, he said.

“We would start the meeting with each participant reporting the total number of cases, ventilator usage, COVID-19 deaths, and one policy change they did that week to address a pressing issue,” Dr. Skandhan said. “Over time the meetings helped address common challenges and were a source of physician well-being.”

In addition, Dr. Skandhan and his chapter colleagues were concerned that academics were taking a back seat to the pandemic, so they rose to the challenge by designing a Twitter-based poster competition using judges from across the country. “This project was led by one of our chapter leaders, Dr. Arash Velayati of Southeast Health Medical Center,” said Dr. Skandhan. The contest included 82 posters, and the participants were able to showcase their work to a large, virtual audience.

Dr. Skandhan and colleagues also decided to partner with religious leaders in their community to help combat the spread of misinformation about COVID-19. “We teamed with the Southern Alabama Baptist Association and Interfaith Council to educate these religious leaders on the issues around COVID-19,” and addressed topics including masking and social distancing, and provided resources for religious leaders to tackle misinformation in their communities, he said.

“As chapter leaders, we need to learn to think outside the box,” Dr. Skandhan emphasized. “We can affect health care quality when we strive to solve more significant problems by bringing people together, brainstorming, and collaborating. SHM and chapter-level engagement provide us with that opportunity.“Hospitalists are often affected by the downstream effects of limited preventive care addressing chronic illnesses. Therefore, we have to strive to see the bigger picture. As we make changes at our local institutions and chapter levels, we will start seeing the improvement we hope to see in the care of our patients and our communities.”

The Society of Hospital Medicine’s annual Chapter Excellence Exemplary Awards have additional meaning this year, in the wake of the persistent challenges faced by the medical profession as a result of the COVID-19 pandemic.

SHM Hampton Roads chapter

“The Chapter Excellence Award program is an annual rewards program to recognize outstanding work conducted by chapters to carry out the SHM mission locally,” Lisa Kroll, associate director of membership at SHM, said in an interview.

The Chapter Excellence Award program is composed of Status Awards (Platinum, Gold, Silver, and Bronze) and Exemplary Awards. “Chapters that receive these awards have demonstrated growth, sustenance, and innovation within their chapter activities,” Ms. Kroll said.

For 2020, the Houston Chapter received the Outstanding Chapter of the Year Award, the Hampton Roads (Va.) Chapter received the Resiliency Award, and Amith Skandhan, MD, SFHM, of the Wiregrass Chapter in Alabama, received the Most Engaged Chapter Leader Award.

“SHM members are assigned to a chapter based on their geographical location and are provided opportunities for education and networking through in-person and virtual events, volunteering in a chapter leadership position, and connecting with local hospitalists through the chapter’s community in HMX, SHM’s online engagement platform,” Ms. Kroll said.

The Houston Chapter received the Outstanding Chapter of the Year Award because it “exemplified high performance during 2020,” Ms. Kroll said. “During a particularly challenging year for everyone, the chapter was able to rethink how they could make the largest impact for members and expand their audience with the use of virtual meetings, provide incentives for participants, and expand their leadership team.”

“The Houston Chapter has been successful in establishing a Houston-wide Resident Interest Group to better involve and provide SHM resources to the residents within the four local internal medicine residency programs who are interested in hospital medicine,” Ms. Kroll said. “Additionally, the chapter created its first curriculum to assist residents in knowing more about hospital medicine and how to approach the job search. The Houston Chapter has provided sources of support, both emotionally and professionally, and incorporated comedians and musicians into their web meetings to provide a much-needed break from medical content.”

The Resiliency Award is a new SHM award category that goes to one chapter that has gone “above and beyond” to showcase their ability to withstand and rise above hardships, as well as to successfully adapt and position the chapter for long term sustainability and success, according to Ms. Kroll. “The Hampton Roads Chapter received this award for the 2020 year. Some of the chapter’s accomplishments included initiating a provider well-being series.”

Ms. Kroll noted that the Hampton Roads Chapter thrived by trying new approaches and ideas to bring hospitalists together across a wide region, such as by utilizing the virtual format to provide more specialized outreach to providers and recognize hospitalists’ contributions to the broader community.

The Most Engaged Chapter Leader Award was given to Alabama-based hospitalist Dr. Skandhan, who “has demonstrated how he goes above and beyond to grow and sustain the Wiregrass Chapter of SHM and continues to carry out the SHM mission,” Ms. Kroll said.

Dr. Skandhan’s accomplishments in 2020 include inviting four Alabama state representatives and three Alabama state senators to participate in a case discussion with Wiregrass Chapter leaders; creating and moderating a weekly check-in platform for the Alabama state hospital-medicine program directors’ forum through the Wiregrass Chapter – a project that enabled him to encourage the sharing of information between hospital medicine program directors; and working with the other Wiregrass Chapter leaders to launch a poster competition on Twitter with more than 80 posters presented. 
 

Hampton Roads Chapter embraces virtual connections

“I believe chapters are one of the best answers to the question: ‘What’s the value of joining SHM?’” Thomas Miller, MD, FHM, leader of the Hampton Roads Chapter, said in an interview.

“Sharing ideas and experiences with other hospitalist teams in a region, coordinating efforts to improve care, and the personal connection with others in your field are very important for hospitalists,” he emphasized. “Chapters are uniquely positioned to do just that. Recognizing individual chapters is a great way to highlight these benefits and to promote new ideas – which other chapters can incorporate into their future plans.”

The Hampton Roads Chapter demonstrated its resilience in many ways during the challenging year of 2020, Dr. Miller said.

“We love our in-person meetings,” he emphasized. “When 2020 took that away from us, we tried to make the most of the situation by embracing the reduced overhead of the virtual format to offer more specialized outreach programs, such as ‘Cultural Context Matters: How Race and Culture Impact Health Outcomes’ and ‘Critical Care: Impact of Immigration Policy on U.S. Healthcare.’ ” The critical care and immigration program “was a great outreach to our many international physicians who have faced special struggles during COVID; it not only highlighted these issues to other hospitalists, but to the broader community, since it was a joint meeting with our local World Affairs Council,” he added.

Dr. Miller also was impressed with the resilience of other chapter members, “such as our vice president, Dr. Gwen Williams, who put together a provider well-being series, ‘Hospitalist Well Being & Support in Times of Crisis.’ ” He expressed further appreciation for the multiple chapter members who supported the chapter’s virtual resident abstract/poster competition.

“Despite the limitations imposed by 2020, we have used unique approaches that have held together a strong core group while broadening outreach to new providers in our region through programs like those described,” said Dr. Miller. “At the same time, we have promoted hospital medicine to the broader community through a joint program, increased social media presence, and achieved cover articles in Hampton Roads Physician about hospital medicine and a ‘Heroes of COVID’ story featuring chapter members. We also continued our effort to add value by providing ready access to the newly state-mandated CME with ‘Opiate Prescribing in the 21st Century.’

“In a time when even family and close friends struggled to maintain connection, we found ways to offer that to our hospitalist teams, at the same time experimenting with new tools that we can put to use long after COVID is gone,” Dr. Miller added.
 

Houston Chapter supports residents, provides levity

“As a medical community, we hope that the award recognition brings more attention to the issues for which our chapter advocates,” Jeffrey W. Chen, MD, of the Houston Chapter and a hospitalist at Memorial Hermann Hospital Texas Medical Center, said in an interview.

“We hope that it encourages more residents to pursue hospital medicine, and encourages early career hospitalists to get plugged in to the incredible opportunities our chapter offers,” he said. “We are so incredibly honored that the Society of Hospital Medicine has recognized the decade of work that has gone on to get to where we are now. We started with one officer, and we have worked so hard to grow and expand over the years so we can help support our fellow hospitalists across the city and state. 

“We are excited about what our chapter has been able to achieve,” said Dr. Chen. “We united the four internal medicine residencies around Houston and created a Houston-wide Hospitalist Interest Group to support residents, providing them the resources they need to be successful in pursuing a career in hospital medicine. We also are proud of the support we provided this year to our early career hospitalists, helping them navigate the transitions and stay up to date in topics relevant to hospital medicine. We held our biggest abstract competition yet, and held a virtual research showcase to celebrate the incredible clinical advancements still happening during the midst of the pandemic.

“It was certainly a tough and challenging year for all chapters, but despite us not being able to hold the in-person dinners that our members love so much, we were proud that we were able to have such a big year,” said Dr. Chen. “We were thankful for the physicians who led our COVID-19 talks, which provided an opportunity for hospitalists across Houston to collaborate and share ideas on which treatments and therapies were working well for their patients. During such a difficult year, we also hosted our first wellness events, including a comedian and band to bring some light during tough times.”
 

Strong leader propels team efforts

“The Chapter Exemplary Awards Program is important because it encourages higher performance while increasing membership engagement and retaining talent,” said Dr. Skandhan, of Southeast Health Medical Center in Dothan, Ala., and winner of the Most Engaged Chapter Leader award. “Being recognized as the most engaged chapter leader is an honor, especially given the national and international presence of SHM.

“Success is achieved through the help and support of your peers and mentors, and I am fortunate to have found them through this organization,” said Dr. Skandhan. “This award brings attention to the fantastic work done by the engaged membership and leadership of the Wiregrass Chapter. This recognition makes me proud to be part of a team that prides itself on improving the quality health and wellbeing of the patients, providers, and public through innovation and collaboration; this is a testament to their work.”

Dr. Skandhan’s activities as a chapter leader included visiting health care facilities in the rural Southeastern United States. “I slowly began to learn how small towns and their economies tied into a health system, how invested the health care providers were towards their communities, and how health care disparities existed between the rural and urban populations,” he explained. “When the COVID-19 pandemic hit, I worried about these hospitals and their providers. COVID-19 was a new disease with limited understanding of the virus, treatment options, and prevention protocols.” To help smaller hospitals, the Wiregrass Chapter created a weekly check-in for hospital medicine program directors in the state of Alabama, he said.

“We would start the meeting with each participant reporting the total number of cases, ventilator usage, COVID-19 deaths, and one policy change they did that week to address a pressing issue,” Dr. Skandhan said. “Over time the meetings helped address common challenges and were a source of physician well-being.”

In addition, Dr. Skandhan and his chapter colleagues were concerned that academics were taking a back seat to the pandemic, so they rose to the challenge by designing a Twitter-based poster competition using judges from across the country. “This project was led by one of our chapter leaders, Dr. Arash Velayati of Southeast Health Medical Center,” said Dr. Skandhan. The contest included 82 posters, and the participants were able to showcase their work to a large, virtual audience.

Dr. Skandhan and colleagues also decided to partner with religious leaders in their community to help combat the spread of misinformation about COVID-19. “We teamed with the Southern Alabama Baptist Association and Interfaith Council to educate these religious leaders on the issues around COVID-19,” and addressed topics including masking and social distancing, and provided resources for religious leaders to tackle misinformation in their communities, he said.

