While the COVID-19 pandemic has generated anxiety and confusion in medicine, one thing should bring a sense of clarity to hospitalists: They’re needed now more than ever.

Larry Wellikson, MD, MHM, the former, longtime CEO of the Society of Hospital Medicine, in a May 6 keynote speech at SHM Converge, the annual conference of the Society of Hospital Medicine, said the COVID-19 era has underscored the singular importance of the specialty.

“I think one thing that this recent pandemic has emphasized is just how important and vital hospitalists are to the United States’ health care system,” Dr. Wellikson said. “The response to the acute care needs in this pandemic would have been impossible in the health care system that existed before hospitalists. And so this is something that we should understand and appreciate.”

The “upheaval” experienced in hospital medicine continues a trend of change that will go on, both in the corporate health care landscape and in the role that hospitalists play in providing care, he said. Insurers have been merging and looking to consolidate. Hospital medicine companies have been merging, and “newfangled bedfellows” have been a trend, such as CVS stepping beyond its pharmacy role into an expanded health care role, Cigna buying Express Scripts, and an Amazon-Berkshire Hathaway-J.P. Morgan health care partnership that ultimately did not pan out, although that hasn’t ended Amazon’s presence in health care.

“You may not realize it, but Amazon is currently one of the largest hospital supply-chain companies,” Dr. Wellikson said. “They’re attempting to become a major pharmacy benefits manager and will only further enter into health care and into our personal and professional lives.”

New models of care point to the way of the future, he said. Mount Sinai’s continuing success with its Hospital at Home program – which involves an acute care nurse and team assigned to a patient in the home – introduces a concept that will be adopted more broadly, because of its cost savings and good outcomes, he said. Mergers of hospital systems, leading to excess hospital capacity, has given rise to what he calls “ED-plus,” or using formerly full-service hospitals as more focused centers – providing emergency, obstetrician, cardiology, x-ray, or orthopedics care, or whatever is needed in a given community.

An increasing focus on population health rather than procedures plays into the strengths of hospitalists, Dr. Wellikson said, and the need for their skills will continue to deepen.

When changes in reimbursement began about 4 years ago, specialties such as cardiology entered into new contracts with hospitals, but the facilities began to notice that many of the services – such as initial heart failure and chest pain management – can be provided by hospitalists.

“They’re signing fewer cardiologists and needing therefore to hire more hospitalists,” he said.

To keep readmissions low and subsequent costs down, hospitalists will continue to handle the first few postdischarge visits with patients, he said. This is crucial in bundled payment systems.

“Most of the savings in those systems comes from being very efficient in the initial postdischarge portion of people’s care,” Dr. Wellikson said.

At the same time, hospitalists are not in “unlimited supply.”

“I think every hospital medicine group should be assessing and working on improving their clinicians’ well-being,” he said. “We need to ration somewhat, so we’re deploying hospitalists for the things that only we can do.” He predicted that hospitalists will be required to work in the electronic medical record less frequently, with this task handled by others.

Dr. Wellikson also called on the specialty to continue to expand its racial and ethnic diversity so that it reflects the patient population it serves.

“We’re looking to create pathways to leadership for everyone and not just a tokenism moving forward,” he said.

The basic strengths of hospital medicine – its flexibility, professional culture, and youth – leave it well prepared for all of these changes, he said.

“There is a bright future and hospitalists are right in the middle of this – we’re not going to be marginalized or on the periphery,” Dr. Wellikson said. “If I had one message for all of you, I would say be relevant and add value and you will not only survive, but thrive.”
 

RIV winners announced

The winners of the 2021 RIV competition were also announced at the May 6 general session of Converge. There were two winners in each of the three categories, as follows:

RESEARCH
Overall: “Suboptimal Communication During Inter-Hospital Transfer,” Stephanie Mueller, MD, MPH, SFHM

Trainee: “Mentorship in Pediatric Hospital Medicine: A Survey of Division Directors,” Brandon Palmer, MD

INNOVATIONS
Overall: “Leveraging Artificial Intelligence for a Team-Based Approach to Advance Care Planning,” Ron Li, MD

Trainee: “A Trainee-Designed Initiative Reshapes Communication for Hospital Medicine Patients During COVID-19,” Smitha Ganeshan, MD, MBA

CLINICAL VIGNETTES
Adults: “Holy Spontaneous Heparin-Induced Thrombocytopenia,” Min Hwang

Pediatrics: “The Great Pretender: A Tale of Two Systems,” Shivani Desai, MD

While the COVID-19 pandemic has generated anxiety and confusion in medicine, one thing should bring a sense of clarity to hospitalists: They’re needed now more than ever.

Larry Wellikson, MD, MHM, the former, longtime CEO of the Society of Hospital Medicine, in a May 6 keynote speech at SHM Converge, the annual conference of the Society of Hospital Medicine, said the COVID-19 era has underscored the singular importance of the specialty.

“I think one thing that this recent pandemic has emphasized is just how important and vital hospitalists are to the United States’ health care system,” Dr. Wellikson said. “The response to the acute care needs in this pandemic would have been impossible in the health care system that existed before hospitalists. And so this is something that we should understand and appreciate.”

The “upheaval” experienced in hospital medicine continues a trend of change that will go on, both in the corporate health care landscape and in the role that hospitalists play in providing care, he said. Insurers have been merging and looking to consolidate. Hospital medicine companies have been merging, and “newfangled bedfellows” have been a trend, such as CVS stepping beyond its pharmacy role into an expanded health care role, Cigna buying Express Scripts, and an Amazon-Berkshire Hathaway-J.P. Morgan health care partnership that ultimately did not pan out, although that hasn’t ended Amazon’s presence in health care.

“You may not realize it, but Amazon is currently one of the largest hospital supply-chain companies,” Dr. Wellikson said. “They’re attempting to become a major pharmacy benefits manager and will only further enter into health care and into our personal and professional lives.”

New models of care point to the way of the future, he said. Mount Sinai’s continuing success with its Hospital at Home program – which involves an acute care nurse and team assigned to a patient in the home – introduces a concept that will be adopted more broadly, because of its cost savings and good outcomes, he said. Mergers of hospital systems, leading to excess hospital capacity, has given rise to what he calls “ED-plus,” or using formerly full-service hospitals as more focused centers – providing emergency, obstetrician, cardiology, x-ray, or orthopedics care, or whatever is needed in a given community.

An increasing focus on population health rather than procedures plays into the strengths of hospitalists, Dr. Wellikson said, and the need for their skills will continue to deepen.

When changes in reimbursement began about 4 years ago, specialties such as cardiology entered into new contracts with hospitals, but the facilities began to notice that many of the services – such as initial heart failure and chest pain management – can be provided by hospitalists.

“They’re signing fewer cardiologists and needing therefore to hire more hospitalists,” he said.

To keep readmissions low and subsequent costs down, hospitalists will continue to handle the first few postdischarge visits with patients, he said. This is crucial in bundled payment systems.

“Most of the savings in those systems comes from being very efficient in the initial postdischarge portion of people’s care,” Dr. Wellikson said.

At the same time, hospitalists are not in “unlimited supply.”

“I think every hospital medicine group should be assessing and working on improving their clinicians’ well-being,” he said. “We need to ration somewhat, so we’re deploying hospitalists for the things that only we can do.” He predicted that hospitalists will be required to work in the electronic medical record less frequently, with this task handled by others.

Dr. Wellikson also called on the specialty to continue to expand its racial and ethnic diversity so that it reflects the patient population it serves.

“We’re looking to create pathways to leadership for everyone and not just a tokenism moving forward,” he said.

The basic strengths of hospital medicine – its flexibility, professional culture, and youth – leave it well prepared for all of these changes, he said.