“As chapter leaders, we need to learn to think outside the box,” Dr. Skandhan emphasized. “We can affect health care quality when we strive to solve more significant problems by bringing people together, brainstorming, and collaborating. SHM and chapter-level engagement provide us with that opportunity.“Hospitalists are often affected by the downstream effects of limited preventive care addressing chronic illnesses. Therefore, we have to strive to see the bigger picture. As we make changes at our local institutions and chapter levels, we will start seeing the improvement we hope to see in the care of our patients and our communities.”

The Society of Hospital Medicine’s annual Chapter Excellence Exemplary Awards have additional meaning this year, in the wake of the persistent challenges faced by the medical profession as a result of the COVID-19 pandemic.

SHM Hampton Roads chapter

“The Chapter Excellence Award program is an annual rewards program to recognize outstanding work conducted by chapters to carry out the SHM mission locally,” Lisa Kroll, associate director of membership at SHM, said in an interview.

The Chapter Excellence Award program is composed of Status Awards (Platinum, Gold, Silver, and Bronze) and Exemplary Awards. “Chapters that receive these awards have demonstrated growth, sustenance, and innovation within their chapter activities,” Ms. Kroll said.

For 2020, the Houston Chapter received the Outstanding Chapter of the Year Award, the Hampton Roads (Va.) Chapter received the Resiliency Award, and Amith Skandhan, MD, SFHM, of the Wiregrass Chapter in Alabama, received the Most Engaged Chapter Leader Award.

“SHM members are assigned to a chapter based on their geographical location and are provided opportunities for education and networking through in-person and virtual events, volunteering in a chapter leadership position, and connecting with local hospitalists through the chapter’s community in HMX, SHM’s online engagement platform,” Ms. Kroll said.

The Houston Chapter received the Outstanding Chapter of the Year Award because it “exemplified high performance during 2020,” Ms. Kroll said. “During a particularly challenging year for everyone, the chapter was able to rethink how they could make the largest impact for members and expand their audience with the use of virtual meetings, provide incentives for participants, and expand their leadership team.”

“The Houston Chapter has been successful in establishing a Houston-wide Resident Interest Group to better involve and provide SHM resources to the residents within the four local internal medicine residency programs who are interested in hospital medicine,” Ms. Kroll said. “Additionally, the chapter created its first curriculum to assist residents in knowing more about hospital medicine and how to approach the job search. The Houston Chapter has provided sources of support, both emotionally and professionally, and incorporated comedians and musicians into their web meetings to provide a much-needed break from medical content.”

The Resiliency Award is a new SHM award category that goes to one chapter that has gone “above and beyond” to showcase their ability to withstand and rise above hardships, as well as to successfully adapt and position the chapter for long term sustainability and success, according to Ms. Kroll. “The Hampton Roads Chapter received this award for the 2020 year. Some of the chapter’s accomplishments included initiating a provider well-being series.”

Ms. Kroll noted that the Hampton Roads Chapter thrived by trying new approaches and ideas to bring hospitalists together across a wide region, such as by utilizing the virtual format to provide more specialized outreach to providers and recognize hospitalists’ contributions to the broader community.

The Most Engaged Chapter Leader Award was given to Alabama-based hospitalist Dr. Skandhan, who “has demonstrated how he goes above and beyond to grow and sustain the Wiregrass Chapter of SHM and continues to carry out the SHM mission,” Ms. Kroll said.

Dr. Skandhan’s accomplishments in 2020 include inviting four Alabama state representatives and three Alabama state senators to participate in a case discussion with Wiregrass Chapter leaders; creating and moderating a weekly check-in platform for the Alabama state hospital-medicine program directors’ forum through the Wiregrass Chapter – a project that enabled him to encourage the sharing of information between hospital medicine program directors; and working with the other Wiregrass Chapter leaders to launch a poster competition on Twitter with more than 80 posters presented. 
 

Hampton Roads Chapter embraces virtual connections

“I believe chapters are one of the best answers to the question: ‘What’s the value of joining SHM?’” Thomas Miller, MD, FHM, leader of the Hampton Roads Chapter, said in an interview.

“Sharing ideas and experiences with other hospitalist teams in a region, coordinating efforts to improve care, and the personal connection with others in your field are very important for hospitalists,” he emphasized. “Chapters are uniquely positioned to do just that. Recognizing individual chapters is a great way to highlight these benefits and to promote new ideas – which other chapters can incorporate into their future plans.”

The Hampton Roads Chapter demonstrated its resilience in many ways during the challenging year of 2020, Dr. Miller said.

“We love our in-person meetings,” he emphasized. “When 2020 took that away from us, we tried to make the most of the situation by embracing the reduced overhead of the virtual format to offer more specialized outreach programs, such as ‘Cultural Context Matters: How Race and Culture Impact Health Outcomes’ and ‘Critical Care: Impact of Immigration Policy on U.S. Healthcare.’ ” The critical care and immigration program “was a great outreach to our many international physicians who have faced special struggles during COVID; it not only highlighted these issues to other hospitalists, but to the broader community, since it was a joint meeting with our local World Affairs Council,” he added.

Dr. Miller also was impressed with the resilience of other chapter members, “such as our vice president, Dr. Gwen Williams, who put together a provider well-being series, ‘Hospitalist Well Being & Support in Times of Crisis.’ ” He expressed further appreciation for the multiple chapter members who supported the chapter’s virtual resident abstract/poster competition.

“Despite the limitations imposed by 2020, we have used unique approaches that have held together a strong core group while broadening outreach to new providers in our region through programs like those described,” said Dr. Miller. “At the same time, we have promoted hospital medicine to the broader community through a joint program, increased social media presence, and achieved cover articles in Hampton Roads Physician about hospital medicine and a ‘Heroes of COVID’ story featuring chapter members. We also continued our effort to add value by providing ready access to the newly state-mandated CME with ‘Opiate Prescribing in the 21st Century.’

“In a time when even family and close friends struggled to maintain connection, we found ways to offer that to our hospitalist teams, at the same time experimenting with new tools that we can put to use long after COVID is gone,” Dr. Miller added.
 

Houston Chapter supports residents, provides levity

“As a medical community, we hope that the award recognition brings more attention to the issues for which our chapter advocates,” Jeffrey W. Chen, MD, of the Houston Chapter and a hospitalist at Memorial Hermann Hospital Texas Medical Center, said in an interview.

“We hope that it encourages more residents to pursue hospital medicine, and encourages early career hospitalists to get plugged in to the incredible opportunities our chapter offers,” he said. “We are so incredibly honored that the Society of Hospital Medicine has recognized the decade of work that has gone on to get to where we are now. We started with one officer, and we have worked so hard to grow and expand over the years so we can help support our fellow hospitalists across the city and state. 

“We are excited about what our chapter has been able to achieve,” said Dr. Chen. “We united the four internal medicine residencies around Houston and created a Houston-wide Hospitalist Interest Group to support residents, providing them the resources they need to be successful in pursuing a career in hospital medicine. We also are proud of the support we provided this year to our early career hospitalists, helping them navigate the transitions and stay up to date in topics relevant to hospital medicine. We held our biggest abstract competition yet, and held a virtual research showcase to celebrate the incredible clinical advancements still happening during the midst of the pandemic.

“It was certainly a tough and challenging year for all chapters, but despite us not being able to hold the in-person dinners that our members love so much, we were proud that we were able to have such a big year,” said Dr. Chen. “We were thankful for the physicians who led our COVID-19 talks, which provided an opportunity for hospitalists across Houston to collaborate and share ideas on which treatments and therapies were working well for their patients. During such a difficult year, we also hosted our first wellness events, including a comedian and band to bring some light during tough times.”
 

Strong leader propels team efforts

“The Chapter Exemplary Awards Program is important because it encourages higher performance while increasing membership engagement and retaining talent,” said Dr. Skandhan, of Southeast Health Medical Center in Dothan, Ala., and winner of the Most Engaged Chapter Leader award. “Being recognized as the most engaged chapter leader is an honor, especially given the national and international presence of SHM.

“Success is achieved through the help and support of your peers and mentors, and I am fortunate to have found them through this organization,” said Dr. Skandhan. “This award brings attention to the fantastic work done by the engaged membership and leadership of the Wiregrass Chapter. This recognition makes me proud to be part of a team that prides itself on improving the quality health and wellbeing of the patients, providers, and public through innovation and collaboration; this is a testament to their work.”

Dr. Skandhan’s activities as a chapter leader included visiting health care facilities in the rural Southeastern United States. “I slowly began to learn how small towns and their economies tied into a health system, how invested the health care providers were towards their communities, and how health care disparities existed between the rural and urban populations,” he explained. “When the COVID-19 pandemic hit, I worried about these hospitals and their providers. COVID-19 was a new disease with limited understanding of the virus, treatment options, and prevention protocols.” To help smaller hospitals, the Wiregrass Chapter created a weekly check-in for hospital medicine program directors in the state of Alabama, he said.

“We would start the meeting with each participant reporting the total number of cases, ventilator usage, COVID-19 deaths, and one policy change they did that week to address a pressing issue,” Dr. Skandhan said. “Over time the meetings helped address common challenges and were a source of physician well-being.”

In addition, Dr. Skandhan and his chapter colleagues were concerned that academics were taking a back seat to the pandemic, so they rose to the challenge by designing a Twitter-based poster competition using judges from across the country. “This project was led by one of our chapter leaders, Dr. Arash Velayati of Southeast Health Medical Center,” said Dr. Skandhan. The contest included 82 posters, and the participants were able to showcase their work to a large, virtual audience.

Dr. Skandhan and colleagues also decided to partner with religious leaders in their community to help combat the spread of misinformation about COVID-19. “We teamed with the Southern Alabama Baptist Association and Interfaith Council to educate these religious leaders on the issues around COVID-19,” and addressed topics including masking and social distancing, and provided resources for religious leaders to tackle misinformation in their communities, he said.

“As chapter leaders, we need to learn to think outside the box,” Dr. Skandhan emphasized. “We can affect health care quality when we strive to solve more significant problems by bringing people together, brainstorming, and collaborating. SHM and chapter-level engagement provide us with that opportunity.“Hospitalists are often affected by the downstream effects of limited preventive care addressing chronic illnesses. Therefore, we have to strive to see the bigger picture. As we make changes at our local institutions and chapter levels, we will start seeing the improvement we hope to see in the care of our patients and our communities.”

Functional luminal imaging probe (FLIP) panometry proved superior to high-resolution manometry (HRM) for evaluation of esophageal motility, according to a new study based on data from 329 adults.

Eraxion/Thinkstock.com

HRM is generally considered the primary method for evaluating esophageal motility, but current recommendations include the use of a FLIP or timed barium esophogram (TBE) if HRM yields inconclusive results, Dustin A. Carlson, MD, of Northwestern University, Chicago, and colleagues wrote in the recent study. FLIP has several potential advantages over HRM, including that “the test is performed on a sedated patient at the time of endoscopy, as opposed to the awake transnasal catheter used for HRM”; however, comparisons of the two methods for predicting esophageal retention are lacking.

In the study published in the American Journal of Gastroenterology, the researchers reviewed data from 329 consecutive patients aged 18-89 years who completed FLIP, HRM, and TBE for evaluation of primary esophageal motility. They excluded patients with previous foregut surgery. The researchers compared the ability of FLIP and HRM to predict esophageal retention based on abnormal TBE findings, which was defined as a 1-minute column height greater than 5 cm or as impaction of a 12.5-mm barium tablet.

For HRM, the integrated relaxation pressure (IRP) was assessed in the supine and upright patient positions to predict abnormal TBE findings. For FLIP, esophagogastric junction (EGJ) opening was assessed with a 16-cm FLIP performed during sedated endoscopy, and the presence of abnormal TBE findings was determined using the EGJ–distensibility index and maximum EGJ diameter.

The area under the ROC curve for identifying abnormal TBE findings was 0.79 (95% confidence interval, 0.75-0.84) for supine, 0.79 (95% CI, 0.76-0.86) for upright IRP, 0.84 (95% CI, 0.79-0.88) for the EGJ–distensibility index, and 0.88 (95% CI, 0.85-0.92) for the maximum EGJ diameter.

In a logistic regression analysis, the odds ratios for predicting abnormal TBE findings were 1.8 (95% confidence interval, 0.84-3.7; P < .133) for consistent elevation of IRP in HRM, compared with normal IRP, and 39.7 (95% CI, 16.4-96.2; P < .001) for reduced EGJ opening on FLIP panometry, compared with normal EGJ opening.

“Both the IRP on HRM and FLIP panometry metrics of EGJ opening (EGJ–[distensibility index] and maximum EGJ diameter) demonstrated capabilities to differentiate between abnormal and normal esophageal retention, which supports confidence in both tools,” the authors explained. “However, FLIP panometry parameters did so more accurately and with greater predictive capability as reflected by ROC and regression analysis.”

A total of 40 patients (12%) showed discordance between their HRM and FLIP panometry measures, and among these, FLIP showed stronger detection of esophageal retention. FLIP panometry was consistent with TBE in 78% of cases, while HRM-IRP was consistent with TBE in 23%. “Discordant results between HRM and FLIP panometry were observed in previous studies and again in this study, a scenario with unclear clinical significance,” the authors noted, which was why they used TBE as “an objective measure of esophageal retention that was independent of both HRM and FLIP to compare the two modalities.”

The study findings were limited by several factors including ones related to the use of TBE as the primary outcome, as well as the lack of longitudinal outcomes, the researchers noted. There is also the potential for referral bias and selection bias with an overrepresentation of patients with achalasia and EGJ outflow obstruction. However, the results were strengthened by the large sample size of patients who completed evaluations with HRM, FLIP, and TBE.

The study “provides additional support for the use of FLIP panometry to evaluate esophageal motility because it accurately identifies normal and abnormal retention, but also identifies patients who should undergo further complementary diagnostic testing,” they noted. Longitudinal studies are needed to explore best practices for managing esophageal motor disorders. In the meantime, evaluation with FLIP panometry, TBE, and HRM likely remains necessary for some patients, “particularly those with equivocal findings on a single test,” to better characterize disease and guide treatment, the researchers concluded.
 

Findings support potential of FLIP

“The endoscopic FLIP is an exciting clinical tool that utilizes distension of a catheter-mounted balloon to different volumes to acquire esophageal dimensions and pressures,” Amit Patel, MD, of Duke University, Durham, N.C., said in an interview.

“Accumulating data on FLIP inspired [recently published guidelines] to suggest the use of FLIP to complement high-resolution manometry in the setting of obstructive esophageal symptoms and borderline HRM findings, for patients in whom an HRM study cannot be completed, and for intraprocedural use during interventions for achalasia,” Dr. Patel said. “However, the comparative utility of FLIP, particularly among foundational esophageal diagnostics such as HRM and TBE, is less well developed at this point.”

Dr. Patel said he was surprised by some of the findings. “The characteristics of FLIP metrics (specifically, EGJ–distensibility index <2 mm²/mm Hg and/or maximum EGJ diameter <12 mm) were numerically superior to those for traditional IRP metrics from HRM in predicting retention on TBE on AUROC, regression analyses, and discordant cases in this study,” said Dr. Patel. “Although this study also corroborated the value of IRP on HRM, these findings were somewhat surprising for HRM, given its well-earned reputation as the gold standard for the diagnosis of esophageal motor disorders, its widespread use, and the record of strong data supporting its important role in clinical practice.”

Overall, this study suggests these metrics from FLIP (namely, EGJ–distensibility index and EGJ diameter) may have “diagnostic value beyond traditional IRP metrics from HRM to identify objective retention on TBE,” said Dr. Patel, who also said these exciting findings “support the growth of the complementary role of FLIP ... particularly in cases where HRM may be inconclusive or not tolerated by patients.”

However, more research is needed. “Taking into account other HRM metrics beyond IRP, such as intrabolus pressures or evaluation of bolus transit on impedance, and provocative maneuvers on HRM, such as rapid drink challenges or solid swallows, may be appropriate for further evaluation, as will improved arbitration of ‘borderline’ metrics or less clear cases,” Dr. Patel emphasized. Future studies should also incorporate management interventions and assessments of outcomes.  

The study was supported by a grant from the Public Health service to a coinvestigator, and by the American College of Gastroenterology Junior Faculty Development Award to lead author Dr. Carlson. Dr. Carlson also disclosed speaking and consulting relationships with Medtronic, which manufactures FLIP panometry systems. Northwestern University and several coauthors also disclosed intellectual property rights and ownership surrounding FLIP panometry systems, methods, and apparatus with Medtronic. Dr. Patel had no financial conflicts to disclose.

This article was updated Oct. 13, 2021.

Functional luminal imaging probe (FLIP) panometry proved superior to high-resolution manometry (HRM) for evaluation of esophageal motility, according to a new study based on data from 329 adults.

Eraxion/Thinkstock.com

HRM is generally considered the primary method for evaluating esophageal motility, but current recommendations include the use of a FLIP or timed barium esophogram (TBE) if HRM yields inconclusive results, Dustin A. Carlson, MD, of Northwestern University, Chicago, and colleagues wrote in the recent study. FLIP has several potential advantages over HRM, including that “the test is performed on a sedated patient at the time of endoscopy, as opposed to the awake transnasal catheter used for HRM”; however, comparisons of the two methods for predicting esophageal retention are lacking.

In the study published in the American Journal of Gastroenterology, the researchers reviewed data from 329 consecutive patients aged 18-89 years who completed FLIP, HRM, and TBE for evaluation of primary esophageal motility. They excluded patients with previous foregut surgery. The researchers compared the ability of FLIP and HRM to predict esophageal retention based on abnormal TBE findings, which was defined as a 1-minute column height greater than 5 cm or as impaction of a 12.5-mm barium tablet.

For HRM, the integrated relaxation pressure (IRP) was assessed in the supine and upright patient positions to predict abnormal TBE findings. For FLIP, esophagogastric junction (EGJ) opening was assessed with a 16-cm FLIP performed during sedated endoscopy, and the presence of abnormal TBE findings was determined using the EGJ–distensibility index and maximum EGJ diameter.

The area under the ROC curve for identifying abnormal TBE findings was 0.79 (95% confidence interval, 0.75-0.84) for supine, 0.79 (95% CI, 0.76-0.86) for upright IRP, 0.84 (95% CI, 0.79-0.88) for the EGJ–distensibility index, and 0.88 (95% CI, 0.85-0.92) for the maximum EGJ diameter.

In a logistic regression analysis, the odds ratios for predicting abnormal TBE findings were 1.8 (95% confidence interval, 0.84-3.7; P < .133) for consistent elevation of IRP in HRM, compared with normal IRP, and 39.7 (95% CI, 16.4-96.2; P < .001) for reduced EGJ opening on FLIP panometry, compared with normal EGJ opening.

“Both the IRP on HRM and FLIP panometry metrics of EGJ opening (EGJ–[distensibility index] and maximum EGJ diameter) demonstrated capabilities to differentiate between abnormal and normal esophageal retention, which supports confidence in both tools,” the authors explained. “However, FLIP panometry parameters did so more accurately and with greater predictive capability as reflected by ROC and regression analysis.”

A total of 40 patients (12%) showed discordance between their HRM and FLIP panometry measures, and among these, FLIP showed stronger detection of esophageal retention. FLIP panometry was consistent with TBE in 78% of cases, while HRM-IRP was consistent with TBE in 23%. “Discordant results between HRM and FLIP panometry were observed in previous studies and again in this study, a scenario with unclear clinical significance,” the authors noted, which was why they used TBE as “an objective measure of esophageal retention that was independent of both HRM and FLIP to compare the two modalities.”

The study findings were limited by several factors including ones related to the use of TBE as the primary outcome, as well as the lack of longitudinal outcomes, the researchers noted. There is also the potential for referral bias and selection bias with an overrepresentation of patients with achalasia and EGJ outflow obstruction. However, the results were strengthened by the large sample size of patients who completed evaluations with HRM, FLIP, and TBE.

The study “provides additional support for the use of FLIP panometry to evaluate esophageal motility because it accurately identifies normal and abnormal retention, but also identifies patients who should undergo further complementary diagnostic testing,” they noted. Longitudinal studies are needed to explore best practices for managing esophageal motor disorders. In the meantime, evaluation with FLIP panometry, TBE, and HRM likely remains necessary for some patients, “particularly those with equivocal findings on a single test,” to better characterize disease and guide treatment, the researchers concluded.
 

Findings support potential of FLIP

“The endoscopic FLIP is an exciting clinical tool that utilizes distension of a catheter-mounted balloon to different volumes to acquire esophageal dimensions and pressures,” Amit Patel, MD, of Duke University, Durham, N.C., said in an interview.

“Accumulating data on FLIP inspired [recently published guidelines] to suggest the use of FLIP to complement high-resolution manometry in the setting of obstructive esophageal symptoms and borderline HRM findings, for patients in whom an HRM study cannot be completed, and for intraprocedural use during interventions for achalasia,” Dr. Patel said. “However, the comparative utility of FLIP, particularly among foundational esophageal diagnostics such as HRM and TBE, is less well developed at this point.”

Dr. Patel said he was surprised by some of the findings. “The characteristics of FLIP metrics (specifically, EGJ–distensibility index <2 mm²/mm Hg and/or maximum EGJ diameter <12 mm) were numerically superior to those for traditional IRP metrics from HRM in predicting retention on TBE on AUROC, regression analyses, and discordant cases in this study,” said Dr. Patel. “Although this study also corroborated the value of IRP on HRM, these findings were somewhat surprising for HRM, given its well-earned reputation as the gold standard for the diagnosis of esophageal motor disorders, its widespread use, and the record of strong data supporting its important role in clinical practice.”

Overall, this study suggests these metrics from FLIP (namely, EGJ–distensibility index and EGJ diameter) may have “diagnostic value beyond traditional IRP metrics from HRM to identify objective retention on TBE,” said Dr. Patel, who also said these exciting findings “support the growth of the complementary role of FLIP ... particularly in cases where HRM may be inconclusive or not tolerated by patients.”