“There is a bright future and hospitalists are right in the middle of this – we’re not going to be marginalized or on the periphery,” Dr. Wellikson said. “If I had one message for all of you, I would say be relevant and add value and you will not only survive, but thrive.”
 

RIV winners announced

The winners of the 2021 RIV competition were also announced at the May 6 general session of Converge. There were two winners in each of the three categories, as follows:

RESEARCH
Overall: “Suboptimal Communication During Inter-Hospital Transfer,” Stephanie Mueller, MD, MPH, SFHM

Trainee: “Mentorship in Pediatric Hospital Medicine: A Survey of Division Directors,” Brandon Palmer, MD

INNOVATIONS
Overall: “Leveraging Artificial Intelligence for a Team-Based Approach to Advance Care Planning,” Ron Li, MD

Trainee: “A Trainee-Designed Initiative Reshapes Communication for Hospital Medicine Patients During COVID-19,” Smitha Ganeshan, MD, MBA

CLINICAL VIGNETTES
Adults: “Holy Spontaneous Heparin-Induced Thrombocytopenia,” Min Hwang

Pediatrics: “The Great Pretender: A Tale of Two Systems,” Shivani Desai, MD

While the COVID-19 pandemic has generated anxiety and confusion in medicine, one thing should bring a sense of clarity to hospitalists: They’re needed now more than ever.

Larry Wellikson, MD, MHM, the former, longtime CEO of the Society of Hospital Medicine, in a May 6 keynote speech at SHM Converge, the annual conference of the Society of Hospital Medicine, said the COVID-19 era has underscored the singular importance of the specialty.

“I think one thing that this recent pandemic has emphasized is just how important and vital hospitalists are to the United States’ health care system,” Dr. Wellikson said. “The response to the acute care needs in this pandemic would have been impossible in the health care system that existed before hospitalists. And so this is something that we should understand and appreciate.”

The “upheaval” experienced in hospital medicine continues a trend of change that will go on, both in the corporate health care landscape and in the role that hospitalists play in providing care, he said. Insurers have been merging and looking to consolidate. Hospital medicine companies have been merging, and “newfangled bedfellows” have been a trend, such as CVS stepping beyond its pharmacy role into an expanded health care role, Cigna buying Express Scripts, and an Amazon-Berkshire Hathaway-J.P. Morgan health care partnership that ultimately did not pan out, although that hasn’t ended Amazon’s presence in health care.

“You may not realize it, but Amazon is currently one of the largest hospital supply-chain companies,” Dr. Wellikson said. “They’re attempting to become a major pharmacy benefits manager and will only further enter into health care and into our personal and professional lives.”

New models of care point to the way of the future, he said. Mount Sinai’s continuing success with its Hospital at Home program – which involves an acute care nurse and team assigned to a patient in the home – introduces a concept that will be adopted more broadly, because of its cost savings and good outcomes, he said. Mergers of hospital systems, leading to excess hospital capacity, has given rise to what he calls “ED-plus,” or using formerly full-service hospitals as more focused centers – providing emergency, obstetrician, cardiology, x-ray, or orthopedics care, or whatever is needed in a given community.

An increasing focus on population health rather than procedures plays into the strengths of hospitalists, Dr. Wellikson said, and the need for their skills will continue to deepen.

When changes in reimbursement began about 4 years ago, specialties such as cardiology entered into new contracts with hospitals, but the facilities began to notice that many of the services – such as initial heart failure and chest pain management – can be provided by hospitalists.

“They’re signing fewer cardiologists and needing therefore to hire more hospitalists,” he said.

To keep readmissions low and subsequent costs down, hospitalists will continue to handle the first few postdischarge visits with patients, he said. This is crucial in bundled payment systems.

“Most of the savings in those systems comes from being very efficient in the initial postdischarge portion of people’s care,” Dr. Wellikson said.

At the same time, hospitalists are not in “unlimited supply.”

“I think every hospital medicine group should be assessing and working on improving their clinicians’ well-being,” he said. “We need to ration somewhat, so we’re deploying hospitalists for the things that only we can do.” He predicted that hospitalists will be required to work in the electronic medical record less frequently, with this task handled by others.

Dr. Wellikson also called on the specialty to continue to expand its racial and ethnic diversity so that it reflects the patient population it serves.

“We’re looking to create pathways to leadership for everyone and not just a tokenism moving forward,” he said.

The basic strengths of hospital medicine – its flexibility, professional culture, and youth – leave it well prepared for all of these changes, he said.

“There is a bright future and hospitalists are right in the middle of this – we’re not going to be marginalized or on the periphery,” Dr. Wellikson said. “If I had one message for all of you, I would say be relevant and add value and you will not only survive, but thrive.”
 

RIV winners announced

The winners of the 2021 RIV competition were also announced at the May 6 general session of Converge. There were two winners in each of the three categories, as follows:

RESEARCH
Overall: “Suboptimal Communication During Inter-Hospital Transfer,” Stephanie Mueller, MD, MPH, SFHM

Trainee: “Mentorship in Pediatric Hospital Medicine: A Survey of Division Directors,” Brandon Palmer, MD

INNOVATIONS
Overall: “Leveraging Artificial Intelligence for a Team-Based Approach to Advance Care Planning,” Ron Li, MD

Trainee: “A Trainee-Designed Initiative Reshapes Communication for Hospital Medicine Patients During COVID-19,” Smitha Ganeshan, MD, MBA

CLINICAL VIGNETTES
Adults: “Holy Spontaneous Heparin-Induced Thrombocytopenia,” Min Hwang

Pediatrics: “The Great Pretender: A Tale of Two Systems,” Shivani Desai, MD

Asking a patient who has concerns about memory loss–particular questions can guide referral decisions, according to new research.

Initial questions should zero in on what the patient is forgetting, said Megan Richie, MD, a neurohospitalist at the University of California, San Francisco, who spoke to a virtual audience at the American College of Physicians (ACP) annual Internal Medicine meeting.

Is the patient forgetting to buy things in a store, having trouble recalling events, forgetting important dates? How often do these incidents occur?

These questions “will help get at how pervasive and how likely the memory loss is affecting their lives, versus a subjective complaint that doesn’t have much impact on the day-to-day function,” she said.

It’s also important to ask whether other neurocognitive symptoms accompany the memory loss, Dr. Richie noted.

Does the patient search for words, struggle with attention, or have problems with executive function? Does the patient have psychiatric symptoms, such as hallucinations or delusions, or other neurologic complaints, including weakness, numbness, vision change, or movement disorders?

“When you know how many neurocognitive symptoms they have, think about how [those symptoms] are affecting their safety and functional status. How are they on their activities of daily living?” Dr. Richie suggests.

Also ask whether the patient is taking medications and whether they drive a vehicle. If they do drive, do they get lost?

“These are all going to help you determine the acuity of the workup,” she said.

After a thorough history, cognitive screening is the next consideration.
 

Cognitive screening can be performed in minutes

One of the tests Dr. Richie recommends is the Mini-Cog. It takes 3 minutes to administer and has been formally recommended by the Alzheimer’s Association because it can be completed in the time frame of a Medicare wellness visit, she said.

It entails a three-word recall and clock-drawing test.

Dr. Richie said it’s important to eliminate some key causes first: “Certainly if the patient has signs and symptoms of depression, pseudodementia is a very real and treatable disease you do not want to miss and should consider in these patients,” she pointed out.

Systemic medical conditions can also lead to memory loss.

If there’s an acute component to the complaint, a new infection or medication withdrawal or a side effect could be driving it, so that’s key in questioning.

Dr. Richie explained that the American Academy of Neurology recommends a very limited workup.

“It’s really just to check their thyroid, their vitamin B12 levels, and then a one-time picture of their brain, which can be either MRI or a CT, to look for structural problems or vascular dementia or hydrocephalus, etc.”

“You do not routinely need spinal fluid testing or an EEG,” she emphasized.

Signs that a neurologist should be involved include a rapid decline, signs of potential seizures, or that the patient doesn’t seem safe in their condition.

Neuropsychological testing is helpful, but it takes nearly 3 hours and may not be a good choice for restless or aggressive patients, Dr. Richie said.

Such testing is often not available, and if it is, insurance coverage is often a barrier because many plans don’t cover it.

Patients often ask about drugs and supplements they see advertised to help with memory loss. Medications are not helpful for mild cognitive impairment, although there is evidence that some are beneficial for patients with dementia, Dr. Richie said.

Celine Goetz, MD, assistant professor of internal medicine at Rush University Medical Center, Chicago, Illinois, told this news organization that it’s easy to relate to the fear that patients and families feel when cognitive impairment begins to emerge.

“[Dr.] Richie’s talk was right on point for internists like myself who see many patients with memory complaints, cognitive impairment, and dementia. I think we’re all terrified of losing our memory and the social and functional impairment that comes with that,” she said.

Although cognitive impairment and dementia aren’t curable or reversible, Dr. Goetz noted, internists can help patients optimize management of conditions such as diabetes and heart disease, which can affect cognitive function.

Dr. Richie pointed out that some interventions lack evidence for the treatment of mild cognitive impairment, but Dr. Goetz emphasized that resources are plentiful and can be effective in combination.

“Engaging social workers, pharmacists, nutritionists, physical and occupational therapists, and, on the inpatient side, delirium protocols, chaplains, and music therapists make a huge difference in patient care,” she said.

Dr. Richie and Dr. Goetz report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Asking a patient who has concerns about memory loss–particular questions can guide referral decisions, according to new research.

Initial questions should zero in on what the patient is forgetting, said Megan Richie, MD, a neurohospitalist at the University of California, San Francisco, who spoke to a virtual audience at the American College of Physicians (ACP) annual Internal Medicine meeting.

Is the patient forgetting to buy things in a store, having trouble recalling events, forgetting important dates? How often do these incidents occur?

These questions “will help get at how pervasive and how likely the memory loss is affecting their lives, versus a subjective complaint that doesn’t have much impact on the day-to-day function,” she said.

It’s also important to ask whether other neurocognitive symptoms accompany the memory loss, Dr. Richie noted.

Does the patient search for words, struggle with attention, or have problems with executive function? Does the patient have psychiatric symptoms, such as hallucinations or delusions, or other neurologic complaints, including weakness, numbness, vision change, or movement disorders?

“When you know how many neurocognitive symptoms they have, think about how [those symptoms] are affecting their safety and functional status. How are they on their activities of daily living?” Dr. Richie suggests.

Also ask whether the patient is taking medications and whether they drive a vehicle. If they do drive, do they get lost?

“These are all going to help you determine the acuity of the workup,” she said.

After a thorough history, cognitive screening is the next consideration.
 

Cognitive screening can be performed in minutes

One of the tests Dr. Richie recommends is the Mini-Cog. It takes 3 minutes to administer and has been formally recommended by the Alzheimer’s Association because it can be completed in the time frame of a Medicare wellness visit, she said.

It entails a three-word recall and clock-drawing test.

Dr. Richie said it’s important to eliminate some key causes first: “Certainly if the patient has signs and symptoms of depression, pseudodementia is a very real and treatable disease you do not want to miss and should consider in these patients,” she pointed out.

Systemic medical conditions can also lead to memory loss.

If there’s an acute component to the complaint, a new infection or medication withdrawal or a side effect could be driving it, so that’s key in questioning.

Dr. Richie explained that the American Academy of Neurology recommends a very limited workup.

“It’s really just to check their thyroid, their vitamin B12 levels, and then a one-time picture of their brain, which can be either MRI or a CT, to look for structural problems or vascular dementia or hydrocephalus, etc.”

“You do not routinely need spinal fluid testing or an EEG,” she emphasized.

Signs that a neurologist should be involved include a rapid decline, signs of potential seizures, or that the patient doesn’t seem safe in their condition.

Neuropsychological testing is helpful, but it takes nearly 3 hours and may not be a good choice for restless or aggressive patients, Dr. Richie said.

Such testing is often not available, and if it is, insurance coverage is often a barrier because many plans don’t cover it.

Patients often ask about drugs and supplements they see advertised to help with memory loss. Medications are not helpful for mild cognitive impairment, although there is evidence that some are beneficial for patients with dementia, Dr. Richie said.

Celine Goetz, MD, assistant professor of internal medicine at Rush University Medical Center, Chicago, Illinois, told this news organization that it’s easy to relate to the fear that patients and families feel when cognitive impairment begins to emerge.

“[Dr.] Richie’s talk was right on point for internists like myself who see many patients with memory complaints, cognitive impairment, and dementia. I think we’re all terrified of losing our memory and the social and functional impairment that comes with that,” she said.

Although cognitive impairment and dementia aren’t curable or reversible, Dr. Goetz noted, internists can help patients optimize management of conditions such as diabetes and heart disease, which can affect cognitive function.

Dr. Richie pointed out that some interventions lack evidence for the treatment of mild cognitive impairment, but Dr. Goetz emphasized that resources are plentiful and can be effective in combination.

“Engaging social workers, pharmacists, nutritionists, physical and occupational therapists, and, on the inpatient side, delirium protocols, chaplains, and music therapists make a huge difference in patient care,” she said.

Dr. Richie and Dr. Goetz report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Asking a patient who has concerns about memory loss–particular questions can guide referral decisions, according to new research.

Initial questions should zero in on what the patient is forgetting, said Megan Richie, MD, a neurohospitalist at the University of California, San Francisco, who spoke to a virtual audience at the American College of Physicians (ACP) annual Internal Medicine meeting.

Is the patient forgetting to buy things in a store, having trouble recalling events, forgetting important dates? How often do these incidents occur?

These questions “will help get at how pervasive and how likely the memory loss is affecting their lives, versus a subjective complaint that doesn’t have much impact on the day-to-day function,” she said.

It’s also important to ask whether other neurocognitive symptoms accompany the memory loss, Dr. Richie noted.

Does the patient search for words, struggle with attention, or have problems with executive function? Does the patient have psychiatric symptoms, such as hallucinations or delusions, or other neurologic complaints, including weakness, numbness, vision change, or movement disorders?

“When you know how many neurocognitive symptoms they have, think about how [those symptoms] are affecting their safety and functional status. How are they on their activities of daily living?” Dr. Richie suggests.

Also ask whether the patient is taking medications and whether they drive a vehicle. If they do drive, do they get lost?

“These are all going to help you determine the acuity of the workup,” she said.

After a thorough history, cognitive screening is the next consideration.
 

Cognitive screening can be performed in minutes

One of the tests Dr. Richie recommends is the Mini-Cog. It takes 3 minutes to administer and has been formally recommended by the Alzheimer’s Association because it can be completed in the time frame of a Medicare wellness visit, she said.

It entails a three-word recall and clock-drawing test.

Dr. Richie said it’s important to eliminate some key causes first: “Certainly if the patient has signs and symptoms of depression, pseudodementia is a very real and treatable disease you do not want to miss and should consider in these patients,” she pointed out.

Systemic medical conditions can also lead to memory loss.

If there’s an acute component to the complaint, a new infection or medication withdrawal or a side effect could be driving it, so that’s key in questioning.

Dr. Richie explained that the American Academy of Neurology recommends a very limited workup.

“It’s really just to check their thyroid, their vitamin B12 levels, and then a one-time picture of their brain, which can be either MRI or a CT, to look for structural problems or vascular dementia or hydrocephalus, etc.”

“You do not routinely need spinal fluid testing or an EEG,” she emphasized.