However, more research is needed. “Taking into account other HRM metrics beyond IRP, such as intrabolus pressures or evaluation of bolus transit on impedance, and provocative maneuvers on HRM, such as rapid drink challenges or solid swallows, may be appropriate for further evaluation, as will improved arbitration of ‘borderline’ metrics or less clear cases,” Dr. Patel emphasized. Future studies should also incorporate management interventions and assessments of outcomes.  

The study was supported by a grant from the Public Health service to a coinvestigator, and by the American College of Gastroenterology Junior Faculty Development Award to lead author Dr. Carlson. Dr. Carlson also disclosed speaking and consulting relationships with Medtronic, which manufactures FLIP panometry systems. Northwestern University and several coauthors also disclosed intellectual property rights and ownership surrounding FLIP panometry systems, methods, and apparatus with Medtronic. Dr. Patel had no financial conflicts to disclose.

This article was updated Oct. 13, 2021.

Functional luminal imaging probe (FLIP) panometry proved superior to high-resolution manometry (HRM) for evaluation of esophageal motility, according to a new study based on data from 329 adults.

Eraxion/Thinkstock.com

HRM is generally considered the primary method for evaluating esophageal motility, but current recommendations include the use of a FLIP or timed barium esophogram (TBE) if HRM yields inconclusive results, Dustin A. Carlson, MD, of Northwestern University, Chicago, and colleagues wrote in the recent study. FLIP has several potential advantages over HRM, including that “the test is performed on a sedated patient at the time of endoscopy, as opposed to the awake transnasal catheter used for HRM”; however, comparisons of the two methods for predicting esophageal retention are lacking.

In the study published in the American Journal of Gastroenterology, the researchers reviewed data from 329 consecutive patients aged 18-89 years who completed FLIP, HRM, and TBE for evaluation of primary esophageal motility. They excluded patients with previous foregut surgery. The researchers compared the ability of FLIP and HRM to predict esophageal retention based on abnormal TBE findings, which was defined as a 1-minute column height greater than 5 cm or as impaction of a 12.5-mm barium tablet.

For HRM, the integrated relaxation pressure (IRP) was assessed in the supine and upright patient positions to predict abnormal TBE findings. For FLIP, esophagogastric junction (EGJ) opening was assessed with a 16-cm FLIP performed during sedated endoscopy, and the presence of abnormal TBE findings was determined using the EGJ–distensibility index and maximum EGJ diameter.

The area under the ROC curve for identifying abnormal TBE findings was 0.79 (95% confidence interval, 0.75-0.84) for supine, 0.79 (95% CI, 0.76-0.86) for upright IRP, 0.84 (95% CI, 0.79-0.88) for the EGJ–distensibility index, and 0.88 (95% CI, 0.85-0.92) for the maximum EGJ diameter.

In a logistic regression analysis, the odds ratios for predicting abnormal TBE findings were 1.8 (95% confidence interval, 0.84-3.7; P < .133) for consistent elevation of IRP in HRM, compared with normal IRP, and 39.7 (95% CI, 16.4-96.2; P < .001) for reduced EGJ opening on FLIP panometry, compared with normal EGJ opening.

“Both the IRP on HRM and FLIP panometry metrics of EGJ opening (EGJ–[distensibility index] and maximum EGJ diameter) demonstrated capabilities to differentiate between abnormal and normal esophageal retention, which supports confidence in both tools,” the authors explained. “However, FLIP panometry parameters did so more accurately and with greater predictive capability as reflected by ROC and regression analysis.”

A total of 40 patients (12%) showed discordance between their HRM and FLIP panometry measures, and among these, FLIP showed stronger detection of esophageal retention. FLIP panometry was consistent with TBE in 78% of cases, while HRM-IRP was consistent with TBE in 23%. “Discordant results between HRM and FLIP panometry were observed in previous studies and again in this study, a scenario with unclear clinical significance,” the authors noted, which was why they used TBE as “an objective measure of esophageal retention that was independent of both HRM and FLIP to compare the two modalities.”

The study findings were limited by several factors including ones related to the use of TBE as the primary outcome, as well as the lack of longitudinal outcomes, the researchers noted. There is also the potential for referral bias and selection bias with an overrepresentation of patients with achalasia and EGJ outflow obstruction. However, the results were strengthened by the large sample size of patients who completed evaluations with HRM, FLIP, and TBE.

The study “provides additional support for the use of FLIP panometry to evaluate esophageal motility because it accurately identifies normal and abnormal retention, but also identifies patients who should undergo further complementary diagnostic testing,” they noted. Longitudinal studies are needed to explore best practices for managing esophageal motor disorders. In the meantime, evaluation with FLIP panometry, TBE, and HRM likely remains necessary for some patients, “particularly those with equivocal findings on a single test,” to better characterize disease and guide treatment, the researchers concluded.
 

Findings support potential of FLIP

“The endoscopic FLIP is an exciting clinical tool that utilizes distension of a catheter-mounted balloon to different volumes to acquire esophageal dimensions and pressures,” Amit Patel, MD, of Duke University, Durham, N.C., said in an interview.

“Accumulating data on FLIP inspired [recently published guidelines] to suggest the use of FLIP to complement high-resolution manometry in the setting of obstructive esophageal symptoms and borderline HRM findings, for patients in whom an HRM study cannot be completed, and for intraprocedural use during interventions for achalasia,” Dr. Patel said. “However, the comparative utility of FLIP, particularly among foundational esophageal diagnostics such as HRM and TBE, is less well developed at this point.”

Dr. Patel said he was surprised by some of the findings. “The characteristics of FLIP metrics (specifically, EGJ–distensibility index <2 mm²/mm Hg and/or maximum EGJ diameter <12 mm) were numerically superior to those for traditional IRP metrics from HRM in predicting retention on TBE on AUROC, regression analyses, and discordant cases in this study,” said Dr. Patel. “Although this study also corroborated the value of IRP on HRM, these findings were somewhat surprising for HRM, given its well-earned reputation as the gold standard for the diagnosis of esophageal motor disorders, its widespread use, and the record of strong data supporting its important role in clinical practice.”

Overall, this study suggests these metrics from FLIP (namely, EGJ–distensibility index and EGJ diameter) may have “diagnostic value beyond traditional IRP metrics from HRM to identify objective retention on TBE,” said Dr. Patel, who also said these exciting findings “support the growth of the complementary role of FLIP ... particularly in cases where HRM may be inconclusive or not tolerated by patients.”

However, more research is needed. “Taking into account other HRM metrics beyond IRP, such as intrabolus pressures or evaluation of bolus transit on impedance, and provocative maneuvers on HRM, such as rapid drink challenges or solid swallows, may be appropriate for further evaluation, as will improved arbitration of ‘borderline’ metrics or less clear cases,” Dr. Patel emphasized. Future studies should also incorporate management interventions and assessments of outcomes.  

The study was supported by a grant from the Public Health service to a coinvestigator, and by the American College of Gastroenterology Junior Faculty Development Award to lead author Dr. Carlson. Dr. Carlson also disclosed speaking and consulting relationships with Medtronic, which manufactures FLIP panometry systems. Northwestern University and several coauthors also disclosed intellectual property rights and ownership surrounding FLIP panometry systems, methods, and apparatus with Medtronic. Dr. Patel had no financial conflicts to disclose.

This article was updated Oct. 13, 2021.

High out-of-pocket costs for medications remain a barrier for patients with psoriasis or psoriatic arthritis on Medicare, according to findings from a cross-sectional analysis of the Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary Data from the fourth quarter of 2020.

Mathier/Thinkstock

Although biologics have demonstrated safety and effectiveness for psoriasis and psoriatic arthritis, their costs have risen, which has led patients to switch or discontinue biologics and consequently incur greater health care costs, wrote Sarah P. Pourali and colleagues at Vanderbilt University, Nashville, Tenn.

The authors also noted that Medicare patients in particular experience a financial burden if they have no limits on out-of-pocket spending, and while patient assistance programs may offset some out-of-pocket spending for specialty drugs, not all patients are aware of or qualify for them. Ineligibility for low-income subsidies also serves as a barrier and is associated with lower adherence to treatment.

In a study published in JAMA Dermatology, the researchers identified 5,011 formularies using the CMS data. The medications were etanercept, adalimumab, golimumab, ustekinumab, certolizumab pegol, apremilast, secukinumab, abatacept, ixekizumab, brodalumab, tofacitinib, tofacitinib XR, guselkumab, tildrakizumab, and risankizumab.

Overall, coverage for those 15 specialty medications ranged from 10.0% to 99.8% across products and Part D plans. The most commonly covered medications were adalimumab and ustekinumab (99.8% for both) and the least covered were brodalumab and tildrakizumab (10.9% and 10.0%, respectively).

Prior authorization was required by 90.5%-100% of the plans when medications were covered, and plans with limits on the quantity of medications covered ranged from 1.0% of plans (for guselkumab) to 78% of plans (for tofacitinib).

Copays were relatively rare; 2.4%-5.5% of the plans offered copays on any of the 15 medications.

The standard Medicare benefit for 2021 included a $445 deductible, 25% coinsurance for initial drug spending, and 5% coinsurance for drug spending in the catastrophic phase of coverage, the researchers noted. Overall, apremilast had the lowest estimated out-of-pocket costs for initial fills, under the catastrophic coverage phase, and annual cost, and ustekinumab had the highest. The estimated out-of-pocket costs for an initial fill ranged from $1,234 for apremilast to $3,426 for ustekinumab. Out-of-pocket costs for medications under the catastrophic phase ranged from $181 for apremilast to $1,175 for ustekinumab. Estimated out-of-pocket costs for a year of treatment ranged from $4,423 for apremilast to $6,950 for ustekinumab.

Median point-of-sale prices per fill – meaning pricing with no rebates or discounts – were lowest for apremilast ($3,620.40) and reached $23,492.93 per fill for ustekinumab, the researchers wrote. Other medications with point-of-sale prices above $10,000 were guselkumab ($11,511.52), tildrakizumab ($14,112.13), and risankizumab ($16,248.90).

The study was supported by grants from the Commonwealth Fund and the Leukemia & Lymphoma Society. One author disclosed receiving grants from Arnold Ventures, the Commonwealth Fund, and the Robert Wood Johnson Foundation for unrelated work, as well as honoraria from West Health and the Institute for Clinical and Economic Review.

High out-of-pocket costs for medications remain a barrier for patients with psoriasis or psoriatic arthritis on Medicare, according to findings from a cross-sectional analysis of the Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary Data from the fourth quarter of 2020.

Mathier/Thinkstock

Although biologics have demonstrated safety and effectiveness for psoriasis and psoriatic arthritis, their costs have risen, which has led patients to switch or discontinue biologics and consequently incur greater health care costs, wrote Sarah P. Pourali and colleagues at Vanderbilt University, Nashville, Tenn.

The authors also noted that Medicare patients in particular experience a financial burden if they have no limits on out-of-pocket spending, and while patient assistance programs may offset some out-of-pocket spending for specialty drugs, not all patients are aware of or qualify for them. Ineligibility for low-income subsidies also serves as a barrier and is associated with lower adherence to treatment.