Signs that a neurologist should be involved include a rapid decline, signs of potential seizures, or that the patient doesn’t seem safe in their condition.

Neuropsychological testing is helpful, but it takes nearly 3 hours and may not be a good choice for restless or aggressive patients, Dr. Richie said.

Such testing is often not available, and if it is, insurance coverage is often a barrier because many plans don’t cover it.

Patients often ask about drugs and supplements they see advertised to help with memory loss. Medications are not helpful for mild cognitive impairment, although there is evidence that some are beneficial for patients with dementia, Dr. Richie said.

Celine Goetz, MD, assistant professor of internal medicine at Rush University Medical Center, Chicago, Illinois, told this news organization that it’s easy to relate to the fear that patients and families feel when cognitive impairment begins to emerge.

“[Dr.] Richie’s talk was right on point for internists like myself who see many patients with memory complaints, cognitive impairment, and dementia. I think we’re all terrified of losing our memory and the social and functional impairment that comes with that,” she said.

Although cognitive impairment and dementia aren’t curable or reversible, Dr. Goetz noted, internists can help patients optimize management of conditions such as diabetes and heart disease, which can affect cognitive function.

Dr. Richie pointed out that some interventions lack evidence for the treatment of mild cognitive impairment, but Dr. Goetz emphasized that resources are plentiful and can be effective in combination.

“Engaging social workers, pharmacists, nutritionists, physical and occupational therapists, and, on the inpatient side, delirium protocols, chaplains, and music therapists make a huge difference in patient care,” she said.

Dr. Richie and Dr. Goetz report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Although the COVID-19 pandemic put telehealth on fast forward, more than one third of patients in the United States engaged with telehealth services before February 2020, according to Ameet Doshi, MD, and Chrisanne Timpe, MD, of HealthPartners in Bloomington, Minn.

Broadly speaking, telehealth is “using virtual tools to evaluate, manage, and care for our patients, regardless of where they are located,” Dr. Doshi said during a May 6 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

The entirety of telehealth includes remote ways to meet almost any patient demand, he said. Some common health terms are used interchangeably, but some use telehealth as a broad term for electronic health care services, while telemedicine may refer specifically to remote patient care, he said.

Telemedicine allows flexibility of delivering patient care in inpatient, outpatient, or at-home settings, said Dr. Doshi. To illustrate the current application of telemedicine, he used an example of a 25-bed critical access hospital serving a growing regional population in which outpatient volume is expanding and ambulatory care services are being added. In this example, inpatient volume is growing, but not enough to support an inpatient consult service, but telehealth access to specialists such as cardiology would be useful in this case, he said.

Hospitalist telehealth means “being able to provide services to changing patient populations regardless of location; we can bring services to where patients are,” said Dr. Doshi.

Benefits of telehealth to patients include less travel and easier access to care, benefits to clinicians include expanding services at lower financial costs, he said.
 

COVID-19 challenges and opportunities

The COVID-19 pandemic presented both challenges and opportunities for telehealth, Dr. Doshi said. One opportunity was the sudden broad acceptance of virtual care out of necessity and concern for patient and staff safety, and to preserve the use of personal protective equipment, he said. In addition, a loosening of regulatory and financial pressures allowed more institutions to expand and initiate telehealth services.

Challenges included technological limitations and, in some cases, the need to develop a telehealth infrastructure from scratch, Dr. Doshi explained. Concerns also remain regarding how telehealth will evolve in the post-pandemic future, he said.

In the meantime, Medicare data show the impact of the pandemic on telehealth services, said Dr. Doshi. A telehealth waiver issued in March 2020 led to an increase in virtual encounters, and Medicare data show approximately 25 million virtual Medicare encounters between March 2020 and October 2020, representing a 3,000% increase from the same period in 2019, he said.

“Telehealth is here to stay, so the questions are how to craft a hospitalist telehealth program and provide essential patient care,” he said.

Dr. Timpe shared some examples of the evolution of telehealth care during the pandemic, including a case of an asymptomatic but frail patient with diabetes, dementia, and coronary artery disease undergoing outpatient care for a foot infection. The patient presented to an emergency department but refused to be hospitalized because of family concerns about patient isolation (no visitors were allowed at the time) and the concerns about COVID-19 infection.

The need to help treat acutely ill patients such as this patient while avoiding hospital admission during and after the pandemic continues to lead to the development of telehealth programs, Dr. Timpe said. She shared details of the Hospital@Home program developed by her organization, Health Partners. The program is designed to treat acutely ill people in the home, if possible, and avoid the need for hospital admission. Patients receive daily medical management from a hospitalist and care from staff, including registered nurses and community paramedics. Services include provision of IV medications and fluids, but the staff also conduct labs and imaging services, Dr. Timpe said.

Conditions that the program has managed at patients’ homes include pneumonia, COPD, asthma, bronchitis, flu, COVID-19, congestive heart failure, cellulitis, and urinary tract infections, said Dr. Timpe.

“We do not accept people into the program who have treatment needs that can only be met in a hospital,” such as the need for blood products, vasopressor support, telemetry, or positive pressure support, she noted.

Between November 2019 and February 15, 2021, the Hospital@Home program has provided services to 132 patients for a total of 287 visits. The program has averted 50 emergency department visits and 40 hospitalizations, and shorted hospital stays in 57 cases, she noted.

Hospitalists are suited for telehealth for several reasons, including the ability to triage acutely ill patients, familiarity with resource utilization, and expertise in management of complex medical care, said Dr. Timpe.
 

Looking ahead

Dr. Doshi emphasized several ongoing issues regarding the future of telemedicine, primarily the need for standardized regulation and reimbursement; reduction of health equity disparity and attention to technological barriers (including access and technology literacy); and identification of the next frontiers in telehealth.

Research on the impact and effectiveness of telehealth is limited, but growing, and next frontiers might include making patients more active participants in telehealth via patient-operated kits, or the option of an open telemedicine marketplace, in which patients can select providers from across the country, he said. No matter where telehealth leads in the future, “we need to make sure we have a positive patient outcome,” he concluded.

Dr. Doshi and Dr. Timpe had no financial conflicts to disclose.

Although the COVID-19 pandemic put telehealth on fast forward, more than one third of patients in the United States engaged with telehealth services before February 2020, according to Ameet Doshi, MD, and Chrisanne Timpe, MD, of HealthPartners in Bloomington, Minn.

Broadly speaking, telehealth is “using virtual tools to evaluate, manage, and care for our patients, regardless of where they are located,” Dr. Doshi said during a May 6 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

The entirety of telehealth includes remote ways to meet almost any patient demand, he said. Some common health terms are used interchangeably, but some use telehealth as a broad term for electronic health care services, while telemedicine may refer specifically to remote patient care, he said.

Telemedicine allows flexibility of delivering patient care in inpatient, outpatient, or at-home settings, said Dr. Doshi. To illustrate the current application of telemedicine, he used an example of a 25-bed critical access hospital serving a growing regional population in which outpatient volume is expanding and ambulatory care services are being added. In this example, inpatient volume is growing, but not enough to support an inpatient consult service, but telehealth access to specialists such as cardiology would be useful in this case, he said.

Hospitalist telehealth means “being able to provide services to changing patient populations regardless of location; we can bring services to where patients are,” said Dr. Doshi.

Benefits of telehealth to patients include less travel and easier access to care, benefits to clinicians include expanding services at lower financial costs, he said.
 

COVID-19 challenges and opportunities

The COVID-19 pandemic presented both challenges and opportunities for telehealth, Dr. Doshi said. One opportunity was the sudden broad acceptance of virtual care out of necessity and concern for patient and staff safety, and to preserve the use of personal protective equipment, he said. In addition, a loosening of regulatory and financial pressures allowed more institutions to expand and initiate telehealth services.

Challenges included technological limitations and, in some cases, the need to develop a telehealth infrastructure from scratch, Dr. Doshi explained. Concerns also remain regarding how telehealth will evolve in the post-pandemic future, he said.

In the meantime, Medicare data show the impact of the pandemic on telehealth services, said Dr. Doshi. A telehealth waiver issued in March 2020 led to an increase in virtual encounters, and Medicare data show approximately 25 million virtual Medicare encounters between March 2020 and October 2020, representing a 3,000% increase from the same period in 2019, he said.

“Telehealth is here to stay, so the questions are how to craft a hospitalist telehealth program and provide essential patient care,” he said.

Dr. Timpe shared some examples of the evolution of telehealth care during the pandemic, including a case of an asymptomatic but frail patient with diabetes, dementia, and coronary artery disease undergoing outpatient care for a foot infection. The patient presented to an emergency department but refused to be hospitalized because of family concerns about patient isolation (no visitors were allowed at the time) and the concerns about COVID-19 infection.

The need to help treat acutely ill patients such as this patient while avoiding hospital admission during and after the pandemic continues to lead to the development of telehealth programs, Dr. Timpe said. She shared details of the Hospital@Home program developed by her organization, Health Partners. The program is designed to treat acutely ill people in the home, if possible, and avoid the need for hospital admission. Patients receive daily medical management from a hospitalist and care from staff, including registered nurses and community paramedics. Services include provision of IV medications and fluids, but the staff also conduct labs and imaging services, Dr. Timpe said.

Conditions that the program has managed at patients’ homes include pneumonia, COPD, asthma, bronchitis, flu, COVID-19, congestive heart failure, cellulitis, and urinary tract infections, said Dr. Timpe.

“We do not accept people into the program who have treatment needs that can only be met in a hospital,” such as the need for blood products, vasopressor support, telemetry, or positive pressure support, she noted.

Between November 2019 and February 15, 2021, the Hospital@Home program has provided services to 132 patients for a total of 287 visits. The program has averted 50 emergency department visits and 40 hospitalizations, and shorted hospital stays in 57 cases, she noted.

Hospitalists are suited for telehealth for several reasons, including the ability to triage acutely ill patients, familiarity with resource utilization, and expertise in management of complex medical care, said Dr. Timpe.
 

Looking ahead

Dr. Doshi emphasized several ongoing issues regarding the future of telemedicine, primarily the need for standardized regulation and reimbursement; reduction of health equity disparity and attention to technological barriers (including access and technology literacy); and identification of the next frontiers in telehealth.

Research on the impact and effectiveness of telehealth is limited, but growing, and next frontiers might include making patients more active participants in telehealth via patient-operated kits, or the option of an open telemedicine marketplace, in which patients can select providers from across the country, he said. No matter where telehealth leads in the future, “we need to make sure we have a positive patient outcome,” he concluded.

Dr. Doshi and Dr. Timpe had no financial conflicts to disclose.

Although the COVID-19 pandemic put telehealth on fast forward, more than one third of patients in the United States engaged with telehealth services before February 2020, according to Ameet Doshi, MD, and Chrisanne Timpe, MD, of HealthPartners in Bloomington, Minn.

Broadly speaking, telehealth is “using virtual tools to evaluate, manage, and care for our patients, regardless of where they are located,” Dr. Doshi said during a May 6 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

The entirety of telehealth includes remote ways to meet almost any patient demand, he said. Some common health terms are used interchangeably, but some use telehealth as a broad term for electronic health care services, while telemedicine may refer specifically to remote patient care, he said.

Telemedicine allows flexibility of delivering patient care in inpatient, outpatient, or at-home settings, said Dr. Doshi. To illustrate the current application of telemedicine, he used an example of a 25-bed critical access hospital serving a growing regional population in which outpatient volume is expanding and ambulatory care services are being added. In this example, inpatient volume is growing, but not enough to support an inpatient consult service, but telehealth access to specialists such as cardiology would be useful in this case, he said.

Hospitalist telehealth means “being able to provide services to changing patient populations regardless of location; we can bring services to where patients are,” said Dr. Doshi.

Benefits of telehealth to patients include less travel and easier access to care, benefits to clinicians include expanding services at lower financial costs, he said.
 

COVID-19 challenges and opportunities

The COVID-19 pandemic presented both challenges and opportunities for telehealth, Dr. Doshi said. One opportunity was the sudden broad acceptance of virtual care out of necessity and concern for patient and staff safety, and to preserve the use of personal protective equipment, he said. In addition, a loosening of regulatory and financial pressures allowed more institutions to expand and initiate telehealth services.

Challenges included technological limitations and, in some cases, the need to develop a telehealth infrastructure from scratch, Dr. Doshi explained. Concerns also remain regarding how telehealth will evolve in the post-pandemic future, he said.

In the meantime, Medicare data show the impact of the pandemic on telehealth services, said Dr. Doshi. A telehealth waiver issued in March 2020 led to an increase in virtual encounters, and Medicare data show approximately 25 million virtual Medicare encounters between March 2020 and October 2020, representing a 3,000% increase from the same period in 2019, he said.

“Telehealth is here to stay, so the questions are how to craft a hospitalist telehealth program and provide essential patient care,” he said.

Dr. Timpe shared some examples of the evolution of telehealth care during the pandemic, including a case of an asymptomatic but frail patient with diabetes, dementia, and coronary artery disease undergoing outpatient care for a foot infection. The patient presented to an emergency department but refused to be hospitalized because of family concerns about patient isolation (no visitors were allowed at the time) and the concerns about COVID-19 infection.

The need to help treat acutely ill patients such as this patient while avoiding hospital admission during and after the pandemic continues to lead to the development of telehealth programs, Dr. Timpe said. She shared details of the Hospital@Home program developed by her organization, Health Partners. The program is designed to treat acutely ill people in the home, if possible, and avoid the need for hospital admission. Patients receive daily medical management from a hospitalist and care from staff, including registered nurses and community paramedics. Services include provision of IV medications and fluids, but the staff also conduct labs and imaging services, Dr. Timpe said.

Conditions that the program has managed at patients’ homes include pneumonia, COPD, asthma, bronchitis, flu, COVID-19, congestive heart failure, cellulitis, and urinary tract infections, said Dr. Timpe.

“We do not accept people into the program who have treatment needs that can only be met in a hospital,” such as the need for blood products, vasopressor support, telemetry, or positive pressure support, she noted.

Between November 2019 and February 15, 2021, the Hospital@Home program has provided services to 132 patients for a total of 287 visits. The program has averted 50 emergency department visits and 40 hospitalizations, and shorted hospital stays in 57 cases, she noted.

Hospitalists are suited for telehealth for several reasons, including the ability to triage acutely ill patients, familiarity with resource utilization, and expertise in management of complex medical care, said Dr. Timpe.
 

Looking ahead

Dr. Doshi emphasized several ongoing issues regarding the future of telemedicine, primarily the need for standardized regulation and reimbursement; reduction of health equity disparity and attention to technological barriers (including access and technology literacy); and identification of the next frontiers in telehealth.

Research on the impact and effectiveness of telehealth is limited, but growing, and next frontiers might include making patients more active participants in telehealth via patient-operated kits, or the option of an open telemedicine marketplace, in which patients can select providers from across the country, he said. No matter where telehealth leads in the future, “we need to make sure we have a positive patient outcome,” he concluded.

Dr. Doshi and Dr. Timpe had no financial conflicts to disclose.

If you don’t have a standardized process for obstructive sleep apnea screening of all patients heading into the operating room at your hospital you should, because perioperative pulmonary complications can occur, according to Efren C. Manjarrez MD, SFHM, FACP.