In a study published in JAMA Dermatology, the researchers identified 5,011 formularies using the CMS data. The medications were etanercept, adalimumab, golimumab, ustekinumab, certolizumab pegol, apremilast, secukinumab, abatacept, ixekizumab, brodalumab, tofacitinib, tofacitinib XR, guselkumab, tildrakizumab, and risankizumab.

Overall, coverage for those 15 specialty medications ranged from 10.0% to 99.8% across products and Part D plans. The most commonly covered medications were adalimumab and ustekinumab (99.8% for both) and the least covered were brodalumab and tildrakizumab (10.9% and 10.0%, respectively).

Prior authorization was required by 90.5%-100% of the plans when medications were covered, and plans with limits on the quantity of medications covered ranged from 1.0% of plans (for guselkumab) to 78% of plans (for tofacitinib).

Copays were relatively rare; 2.4%-5.5% of the plans offered copays on any of the 15 medications.

The standard Medicare benefit for 2021 included a $445 deductible, 25% coinsurance for initial drug spending, and 5% coinsurance for drug spending in the catastrophic phase of coverage, the researchers noted. Overall, apremilast had the lowest estimated out-of-pocket costs for initial fills, under the catastrophic coverage phase, and annual cost, and ustekinumab had the highest. The estimated out-of-pocket costs for an initial fill ranged from $1,234 for apremilast to $3,426 for ustekinumab. Out-of-pocket costs for medications under the catastrophic phase ranged from $181 for apremilast to $1,175 for ustekinumab. Estimated out-of-pocket costs for a year of treatment ranged from $4,423 for apremilast to $6,950 for ustekinumab.

Median point-of-sale prices per fill – meaning pricing with no rebates or discounts – were lowest for apremilast ($3,620.40) and reached $23,492.93 per fill for ustekinumab, the researchers wrote. Other medications with point-of-sale prices above $10,000 were guselkumab ($11,511.52), tildrakizumab ($14,112.13), and risankizumab ($16,248.90).

The study was supported by grants from the Commonwealth Fund and the Leukemia & Lymphoma Society. One author disclosed receiving grants from Arnold Ventures, the Commonwealth Fund, and the Robert Wood Johnson Foundation for unrelated work, as well as honoraria from West Health and the Institute for Clinical and Economic Review.

High out-of-pocket costs for medications remain a barrier for patients with psoriasis or psoriatic arthritis on Medicare, according to findings from a cross-sectional analysis of the Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary Data from the fourth quarter of 2020.

Mathier/Thinkstock

Although biologics have demonstrated safety and effectiveness for psoriasis and psoriatic arthritis, their costs have risen, which has led patients to switch or discontinue biologics and consequently incur greater health care costs, wrote Sarah P. Pourali and colleagues at Vanderbilt University, Nashville, Tenn.

The authors also noted that Medicare patients in particular experience a financial burden if they have no limits on out-of-pocket spending, and while patient assistance programs may offset some out-of-pocket spending for specialty drugs, not all patients are aware of or qualify for them. Ineligibility for low-income subsidies also serves as a barrier and is associated with lower adherence to treatment.

In a study published in JAMA Dermatology, the researchers identified 5,011 formularies using the CMS data. The medications were etanercept, adalimumab, golimumab, ustekinumab, certolizumab pegol, apremilast, secukinumab, abatacept, ixekizumab, brodalumab, tofacitinib, tofacitinib XR, guselkumab, tildrakizumab, and risankizumab.

Overall, coverage for those 15 specialty medications ranged from 10.0% to 99.8% across products and Part D plans. The most commonly covered medications were adalimumab and ustekinumab (99.8% for both) and the least covered were brodalumab and tildrakizumab (10.9% and 10.0%, respectively).

Prior authorization was required by 90.5%-100% of the plans when medications were covered, and plans with limits on the quantity of medications covered ranged from 1.0% of plans (for guselkumab) to 78% of plans (for tofacitinib).

Copays were relatively rare; 2.4%-5.5% of the plans offered copays on any of the 15 medications.

The standard Medicare benefit for 2021 included a $445 deductible, 25% coinsurance for initial drug spending, and 5% coinsurance for drug spending in the catastrophic phase of coverage, the researchers noted. Overall, apremilast had the lowest estimated out-of-pocket costs for initial fills, under the catastrophic coverage phase, and annual cost, and ustekinumab had the highest. The estimated out-of-pocket costs for an initial fill ranged from $1,234 for apremilast to $3,426 for ustekinumab. Out-of-pocket costs for medications under the catastrophic phase ranged from $181 for apremilast to $1,175 for ustekinumab. Estimated out-of-pocket costs for a year of treatment ranged from $4,423 for apremilast to $6,950 for ustekinumab.

Median point-of-sale prices per fill – meaning pricing with no rebates or discounts – were lowest for apremilast ($3,620.40) and reached $23,492.93 per fill for ustekinumab, the researchers wrote. Other medications with point-of-sale prices above $10,000 were guselkumab ($11,511.52), tildrakizumab ($14,112.13), and risankizumab ($16,248.90).

The study was supported by grants from the Commonwealth Fund and the Leukemia & Lymphoma Society. One author disclosed receiving grants from Arnold Ventures, the Commonwealth Fund, and the Robert Wood Johnson Foundation for unrelated work, as well as honoraria from West Health and the Institute for Clinical and Economic Review.

Use of cannabidiol (CBD) as an add-on pain management technique in patients with either hand osteoarthritis (OA) or psoriatic arthritis (PsA) did not significantly decrease pain intensity when compared with a placebo in a randomized, double-blind trial described as the first of its kind to investigate the effect of pure CBD as an add-on analgesic therapy in patients with joint disease.

Anatoliy Sizov/Getty Images

Although data on the use of medical cannabis as a modulator of joint pain are limited, some studies suggest an effect from CBD without the addition of delta-9-tetrahydrocannabinol (THC), wrote Jonathan Vela, MD, of Aalborg (Denmark) University Hospital, and colleagues.

CBD is being used for pain conditions despite a lack of data on safety and effectiveness, the researchers emphasized. Notably, in a 2018 online survey, 62% of respondents reported using CBD for medical conditions, primarily for chronic pain and arthritis or joint pain, they wrote.

In a study published in the journal Pain, the researchers randomized 59 adults with PsA and 77 adults with hand OA to 20-30 mg of synthetic CBD or a placebo daily for 12 weeks in addition to conventional pain management. Patients initially received either oral CBD 10 mg or a placebo tablet once daily, increasing to 10 mg twice daily after 2 weeks, and once again up to 10 mg three times daily at 4 weeks if the patient did not experience more than 20-mm improvement on the visual analog scale (VAS).

The primary outcome in the trial was patient-reported pain intensity during the last 24 hours as assessed on a paper-based 100-mm VAS with the text, “How much pain have you experienced in the most symptomatic joint during the last 24 hours?” with 0 representing no pain and 100 representing the worst pain imaginable.

Overall, both CBD and placebo groups achieved significant reductions in pain intensity of 11-12 mm at 12 weeks. The mean between-group difference on the VAS was 0.23 mm (P = .96). Twenty-two percent of patients who received CBD and 21% who received placebo demonstrated a pain intensity reduction greater than 30 mm on the VAS. Pain reduction greater than 50% was reported by 17 patients (25%) in the CBD group and 16 (27%) in the placebo group. CBD had a similar effect in patients with either PsA or hand OA.

Four serious adverse events occurred during the 12-week study period, but none of these were deemed adverse drug reactions. Serious adverse events in the CBD patients included one case of ductal carcinoma and one case of lipotymia; serious adverse events in the placebo group included one case of acute shoulder fracture and one case of malignant hypertension. Fifty-nine patients reported adverse events during the study. The CBD group reported more ear-nose-throat adverse events, compared with the placebo group (8 vs. 0).

The researchers assessed the impact of CBD vs. placebo on sleep quality, depression, anxiety, or pain catastrophizing scores using the Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and Health Assessment Questionnaire but found no differences in patients taking CBD vs. placebo.

The study findings were limited by several factors, including the potentially insufficient dose level to evoke a pain relief response, and a lack of data on additional daily use of analgesics or of the study drug beyond the prescribed dosage, the researchers noted.

The results were strengthened by the randomized, double-blind trial design and its relatively large sample size, they wrote. However, the researchers also cautioned that their study focused on CBD as a single ingredient, and the results might not generalize to other CBD formulations. They also noted that more research is needed to examine both higher doses of CBD and different types of pain disorders.

The study was supported by the Danish Psoriasis Foundation Grant and the Danish Rheumatism Foundation. The researchers had no financial conflicts to disclose.

Use of cannabidiol (CBD) as an add-on pain management technique in patients with either hand osteoarthritis (OA) or psoriatic arthritis (PsA) did not significantly decrease pain intensity when compared with a placebo in a randomized, double-blind trial described as the first of its kind to investigate the effect of pure CBD as an add-on analgesic therapy in patients with joint disease.

Anatoliy Sizov/Getty Images

Although data on the use of medical cannabis as a modulator of joint pain are limited, some studies suggest an effect from CBD without the addition of delta-9-tetrahydrocannabinol (THC), wrote Jonathan Vela, MD, of Aalborg (Denmark) University Hospital, and colleagues.

CBD is being used for pain conditions despite a lack of data on safety and effectiveness, the researchers emphasized. Notably, in a 2018 online survey, 62% of respondents reported using CBD for medical conditions, primarily for chronic pain and arthritis or joint pain, they wrote.

In a study published in the journal Pain, the researchers randomized 59 adults with PsA and 77 adults with hand OA to 20-30 mg of synthetic CBD or a placebo daily for 12 weeks in addition to conventional pain management. Patients initially received either oral CBD 10 mg or a placebo tablet once daily, increasing to 10 mg twice daily after 2 weeks, and once again up to 10 mg three times daily at 4 weeks if the patient did not experience more than 20-mm improvement on the visual analog scale (VAS).

The primary outcome in the trial was patient-reported pain intensity during the last 24 hours as assessed on a paper-based 100-mm VAS with the text, “How much pain have you experienced in the most symptomatic joint during the last 24 hours?” with 0 representing no pain and 100 representing the worst pain imaginable.

Overall, both CBD and placebo groups achieved significant reductions in pain intensity of 11-12 mm at 12 weeks. The mean between-group difference on the VAS was 0.23 mm (P = .96). Twenty-two percent of patients who received CBD and 21% who received placebo demonstrated a pain intensity reduction greater than 30 mm on the VAS. Pain reduction greater than 50% was reported by 17 patients (25%) in the CBD group and 16 (27%) in the placebo group. CBD had a similar effect in patients with either PsA or hand OA.

Four serious adverse events occurred during the 12-week study period, but none of these were deemed adverse drug reactions. Serious adverse events in the CBD patients included one case of ductal carcinoma and one case of lipotymia; serious adverse events in the placebo group included one case of acute shoulder fracture and one case of malignant hypertension. Fifty-nine patients reported adverse events during the study. The CBD group reported more ear-nose-throat adverse events, compared with the placebo group (8 vs. 0).

The researchers assessed the impact of CBD vs. placebo on sleep quality, depression, anxiety, or pain catastrophizing scores using the Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and Health Assessment Questionnaire but found no differences in patients taking CBD vs. placebo.