If OSA is not documented in the patient’s chart, you may find yourself making a bedside assessment. “I usually don’t ask the patients this because they can’t necessarily answer the questions,” Dr. Manjarrez, associate professor in the division of hospital medicine at the University of Miami, said at SHM Converge, the annual conference of the Society of Hospital Medicine. “So, I ask their partner: ‘Does your partner snore loudly? Are they sleepy during the daytime, or are they gasping or choking in the middle of the night?’”

The following factors have a relatively high specificity for OSA: a STOP-Bang score of 5 or greater, a STOP-Bang score of 2 or greater plus male gender, and a STOP-Bang score of 2 or greater plus a body mass index greater than 35 kg/m². Clinicians can also check the Mallampati score on their patients by having them tilt their heads back and stick out their tongues.

“If the uvula is not touching the tongue, that’s a Mallampati score of 1; that’s a pretty wide-open airway,” Dr. Manjarrez said. “However, when you do not have any form of an airway and the palate is touching the tongue, that is a Mallampati score of 4, which indicates OSA.”

Other objective data suggestive of OSA include high blood pressure, a BMI over 35 kg/m², a neck circumference of greater than 40 cm, and male gender. In a study of patients who presented for surgery who did not have a diagnosis of sleep apnea, a high STOP-Bang score indicated a high probability of moderate to severe sleep apnea (Br J. Anaesth 2012;108[5]:768-75).

“If the STOP-Bang score is 0-2, your workup stops,” Dr. Manjarrez said. “If your STOP-Bang score is 5 or above, there’s a high likelihood they have moderate or severe sleep apnea. Patients who have a STOP-Bang of 3-4, calculate their STOP score. If the STOP score is 2 or more and they’re male, obese, and have a neck circumference of greater than 40 cm, there’s a pretty good chance they’ve got OSA.”

Screening for OSA prior to surgery matters, because the potential pulmonary complications are fairly high, “anywhere from postoperative respiratory failure to COPD exacerbation and hypoxia to pneumonia,” he continued. “These patients very commonly desaturate and are difficult for the anesthesiologists to intubate. Fortunately, we have not found significant cardiac complications in the medical literature, but we do know that patients with OSA commonly get postoperative atrial fibrillation. There are also combined complications like desaturation and AFib and difficult intubations. Patients with sleep apnea do have a higher resource utilization perioperatively. Fortunately, at this point in time the data does not show that patients with OSA going in for surgery have an increased mortality.”

To optimize the care of these patients prior to surgery, Dr. Manjarrez recommends that hospitalists document that a patient either has known OSA or suspected OSA. “If possible, obtain their sleep study results and recommended PAP settings,” he said. “Ask patients to bring their PAP device to the hospital or to assure the hospital has appropriate surrogate devices available. You also want to advise the patient and the perioperative care team of the increased risk of complications in patients at high risk for OSA and optimize other conditions that may impair cardiorespiratory function.”

Perioperative risk reduction strategies include planning for difficult intubation and mask ventilation, using regional anesthesia and analgesia, using sedatives with caution, minimizing the use of opioids and anticipating variable opioid responses. “When I have a patient with suspected sleep apnea and no red flags I write down ‘OSA precautions,’ in the chart, which means elevate the head of the bed, perform continuous pulse oximetry, and cautiously supply supplemental oxygen as needed,” he said.

Postoperatively, he continued, minimize sedative agents and opioids, use regional and nonopioid analgesics when possible, provide supplemental oxygen until the patient is able to maintain baseline SaO₂ on room air in a monitored setting, maintain the patient in nonsupine position when feasible, and continuously monitor pulse oximetry.

Consider delay of elective surgery and referral to a sleep medicine specialist in cases of uncontrolled systemic conditions or impaired gas exchange, including hypoventilation syndromes (a clue being a serum HC03 of 28 or higher), severe pulmonary hypertension (a clue being right ventricular systolic blood pressure or pulmonary systolic pressure of 70 mm Hg or above, or right ventricular dilatation/dysfunction), and hypoxemia not explained by cardiac disease.

A systematic review and meta-analysis of six studies that included 904 patients with sleep apnea found that there was no significant difference in the postoperative adverse events between CPAP and no-CPAP treatment (Anesth Analg 2015;120:1013-23). However, there was a significant reduction in the Apnea-Hypopnea Index postoperatively among those who used CPAP (37 vs. 12 events per hour; P less than .001), as well as a significant reduction in hospital length of stay 4 vs. 4.4 days; P = .05).

Dr. Manjarrez reported having no financial disclosures.

If you don’t have a standardized process for obstructive sleep apnea screening of all patients heading into the operating room at your hospital you should, because perioperative pulmonary complications can occur, according to Efren C. Manjarrez MD, SFHM, FACP.

If OSA is not documented in the patient’s chart, you may find yourself making a bedside assessment. “I usually don’t ask the patients this because they can’t necessarily answer the questions,” Dr. Manjarrez, associate professor in the division of hospital medicine at the University of Miami, said at SHM Converge, the annual conference of the Society of Hospital Medicine. “So, I ask their partner: ‘Does your partner snore loudly? Are they sleepy during the daytime, or are they gasping or choking in the middle of the night?’”

The following factors have a relatively high specificity for OSA: a STOP-Bang score of 5 or greater, a STOP-Bang score of 2 or greater plus male gender, and a STOP-Bang score of 2 or greater plus a body mass index greater than 35 kg/m². Clinicians can also check the Mallampati score on their patients by having them tilt their heads back and stick out their tongues.

“If the uvula is not touching the tongue, that’s a Mallampati score of 1; that’s a pretty wide-open airway,” Dr. Manjarrez said. “However, when you do not have any form of an airway and the palate is touching the tongue, that is a Mallampati score of 4, which indicates OSA.”

Other objective data suggestive of OSA include high blood pressure, a BMI over 35 kg/m², a neck circumference of greater than 40 cm, and male gender. In a study of patients who presented for surgery who did not have a diagnosis of sleep apnea, a high STOP-Bang score indicated a high probability of moderate to severe sleep apnea (Br J. Anaesth 2012;108[5]:768-75).

“If the STOP-Bang score is 0-2, your workup stops,” Dr. Manjarrez said. “If your STOP-Bang score is 5 or above, there’s a high likelihood they have moderate or severe sleep apnea. Patients who have a STOP-Bang of 3-4, calculate their STOP score. If the STOP score is 2 or more and they’re male, obese, and have a neck circumference of greater than 40 cm, there’s a pretty good chance they’ve got OSA.”

Screening for OSA prior to surgery matters, because the potential pulmonary complications are fairly high, “anywhere from postoperative respiratory failure to COPD exacerbation and hypoxia to pneumonia,” he continued. “These patients very commonly desaturate and are difficult for the anesthesiologists to intubate. Fortunately, we have not found significant cardiac complications in the medical literature, but we do know that patients with OSA commonly get postoperative atrial fibrillation. There are also combined complications like desaturation and AFib and difficult intubations. Patients with sleep apnea do have a higher resource utilization perioperatively. Fortunately, at this point in time the data does not show that patients with OSA going in for surgery have an increased mortality.”

To optimize the care of these patients prior to surgery, Dr. Manjarrez recommends that hospitalists document that a patient either has known OSA or suspected OSA. “If possible, obtain their sleep study results and recommended PAP settings,” he said. “Ask patients to bring their PAP device to the hospital or to assure the hospital has appropriate surrogate devices available. You also want to advise the patient and the perioperative care team of the increased risk of complications in patients at high risk for OSA and optimize other conditions that may impair cardiorespiratory function.”

Perioperative risk reduction strategies include planning for difficult intubation and mask ventilation, using regional anesthesia and analgesia, using sedatives with caution, minimizing the use of opioids and anticipating variable opioid responses. “When I have a patient with suspected sleep apnea and no red flags I write down ‘OSA precautions,’ in the chart, which means elevate the head of the bed, perform continuous pulse oximetry, and cautiously supply supplemental oxygen as needed,” he said.

Postoperatively, he continued, minimize sedative agents and opioids, use regional and nonopioid analgesics when possible, provide supplemental oxygen until the patient is able to maintain baseline SaO₂ on room air in a monitored setting, maintain the patient in nonsupine position when feasible, and continuously monitor pulse oximetry.

Consider delay of elective surgery and referral to a sleep medicine specialist in cases of uncontrolled systemic conditions or impaired gas exchange, including hypoventilation syndromes (a clue being a serum HC03 of 28 or higher), severe pulmonary hypertension (a clue being right ventricular systolic blood pressure or pulmonary systolic pressure of 70 mm Hg or above, or right ventricular dilatation/dysfunction), and hypoxemia not explained by cardiac disease.

A systematic review and meta-analysis of six studies that included 904 patients with sleep apnea found that there was no significant difference in the postoperative adverse events between CPAP and no-CPAP treatment (Anesth Analg 2015;120:1013-23). However, there was a significant reduction in the Apnea-Hypopnea Index postoperatively among those who used CPAP (37 vs. 12 events per hour; P less than .001), as well as a significant reduction in hospital length of stay 4 vs. 4.4 days; P = .05).

Dr. Manjarrez reported having no financial disclosures.

If you don’t have a standardized process for obstructive sleep apnea screening of all patients heading into the operating room at your hospital you should, because perioperative pulmonary complications can occur, according to Efren C. Manjarrez MD, SFHM, FACP.

If OSA is not documented in the patient’s chart, you may find yourself making a bedside assessment. “I usually don’t ask the patients this because they can’t necessarily answer the questions,” Dr. Manjarrez, associate professor in the division of hospital medicine at the University of Miami, said at SHM Converge, the annual conference of the Society of Hospital Medicine. “So, I ask their partner: ‘Does your partner snore loudly? Are they sleepy during the daytime, or are they gasping or choking in the middle of the night?’”

The following factors have a relatively high specificity for OSA: a STOP-Bang score of 5 or greater, a STOP-Bang score of 2 or greater plus male gender, and a STOP-Bang score of 2 or greater plus a body mass index greater than 35 kg/m². Clinicians can also check the Mallampati score on their patients by having them tilt their heads back and stick out their tongues.

“If the uvula is not touching the tongue, that’s a Mallampati score of 1; that’s a pretty wide-open airway,” Dr. Manjarrez said. “However, when you do not have any form of an airway and the palate is touching the tongue, that is a Mallampati score of 4, which indicates OSA.”

Other objective data suggestive of OSA include high blood pressure, a BMI over 35 kg/m², a neck circumference of greater than 40 cm, and male gender. In a study of patients who presented for surgery who did not have a diagnosis of sleep apnea, a high STOP-Bang score indicated a high probability of moderate to severe sleep apnea (Br J. Anaesth 2012;108[5]:768-75).

“If the STOP-Bang score is 0-2, your workup stops,” Dr. Manjarrez said. “If your STOP-Bang score is 5 or above, there’s a high likelihood they have moderate or severe sleep apnea. Patients who have a STOP-Bang of 3-4, calculate their STOP score. If the STOP score is 2 or more and they’re male, obese, and have a neck circumference of greater than 40 cm, there’s a pretty good chance they’ve got OSA.”

Screening for OSA prior to surgery matters, because the potential pulmonary complications are fairly high, “anywhere from postoperative respiratory failure to COPD exacerbation and hypoxia to pneumonia,” he continued. “These patients very commonly desaturate and are difficult for the anesthesiologists to intubate. Fortunately, we have not found significant cardiac complications in the medical literature, but we do know that patients with OSA commonly get postoperative atrial fibrillation. There are also combined complications like desaturation and AFib and difficult intubations. Patients with sleep apnea do have a higher resource utilization perioperatively. Fortunately, at this point in time the data does not show that patients with OSA going in for surgery have an increased mortality.”

To optimize the care of these patients prior to surgery, Dr. Manjarrez recommends that hospitalists document that a patient either has known OSA or suspected OSA. “If possible, obtain their sleep study results and recommended PAP settings,” he said. “Ask patients to bring their PAP device to the hospital or to assure the hospital has appropriate surrogate devices available. You also want to advise the patient and the perioperative care team of the increased risk of complications in patients at high risk for OSA and optimize other conditions that may impair cardiorespiratory function.”

Perioperative risk reduction strategies include planning for difficult intubation and mask ventilation, using regional anesthesia and analgesia, using sedatives with caution, minimizing the use of opioids and anticipating variable opioid responses. “When I have a patient with suspected sleep apnea and no red flags I write down ‘OSA precautions,’ in the chart, which means elevate the head of the bed, perform continuous pulse oximetry, and cautiously supply supplemental oxygen as needed,” he said.

Postoperatively, he continued, minimize sedative agents and opioids, use regional and nonopioid analgesics when possible, provide supplemental oxygen until the patient is able to maintain baseline SaO₂ on room air in a monitored setting, maintain the patient in nonsupine position when feasible, and continuously monitor pulse oximetry.

Consider delay of elective surgery and referral to a sleep medicine specialist in cases of uncontrolled systemic conditions or impaired gas exchange, including hypoventilation syndromes (a clue being a serum HC03 of 28 or higher), severe pulmonary hypertension (a clue being right ventricular systolic blood pressure or pulmonary systolic pressure of 70 mm Hg or above, or right ventricular dilatation/dysfunction), and hypoxemia not explained by cardiac disease.

A systematic review and meta-analysis of six studies that included 904 patients with sleep apnea found that there was no significant difference in the postoperative adverse events between CPAP and no-CPAP treatment (Anesth Analg 2015;120:1013-23). However, there was a significant reduction in the Apnea-Hypopnea Index postoperatively among those who used CPAP (37 vs. 12 events per hour; P less than .001), as well as a significant reduction in hospital length of stay 4 vs. 4.4 days; P = .05).

Dr. Manjarrez reported having no financial disclosures.

The Food and Drug Administration granted accelerated approval to pembrolizumab (Keytruda) in combination with other agents for the first-line treatment of patients with locally advanced unresectable or metastatic HER2-positive gastric or gastroesophageal junction (GEJ) adenocarcinoma.

The checkpoint inhibitor is to be used in conjunction with trastuzumab (Herceptin) and fluoropyrimidine- and platinum-containing chemotherapy.

Previously, pembrolizumab was approved as a single agent for these cancers for patients whose tumors express PD-L1 and whose disease progressed after two or more lines of treatment that included chemotherapy and HER2-targeted therapy.

The new approval comes about a year after the FDA’s first-ever approval of a checkpoint inhibitor (nivolumab [Opdivo] in combination with chemotherapies) for the frontline treatment of gastric cancers, as reported by this news organization.

The new approval is based on interim data from the first 264 patients of the ongoing KEYNOTE-811 trial, a randomized, double-blind, placebo-controlled trial involving patients with HER2-positive advanced gastric or GEJ adenocarcinoma who had not previously received systemic therapy for their metastatic disease.

Patients were randomly assigned (1:1) to receive either pembrolizumab at 200 mg or placebo every 3 weeks in combination with trastuzumab and either fluorouracil plus cisplatin or capecitabine plus oxaliplatin.

The overall response rate, which is the primary outcome, was 74% in the pembrolizumab arm and 52% in the placebo arm (one-sided P < .0001).

The median duration of response was 10.6 months in the pembrolizumab arm and 9.5 months in the placebo arm.

The adverse-reaction profile for patients receiving pembrolizumab is consistent with the known pembrolizumab safety profile, the FDA said in a statement.

The recommended pembrolizumab dose in this setting is 200 mg every 3 weeks or 400 mg every 6 weeks.