The study findings were limited by several factors, including the potentially insufficient dose level to evoke a pain relief response, and a lack of data on additional daily use of analgesics or of the study drug beyond the prescribed dosage, the researchers noted.

The results were strengthened by the randomized, double-blind trial design and its relatively large sample size, they wrote. However, the researchers also cautioned that their study focused on CBD as a single ingredient, and the results might not generalize to other CBD formulations. They also noted that more research is needed to examine both higher doses of CBD and different types of pain disorders.

The study was supported by the Danish Psoriasis Foundation Grant and the Danish Rheumatism Foundation. The researchers had no financial conflicts to disclose.

Use of cannabidiol (CBD) as an add-on pain management technique in patients with either hand osteoarthritis (OA) or psoriatic arthritis (PsA) did not significantly decrease pain intensity when compared with a placebo in a randomized, double-blind trial described as the first of its kind to investigate the effect of pure CBD as an add-on analgesic therapy in patients with joint disease.

Anatoliy Sizov/Getty Images

Although data on the use of medical cannabis as a modulator of joint pain are limited, some studies suggest an effect from CBD without the addition of delta-9-tetrahydrocannabinol (THC), wrote Jonathan Vela, MD, of Aalborg (Denmark) University Hospital, and colleagues.

CBD is being used for pain conditions despite a lack of data on safety and effectiveness, the researchers emphasized. Notably, in a 2018 online survey, 62% of respondents reported using CBD for medical conditions, primarily for chronic pain and arthritis or joint pain, they wrote.

In a study published in the journal Pain, the researchers randomized 59 adults with PsA and 77 adults with hand OA to 20-30 mg of synthetic CBD or a placebo daily for 12 weeks in addition to conventional pain management. Patients initially received either oral CBD 10 mg or a placebo tablet once daily, increasing to 10 mg twice daily after 2 weeks, and once again up to 10 mg three times daily at 4 weeks if the patient did not experience more than 20-mm improvement on the visual analog scale (VAS).

The primary outcome in the trial was patient-reported pain intensity during the last 24 hours as assessed on a paper-based 100-mm VAS with the text, “How much pain have you experienced in the most symptomatic joint during the last 24 hours?” with 0 representing no pain and 100 representing the worst pain imaginable.

Overall, both CBD and placebo groups achieved significant reductions in pain intensity of 11-12 mm at 12 weeks. The mean between-group difference on the VAS was 0.23 mm (P = .96). Twenty-two percent of patients who received CBD and 21% who received placebo demonstrated a pain intensity reduction greater than 30 mm on the VAS. Pain reduction greater than 50% was reported by 17 patients (25%) in the CBD group and 16 (27%) in the placebo group. CBD had a similar effect in patients with either PsA or hand OA.

Four serious adverse events occurred during the 12-week study period, but none of these were deemed adverse drug reactions. Serious adverse events in the CBD patients included one case of ductal carcinoma and one case of lipotymia; serious adverse events in the placebo group included one case of acute shoulder fracture and one case of malignant hypertension. Fifty-nine patients reported adverse events during the study. The CBD group reported more ear-nose-throat adverse events, compared with the placebo group (8 vs. 0).

The researchers assessed the impact of CBD vs. placebo on sleep quality, depression, anxiety, or pain catastrophizing scores using the Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and Health Assessment Questionnaire but found no differences in patients taking CBD vs. placebo.

The study findings were limited by several factors, including the potentially insufficient dose level to evoke a pain relief response, and a lack of data on additional daily use of analgesics or of the study drug beyond the prescribed dosage, the researchers noted.

The results were strengthened by the randomized, double-blind trial design and its relatively large sample size, they wrote. However, the researchers also cautioned that their study focused on CBD as a single ingredient, and the results might not generalize to other CBD formulations. They also noted that more research is needed to examine both higher doses of CBD and different types of pain disorders.

The study was supported by the Danish Psoriasis Foundation Grant and the Danish Rheumatism Foundation. The researchers had no financial conflicts to disclose.

The 30-day mortality rate was significantly lower among hospitalized patients treated by full-time clinicians, compared with those treated by part-time clinicians, in a new study.

The number of physicians working part time in the United States has increased by nearly 11% since 1993, and as more physicians opt for part-time work, quality of care deserves further study, the investigators wrote in JAMA Internal Medicine. Most studies comparing outcomes for patients treated by full-timers and part-timers have focused on outpatient care settings, where mortality is low and the potential for confounding is high, according to the study authors Hirotaka Kato, PhD, of Keio University in Tokyo, and colleagues. The new study, in contrast, is based on data from nearly 400,000 hospitalizations.

The researchers conducted a cross-sectional analysis on a 20% random sample of Medicare patients aged 65 years and older who were treated by a hospitalist for an emergency medical condition between 2011 and 2016. They examined associations between the number of days per year worked by hospitalists and they 30-day mortality rates among the patients they treated. The researchers analyzed a total of 392,797 hospitalizations in which patients were treated by 19,170 hospitalists. The mean age of the hospitalists was 41 years; 39% were female. Clinician work days were divided into quartiles.

Overall, the 30-day mortality was significantly higher among patients treated by clinicians in the bottom quartile with the fewest number of days worked, compared with those treated by clinicians in the top quartile with the most days worked (10.5% vs. 9.6%). The rates were similar in the second and third quartiles (10.0% and 9.5%).

The average number of days worked clinically per year was 57.6 in the lowest quartile versus 163.3 in the highest quartile, a 65% difference. No significant associations were noted between days worked and patient outcomes with regard to physician age, gender, or hospital teaching status.

Hospital 30-day readmission rates were examined as a secondary outcome, but there was no association between patient readmission and the number of days worked by the clinician. The adjusted 30-day readmission rate for clinicians in the bottom quartile of days worked, compared with those in the top quartile, was 15.3% versus 15.2% (P = .61).

The researchers found no difference in patients’ severity of illness (defined by expected mortality) or reason for admission between physicians in the different quartiles of days worked. They eliminated confounding from hospital-level differences by comparing outcomes of patients between physicians in the same hospital.
 

Possible explanations for worse patient outcomes

“As the number of physicians who engage in part-time clinical work continues to increase, these findings should lead to careful consideration by health systems to reevaluate preventive measures to address potential unintended patient harm,” the researchers wrote.

The researchers proposed several reasons for the association between fewer clinical work days and worse patient outcomes. First, physicians putting in less clinical time may be less updated on the latest guidelines, their skills may decline with less frequent patient care, and they may be less familiar with the nurses, medical assistants, and support staff, which may contribute to poor teamwork. The researchers also stated that some part-time physicians may need to balance nonclinical responsibilities, such as research or administrative tasks, concurrently with inpatient care. “It is also possible that physicians with less clinical knowledge or skills select to become part-time physicians, whereas physicians with higher clinical performance decide to work full time,” they noted.

The study findings were limited by several factors including the observational design and potential for unmeasured confounding variables, and the results may not generalize to younger patients or surgical patients, the researchers noted. Also, the study did not include care by hospitalists that was not billed, days in which clinicians treated non-Medicare patients or patients not part of the Medicare sample, or information about the reasons for clinicians’ part-time work.

However, the results were strengthened by the large sample size, and suggest the need for better institutional support to maintain the clinical performance of physicians who may be balancing a range of obligations, they concluded.

Clinician work issues have renewed relevance

“The data in this paper are from 2016 and earlier, but it is possibly event more relevant today than then,” Eileen Barrett, MD, of the University of New Mexico, Albuquerque, said in an interview. “The pandemic has exacerbated stressors being experienced by physicians and other health care workers, including higher clinical workloads and burnout, and spotlighted gendered effects on women in the workforce, which is likely to drive more physicians to part-time work.

“Reporting these findings now is so important so they can contribute to a shared mental model of the challenges physicians and hospitals face as we seek solutions to deliver high-quality and high-value care with an engaged, professionally fulfilled workforce,” she emphasized.

Dr. Barrett said she was surprised that the study did not show differences in readmission rates depending on the number of shifts worked, and also that the results were not different when considering expected mortality.

“However unpopular it may be to say so, physicians and administrators should assume these results apply to their practice unless they have examined their own data and know it does not,” Dr. Barrett said. “With that in mind, hospitals, administrators, and regulatory bodies have an urgent need to examine and reduce the forces driving physicians to part-time clinical work. Some of these factors include the absence of childcare, excessive paperwork, burnout, administrative duties, and valued experiences such as teaching, leadership, and research that keep clinicians from the bedside.

“Additionally, steps should be taken to reduce the administrative complexity that makes providing the best care to patients difficult and requires hospitalists to create ‘workarounds,’ because those who work fewer clinical hours may not know how to do these, nor how to advocate for their patients,” Dr. Barrett emphasized.

“Additional research is needed to determine how mortality varies by number of clinical shifts for pediatric and obstetric patients who are infrequently covered by Medicare, also how the pandemic and increasing administrative complexity since the time the data was obtained affect patient care,” Dr. Barrett noted.

The study was supported by a grant from the Japan Society for the Promotion of Science to lead author Dr. Kato, who had no financial conflicts to disclose. Dr. Barrett, who serves on the editorial advisory board of Internal Medicine News, had no financial conflicts.

The 30-day mortality rate was significantly lower among hospitalized patients treated by full-time clinicians, compared with those treated by part-time clinicians, in a new study.

The number of physicians working part time in the United States has increased by nearly 11% since 1993, and as more physicians opt for part-time work, quality of care deserves further study, the investigators wrote in JAMA Internal Medicine. Most studies comparing outcomes for patients treated by full-timers and part-timers have focused on outpatient care settings, where mortality is low and the potential for confounding is high, according to the study authors Hirotaka Kato, PhD, of Keio University in Tokyo, and colleagues. The new study, in contrast, is based on data from nearly 400,000 hospitalizations.

The researchers conducted a cross-sectional analysis on a 20% random sample of Medicare patients aged 65 years and older who were treated by a hospitalist for an emergency medical condition between 2011 and 2016. They examined associations between the number of days per year worked by hospitalists and they 30-day mortality rates among the patients they treated. The researchers analyzed a total of 392,797 hospitalizations in which patients were treated by 19,170 hospitalists. The mean age of the hospitalists was 41 years; 39% were female. Clinician work days were divided into quartiles.

Overall, the 30-day mortality was significantly higher among patients treated by clinicians in the bottom quartile with the fewest number of days worked, compared with those treated by clinicians in the top quartile with the most days worked (10.5% vs. 9.6%). The rates were similar in the second and third quartiles (10.0% and 9.5%).

The average number of days worked clinically per year was 57.6 in the lowest quartile versus 163.3 in the highest quartile, a 65% difference. No significant associations were noted between days worked and patient outcomes with regard to physician age, gender, or hospital teaching status.

Hospital 30-day readmission rates were examined as a secondary outcome, but there was no association between patient readmission and the number of days worked by the clinician. The adjusted 30-day readmission rate for clinicians in the bottom quartile of days worked, compared with those in the top quartile, was 15.3% versus 15.2% (P = .61).

The researchers found no difference in patients’ severity of illness (defined by expected mortality) or reason for admission between physicians in the different quartiles of days worked. They eliminated confounding from hospital-level differences by comparing outcomes of patients between physicians in the same hospital.
 

Possible explanations for worse patient outcomes

“As the number of physicians who engage in part-time clinical work continues to increase, these findings should lead to careful consideration by health systems to reevaluate preventive measures to address potential unintended patient harm,” the researchers wrote.

The researchers proposed several reasons for the association between fewer clinical work days and worse patient outcomes. First, physicians putting in less clinical time may be less updated on the latest guidelines, their skills may decline with less frequent patient care, and they may be less familiar with the nurses, medical assistants, and support staff, which may contribute to poor teamwork. The researchers also stated that some part-time physicians may need to balance nonclinical responsibilities, such as research or administrative tasks, concurrently with inpatient care. “It is also possible that physicians with less clinical knowledge or skills select to become part-time physicians, whereas physicians with higher clinical performance decide to work full time,” they noted.

The study findings were limited by several factors including the observational design and potential for unmeasured confounding variables, and the results may not generalize to younger patients or surgical patients, the researchers noted. Also, the study did not include care by hospitalists that was not billed, days in which clinicians treated non-Medicare patients or patients not part of the Medicare sample, or information about the reasons for clinicians’ part-time work.

However, the results were strengthened by the large sample size, and suggest the need for better institutional support to maintain the clinical performance of physicians who may be balancing a range of obligations, they concluded.

Clinician work issues have renewed relevance

“The data in this paper are from 2016 and earlier, but it is possibly event more relevant today than then,” Eileen Barrett, MD, of the University of New Mexico, Albuquerque, said in an interview. “The pandemic has exacerbated stressors being experienced by physicians and other health care workers, including higher clinical workloads and burnout, and spotlighted gendered effects on women in the workforce, which is likely to drive more physicians to part-time work.

“Reporting these findings now is so important so they can contribute to a shared mental model of the challenges physicians and hospitals face as we seek solutions to deliver high-quality and high-value care with an engaged, professionally fulfilled workforce,” she emphasized.

Dr. Barrett said she was surprised that the study did not show differences in readmission rates depending on the number of shifts worked, and also that the results were not different when considering expected mortality.

“However unpopular it may be to say so, physicians and administrators should assume these results apply to their practice unless they have examined their own data and know it does not,” Dr. Barrett said. “With that in mind, hospitals, administrators, and regulatory bodies have an urgent need to examine and reduce the forces driving physicians to part-time clinical work. Some of these factors include the absence of childcare, excessive paperwork, burnout, administrative duties, and valued experiences such as teaching, leadership, and research that keep clinicians from the bedside.

“Additionally, steps should be taken to reduce the administrative complexity that makes providing the best care to patients difficult and requires hospitalists to create ‘workarounds,’ because those who work fewer clinical hours may not know how to do these, nor how to advocate for their patients,” Dr. Barrett emphasized.

“Additional research is needed to determine how mortality varies by number of clinical shifts for pediatric and obstetric patients who are infrequently covered by Medicare, also how the pandemic and increasing administrative complexity since the time the data was obtained affect patient care,” Dr. Barrett noted.

The study was supported by a grant from the Japan Society for the Promotion of Science to lead author Dr. Kato, who had no financial conflicts to disclose. Dr. Barrett, who serves on the editorial advisory board of Internal Medicine News, had no financial conflicts.

The 30-day mortality rate was significantly lower among hospitalized patients treated by full-time clinicians, compared with those treated by part-time clinicians, in a new study.

The number of physicians working part time in the United States has increased by nearly 11% since 1993, and as more physicians opt for part-time work, quality of care deserves further study, the investigators wrote in JAMA Internal Medicine. Most studies comparing outcomes for patients treated by full-timers and part-timers have focused on outpatient care settings, where mortality is low and the potential for confounding is high, according to the study authors Hirotaka Kato, PhD, of Keio University in Tokyo, and colleagues. The new study, in contrast, is based on data from nearly 400,000 hospitalizations.

The researchers conducted a cross-sectional analysis on a 20% random sample of Medicare patients aged 65 years and older who were treated by a hospitalist for an emergency medical condition between 2011 and 2016. They examined associations between the number of days per year worked by hospitalists and they 30-day mortality rates among the patients they treated. The researchers analyzed a total of 392,797 hospitalizations in which patients were treated by 19,170 hospitalists. The mean age of the hospitalists was 41 years; 39% were female. Clinician work days were divided into quartiles.

Overall, the 30-day mortality was significantly higher among patients treated by clinicians in the bottom quartile with the fewest number of days worked, compared with those treated by clinicians in the top quartile with the most days worked (10.5% vs. 9.6%). The rates were similar in the second and third quartiles (10.0% and 9.5%).

The average number of days worked clinically per year was 57.6 in the lowest quartile versus 163.3 in the highest quartile, a 65% difference. No significant associations were noted between days worked and patient outcomes with regard to physician age, gender, or hospital teaching status.

Hospital 30-day readmission rates were examined as a secondary outcome, but there was no association between patient readmission and the number of days worked by the clinician. The adjusted 30-day readmission rate for clinicians in the bottom quartile of days worked, compared with those in the top quartile, was 15.3% versus 15.2% (P = .61).

The researchers found no difference in patients’ severity of illness (defined by expected mortality) or reason for admission between physicians in the different quartiles of days worked. They eliminated confounding from hospital-level differences by comparing outcomes of patients between physicians in the same hospital.
 

Possible explanations for worse patient outcomes

“As the number of physicians who engage in part-time clinical work continues to increase, these findings should lead to careful consideration by health systems to reevaluate preventive measures to address potential unintended patient harm,” the researchers wrote.

The researchers proposed several reasons for the association between fewer clinical work days and worse patient outcomes. First, physicians putting in less clinical time may be less updated on the latest guidelines, their skills may decline with less frequent patient care, and they may be less familiar with the nurses, medical assistants, and support staff, which may contribute to poor teamwork. The researchers also stated that some part-time physicians may need to balance nonclinical responsibilities, such as research or administrative tasks, concurrently with inpatient care. “It is also possible that physicians with less clinical knowledge or skills select to become part-time physicians, whereas physicians with higher clinical performance decide to work full time,” they noted.

The study findings were limited by several factors including the observational design and potential for unmeasured confounding variables, and the results may not generalize to younger patients or surgical patients, the researchers noted. Also, the study did not include care by hospitalists that was not billed, days in which clinicians treated non-Medicare patients or patients not part of the Medicare sample, or information about the reasons for clinicians’ part-time work.

However, the results were strengthened by the large sample size, and suggest the need for better institutional support to maintain the clinical performance of physicians who may be balancing a range of obligations, they concluded.

Clinician work issues have renewed relevance

“The data in this paper are from 2016 and earlier, but it is possibly event more relevant today than then,” Eileen Barrett, MD, of the University of New Mexico, Albuquerque, said in an interview. “The pandemic has exacerbated stressors being experienced by physicians and other health care workers, including higher clinical workloads and burnout, and spotlighted gendered effects on women in the workforce, which is likely to drive more physicians to part-time work.

“Reporting these findings now is so important so they can contribute to a shared mental model of the challenges physicians and hospitals face as we seek solutions to deliver high-quality and high-value care with an engaged, professionally fulfilled workforce,” she emphasized.

Dr. Barrett said she was surprised that the study did not show differences in readmission rates depending on the number of shifts worked, and also that the results were not different when considering expected mortality.

“However unpopular it may be to say so, physicians and administrators should assume these results apply to their practice unless they have examined their own data and know it does not,” Dr. Barrett said. “With that in mind, hospitals, administrators, and regulatory bodies have an urgent need to examine and reduce the forces driving physicians to part-time clinical work. Some of these factors include the absence of childcare, excessive paperwork, burnout, administrative duties, and valued experiences such as teaching, leadership, and research that keep clinicians from the bedside.

“Additionally, steps should be taken to reduce the administrative complexity that makes providing the best care to patients difficult and requires hospitalists to create ‘workarounds,’ because those who work fewer clinical hours may not know how to do these, nor how to advocate for their patients,” Dr. Barrett emphasized.

“Additional research is needed to determine how mortality varies by number of clinical shifts for pediatric and obstetric patients who are infrequently covered by Medicare, also how the pandemic and increasing administrative complexity since the time the data was obtained affect patient care,” Dr. Barrett noted.

The study was supported by a grant from the Japan Society for the Promotion of Science to lead author Dr. Kato, who had no financial conflicts to disclose. Dr. Barrett, who serves on the editorial advisory board of Internal Medicine News, had no financial conflicts.

“All physicians, regardless of specialty, will work with patients with disabilities,” Corrie Harris, MD, of the University of Louisville (Ky.), said in a plenary session presentation at the 2021 virtual Pediatric Hospital Medicine conference.

Disabilities vary in their visibility, from cognitive and sensory impairments that are not immediately obvious to an obvious physical disability, she said.

One in four adults and one in six children in the United States has a disability, said Dr. Harris. The prevalence of disability increases with age, but occurs across the lifespan, and will likely increase in the future with greater improvements in health care overall.

Dr. Harris reviewed the current conceptual model that forms the basis for the World Health Organization definition of functioning disability. This “functional model” defines disability as caused by interactions between health conditions and the environment, and the response is to “prioritize function to meet patient goals,” Dr. Harris said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

This model is based on collaboration between health care providers and their patients with disabilities, and training is important to help providers make this collaboration successful, said Dr. Harris. Without training, physicians may be ineffective in communicating with patients with disabilities by not speaking directly to the patient, not speaking in a way the patient can understand clearly, and not providing accessible patient education materials. Physicians also tend to minimize the extent of the patient’s expertise in their own condition based on their lived experiences, and tend to underestimate the abilities of patients with disabilities.

However, direct experience with disabled patients and an understanding of the health disparities they endure can help physicians look at these patients “through a more intersectional lens,” that also takes into account social determinants of health, Dr. Harris said. “I have found that people with disabilities are the best teachers about disability, because they have expertise that comes from their lived experience.”
 

Patients are the best teachers

Several initiatives are helping physicians to bridge this gap in understanding and reduce disparities in care. One such program is FRAME: Faces Redefining the Art of Medical Education. FRAME is a web-based film library designed to present medical information to health care providers in training, clinicians, families, and communities in a dignified and humanizing way. FRAME was developed in part by fashion photographer Rick Guidotti, who was inspired after meeting a young woman with albinism to create Positive Exposure, an ongoing project featuring children and adolescents with various disabilities.

FRAME films are “short films presenting all the basic hallmark characteristics of a certain genetic condition, but presented by somebody living with that condition,” said Mr. Guidotti in his presentation during the session.

The National Curriculum Initiative in Developmental Medicine (NCIDM) is designed to incorporate care for individuals with disabilities into medical education. NCIDM is a project created by the American Academy of Developmental Medicine and Dentistry (AADMD).

“The need for this program is that there is no U.S. requirement for medical schools to teach about intellectual and developmental disabilities,” Priya Chandan, MD, also of the University of Louisville, said in her presentation during the session. “Approximately 81% of graduating medical students have no training in caring for adults with disabilities,” said Dr. Chandan, who serves as director of the NCIDM.

The current NCIDM was created as a 5-year partnership between the AADMD and Special Olympics, supported in part by the Centers for Disease Control and Prevention, Dr. Chandan said. The purpose was to provide training to medical students in the field of developmental medicine, meaning the care of individuals with intellectual/developmental disabilities (IDD) across the lifespan. The AADMD has expanded to 26 medical schools in the United States and will reach approximately 4,000 medical students by the conclusion of the current initiative.

One challenge in medical education is getting past the idea that people living with disabilities need to be fixed, said Dr. Chandan. The NCIDM approach reflects Mr. Guidotti’s approach in both the FRAME initiatives and his Positive Exposure foundation, with a focus on treating people as people, and letting individuals with disabilities represent themselves.

Dr. Chandan described the NCIDM curriculum as allowing for flexible teaching methodologies and materials, as long as they meet the NCIDM-created learning goals and objectives. The curriculum also includes standardized evaluations. Each NCIDM program in a participating medical school includes a faculty champion, and the curriculum supports meeting people with IDD not only inside medical settings, but also outside in the community.

NCIDM embraces the idea of community-engaged scholarship, which Dr. Chandan defined as “a form of scholarship that directly benefits the community and is consistent with university and unit missions.” This method combined teaching and conducting research while providing a service to the community.

The next steps for the current NCIDM initiative are to complete collection of data and course evaluations from participating schools by early 2022, followed by continued dissemination and collaboration through AADMD.

Overall, the content of the curriculum explores how and where IDD fits into clinical care, Dr. Chandan said, who also emphasized the implications of communication. “How we think affects how we communicate,” she added. Be mindful of the language used to talk to and about patients with disabilities, both to colleagues and to learners.

When talking to the patient, find something in common, beyond the diagnosis, said Dr. Chandan. Remember that some disabilities are visible and some are not. “Treat people with respect, because you won’t know what their functional level is just by looking,” she concluded.

The presenters had no financial conflicts to disclose.

“All physicians, regardless of specialty, will work with patients with disabilities,” Corrie Harris, MD, of the University of Louisville (Ky.), said in a plenary session presentation at the 2021 virtual Pediatric Hospital Medicine conference.

Disabilities vary in their visibility, from cognitive and sensory impairments that are not immediately obvious to an obvious physical disability, she said.

One in four adults and one in six children in the United States has a disability, said Dr. Harris. The prevalence of disability increases with age, but occurs across the lifespan, and will likely increase in the future with greater improvements in health care overall.

Dr. Harris reviewed the current conceptual model that forms the basis for the World Health Organization definition of functioning disability. This “functional model” defines disability as caused by interactions between health conditions and the environment, and the response is to “prioritize function to meet patient goals,” Dr. Harris said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

This model is based on collaboration between health care providers and their patients with disabilities, and training is important to help providers make this collaboration successful, said Dr. Harris. Without training, physicians may be ineffective in communicating with patients with disabilities by not speaking directly to the patient, not speaking in a way the patient can understand clearly, and not providing accessible patient education materials. Physicians also tend to minimize the extent of the patient’s expertise in their own condition based on their lived experiences, and tend to underestimate the abilities of patients with disabilities.

However, direct experience with disabled patients and an understanding of the health disparities they endure can help physicians look at these patients “through a more intersectional lens,” that also takes into account social determinants of health, Dr. Harris said. “I have found that people with disabilities are the best teachers about disability, because they have expertise that comes from their lived experience.”
 

Patients are the best teachers

Several initiatives are helping physicians to bridge this gap in understanding and reduce disparities in care. One such program is FRAME: Faces Redefining the Art of Medical Education. FRAME is a web-based film library designed to present medical information to health care providers in training, clinicians, families, and communities in a dignified and humanizing way. FRAME was developed in part by fashion photographer Rick Guidotti, who was inspired after meeting a young woman with albinism to create Positive Exposure, an ongoing project featuring children and adolescents with various disabilities.

FRAME films are “short films presenting all the basic hallmark characteristics of a certain genetic condition, but presented by somebody living with that condition,” said Mr. Guidotti in his presentation during the session.

The National Curriculum Initiative in Developmental Medicine (NCIDM) is designed to incorporate care for individuals with disabilities into medical education. NCIDM is a project created by the American Academy of Developmental Medicine and Dentistry (AADMD).

“The need for this program is that there is no U.S. requirement for medical schools to teach about intellectual and developmental disabilities,” Priya Chandan, MD, also of the University of Louisville, said in her presentation during the session. “Approximately 81% of graduating medical students have no training in caring for adults with disabilities,” said Dr. Chandan, who serves as director of the NCIDM.

The current NCIDM was created as a 5-year partnership between the AADMD and Special Olympics, supported in part by the Centers for Disease Control and Prevention, Dr. Chandan said. The purpose was to provide training to medical students in the field of developmental medicine, meaning the care of individuals with intellectual/developmental disabilities (IDD) across the lifespan. The AADMD has expanded to 26 medical schools in the United States and will reach approximately 4,000 medical students by the conclusion of the current initiative.

One challenge in medical education is getting past the idea that people living with disabilities need to be fixed, said Dr. Chandan. The NCIDM approach reflects Mr. Guidotti’s approach in both the FRAME initiatives and his Positive Exposure foundation, with a focus on treating people as people, and letting individuals with disabilities represent themselves.

Dr. Chandan described the NCIDM curriculum as allowing for flexible teaching methodologies and materials, as long as they meet the NCIDM-created learning goals and objectives. The curriculum also includes standardized evaluations. Each NCIDM program in a participating medical school includes a faculty champion, and the curriculum supports meeting people with IDD not only inside medical settings, but also outside in the community.

NCIDM embraces the idea of community-engaged scholarship, which Dr. Chandan defined as “a form of scholarship that directly benefits the community and is consistent with university and unit missions.” This method combined teaching and conducting research while providing a service to the community.

The next steps for the current NCIDM initiative are to complete collection of data and course evaluations from participating schools by early 2022, followed by continued dissemination and collaboration through AADMD.

Overall, the content of the curriculum explores how and where IDD fits into clinical care, Dr. Chandan said, who also emphasized the implications of communication. “How we think affects how we communicate,” she added. Be mindful of the language used to talk to and about patients with disabilities, both to colleagues and to learners.

When talking to the patient, find something in common, beyond the diagnosis, said Dr. Chandan. Remember that some disabilities are visible and some are not. “Treat people with respect, because you won’t know what their functional level is just by looking,” she concluded.

The presenters had no financial conflicts to disclose.

“All physicians, regardless of specialty, will work with patients with disabilities,” Corrie Harris, MD, of the University of Louisville (Ky.), said in a plenary session presentation at the 2021 virtual Pediatric Hospital Medicine conference.

Disabilities vary in their visibility, from cognitive and sensory impairments that are not immediately obvious to an obvious physical disability, she said.

One in four adults and one in six children in the United States has a disability, said Dr. Harris. The prevalence of disability increases with age, but occurs across the lifespan, and will likely increase in the future with greater improvements in health care overall.

Dr. Harris reviewed the current conceptual model that forms the basis for the World Health Organization definition of functioning disability. This “functional model” defines disability as caused by interactions between health conditions and the environment, and the response is to “prioritize function to meet patient goals,” Dr. Harris said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

This model is based on collaboration between health care providers and their patients with disabilities, and training is important to help providers make this collaboration successful, said Dr. Harris. Without training, physicians may be ineffective in communicating with patients with disabilities by not speaking directly to the patient, not speaking in a way the patient can understand clearly, and not providing accessible patient education materials. Physicians also tend to minimize the extent of the patient’s expertise in their own condition based on their lived experiences, and tend to underestimate the abilities of patients with disabilities.

However, direct experience with disabled patients and an understanding of the health disparities they endure can help physicians look at these patients “through a more intersectional lens,” that also takes into account social determinants of health, Dr. Harris said. “I have found that people with disabilities are the best teachers about disability, because they have expertise that comes from their lived experience.”
 

Patients are the best teachers

Several initiatives are helping physicians to bridge this gap in understanding and reduce disparities in care. One such program is FRAME: Faces Redefining the Art of Medical Education. FRAME is a web-based film library designed to present medical information to health care providers in training, clinicians, families, and communities in a dignified and humanizing way. FRAME was developed in part by fashion photographer Rick Guidotti, who was inspired after meeting a young woman with albinism to create Positive Exposure, an ongoing project featuring children and adolescents with various disabilities.

FRAME films are “short films presenting all the basic hallmark characteristics of a certain genetic condition, but presented by somebody living with that condition,” said Mr. Guidotti in his presentation during the session.

The National Curriculum Initiative in Developmental Medicine (NCIDM) is designed to incorporate care for individuals with disabilities into medical education. NCIDM is a project created by the American Academy of Developmental Medicine and Dentistry (AADMD).

“The need for this program is that there is no U.S. requirement for medical schools to teach about intellectual and developmental disabilities,” Priya Chandan, MD, also of the University of Louisville, said in her presentation during the session. “Approximately 81% of graduating medical students have no training in caring for adults with disabilities,” said Dr. Chandan, who serves as director of the NCIDM.

The current NCIDM was created as a 5-year partnership between the AADMD and Special Olympics, supported in part by the Centers for Disease Control and Prevention, Dr. Chandan said. The purpose was to provide training to medical students in the field of developmental medicine, meaning the care of individuals with intellectual/developmental disabilities (IDD) across the lifespan. The AADMD has expanded to 26 medical schools in the United States and will reach approximately 4,000 medical students by the conclusion of the current initiative.

One challenge in medical education is getting past the idea that people living with disabilities need to be fixed, said Dr. Chandan. The NCIDM approach reflects Mr. Guidotti’s approach in both the FRAME initiatives and his Positive Exposure foundation, with a focus on treating people as people, and letting individuals with disabilities represent themselves.

Dr. Chandan described the NCIDM curriculum as allowing for flexible teaching methodologies and materials, as long as they meet the NCIDM-created learning goals and objectives. The curriculum also includes standardized evaluations. Each NCIDM program in a participating medical school includes a faculty champion, and the curriculum supports meeting people with IDD not only inside medical settings, but also outside in the community.

NCIDM embraces the idea of community-engaged scholarship, which Dr. Chandan defined as “a form of scholarship that directly benefits the community and is consistent with university and unit missions.” This method combined teaching and conducting research while providing a service to the community.

The next steps for the current NCIDM initiative are to complete collection of data and course evaluations from participating schools by early 2022, followed by continued dissemination and collaboration through AADMD.

Overall, the content of the curriculum explores how and where IDD fits into clinical care, Dr. Chandan said, who also emphasized the implications of communication. “How we think affects how we communicate,” she added. Be mindful of the language used to talk to and about patients with disabilities, both to colleagues and to learners.

When talking to the patient, find something in common, beyond the diagnosis, said Dr. Chandan. Remember that some disabilities are visible and some are not. “Treat people with respect, because you won’t know what their functional level is just by looking,” she concluded.

The presenters had no financial conflicts to disclose.