The FDA’s review, which was granted priority status, used the Real-Time Oncology Review pilot program, which allows streamlined data submission prior to the filing of the full clinical application, and Assessment Aid, a voluntary submission that facilitates the FDA’s assessment.

A version of this article first appeared on Medscape.com.

The Food and Drug Administration granted accelerated approval to pembrolizumab (Keytruda) in combination with other agents for the first-line treatment of patients with locally advanced unresectable or metastatic HER2-positive gastric or gastroesophageal junction (GEJ) adenocarcinoma.

The checkpoint inhibitor is to be used in conjunction with trastuzumab (Herceptin) and fluoropyrimidine- and platinum-containing chemotherapy.

Previously, pembrolizumab was approved as a single agent for these cancers for patients whose tumors express PD-L1 and whose disease progressed after two or more lines of treatment that included chemotherapy and HER2-targeted therapy.

The new approval comes about a year after the FDA’s first-ever approval of a checkpoint inhibitor (nivolumab [Opdivo] in combination with chemotherapies) for the frontline treatment of gastric cancers, as reported by this news organization.

The new approval is based on interim data from the first 264 patients of the ongoing KEYNOTE-811 trial, a randomized, double-blind, placebo-controlled trial involving patients with HER2-positive advanced gastric or GEJ adenocarcinoma who had not previously received systemic therapy for their metastatic disease.

Patients were randomly assigned (1:1) to receive either pembrolizumab at 200 mg or placebo every 3 weeks in combination with trastuzumab and either fluorouracil plus cisplatin or capecitabine plus oxaliplatin.

The overall response rate, which is the primary outcome, was 74% in the pembrolizumab arm and 52% in the placebo arm (one-sided P < .0001).

The median duration of response was 10.6 months in the pembrolizumab arm and 9.5 months in the placebo arm.

The adverse-reaction profile for patients receiving pembrolizumab is consistent with the known pembrolizumab safety profile, the FDA said in a statement.

The recommended pembrolizumab dose in this setting is 200 mg every 3 weeks or 400 mg every 6 weeks.

The FDA’s review, which was granted priority status, used the Real-Time Oncology Review pilot program, which allows streamlined data submission prior to the filing of the full clinical application, and Assessment Aid, a voluntary submission that facilitates the FDA’s assessment.

A version of this article first appeared on Medscape.com.

The Food and Drug Administration granted accelerated approval to pembrolizumab (Keytruda) in combination with other agents for the first-line treatment of patients with locally advanced unresectable or metastatic HER2-positive gastric or gastroesophageal junction (GEJ) adenocarcinoma.

The checkpoint inhibitor is to be used in conjunction with trastuzumab (Herceptin) and fluoropyrimidine- and platinum-containing chemotherapy.

Previously, pembrolizumab was approved as a single agent for these cancers for patients whose tumors express PD-L1 and whose disease progressed after two or more lines of treatment that included chemotherapy and HER2-targeted therapy.

The new approval comes about a year after the FDA’s first-ever approval of a checkpoint inhibitor (nivolumab [Opdivo] in combination with chemotherapies) for the frontline treatment of gastric cancers, as reported by this news organization.

The new approval is based on interim data from the first 264 patients of the ongoing KEYNOTE-811 trial, a randomized, double-blind, placebo-controlled trial involving patients with HER2-positive advanced gastric or GEJ adenocarcinoma who had not previously received systemic therapy for their metastatic disease.

Patients were randomly assigned (1:1) to receive either pembrolizumab at 200 mg or placebo every 3 weeks in combination with trastuzumab and either fluorouracil plus cisplatin or capecitabine plus oxaliplatin.

The overall response rate, which is the primary outcome, was 74% in the pembrolizumab arm and 52% in the placebo arm (one-sided P < .0001).

The median duration of response was 10.6 months in the pembrolizumab arm and 9.5 months in the placebo arm.

The adverse-reaction profile for patients receiving pembrolizumab is consistent with the known pembrolizumab safety profile, the FDA said in a statement.

The recommended pembrolizumab dose in this setting is 200 mg every 3 weeks or 400 mg every 6 weeks.

The FDA’s review, which was granted priority status, used the Real-Time Oncology Review pilot program, which allows streamlined data submission prior to the filing of the full clinical application, and Assessment Aid, a voluntary submission that facilitates the FDA’s assessment.

A version of this article first appeared on Medscape.com.

Girls in late stages of puberty who had elevated levels of body fat showed unusually high levels of several hormones that could contribute to an earlier age of menarche and also slow breast development, according to data from 90 girls who spanned a wide range of body fat in the first longitudinal study to examine links between fat volume, levels of reproductive hormones, and clinical manifestations of hormone action during puberty.

The results showed that girls with greater body fat had higher levels of follicle stimulating hormone, inhibin B, estrone, and certain male-like reproductive hormones, and that this pattern “is specifically tied to body fat,” said Natalie D. Shaw, MD, senior investigator for the study, reported at the annual meeting of the Endocrine Society.

“We found that total body fat is associated with the timing of menarche, as others have reported for body weight,” she noted. The new findings showed that every 1% rise in percent total body fat linked with a significant 3% rise in the likelihood of menarche, menstrual onset. In the new study the average age of menarche was 11.7 years among the overweight or obese girls and 12.8 years among those with normal weights.

But the study’s unique use of an average of about three serial ultrasound breast examinations of each subject during an average 4 years of follow-up also showed that higher levels of body fat linked with slowed breast development in later stages, specifically maturation from stage D to stages D/E and E.

For example, girls with 33% body fat spent an average of 8.2 months in stage D, which stretched to an average of 11.2 months among girls with 38% body fat, reported Madison T. Ortega, a researcher with the Pediatric Endocrinology Group of the National Institute of Environmental Health Sciences in Research Triangle Park, N.C., who presented the report at the meeting.
 

Ultrasound shows what inspection can’t

Results from “several studies have shown earlier breast development in overweight and obese girls by inspection and palpation,” but the new findings from ultrasound examination provide more nuance about the structural breast changes actually occurring in these adolescents, said Dr. Shaw, who heads the Pediatric Endocrinology Group. The current study “was not designed to capture the onset of breast development,” and “it is possible that increased androgens or insulin resistance in girls with higher body fat interferes with normal breast development,” she explained in an interview.

“The authors showed that the timing and progress of early stages of puberty were not earlier in overweight or obese girls. Luteinizing hormone, the indicator of neuroendocrine pubertal onset, and timing of early stages of breast development were the same in all weight groups. The authors also discovered falsely advanced Turner breast stage designations with ultrasonography in some girls with obesity. This might suggest that prior findings in epidemiologic studies of an earlier start to puberty based mostly on breast development stages identified by self-reported inspection and, rarely, palpation, may have been biased by breast adipose tissue,” said Christine M. Burt Solorzano, MD, a pediatric endocrinologist at the University of Virginia in Charlottesville, who was not involved in the study.

“Development of increased follicle-stimulating hormone in late puberty suggests that pubertal tempo, not onset, may be increased in girls with obesity, and goes along with earlier menarche. Their finding of increased androgen levels during mid to late puberty with obesity are consistent with prior findings,” including work published Dr. Burt Solorzano and her associates, she noted. “Delayed timing of advanced breast morphology was unexpected and may reflect relatively lower levels of progesterone in girls with obesity,” a hormone necessary for later stages of breast maturation.

The findings “reinforce that early breast development in the setting of obesity may in fact reflect adipose tissue and not be a true representation of neuroendocrine precocious puberty,” Dr. Burt Solorzano said in an interview. The findings “also suggest that pubertal initiation may not happen earlier in girls with obesity, as has been thought, but rather the tempo of puberty may be more rapid, leading to earlier menarche.”

A possible step toward PCOS

The long-term clinical consequences of the hormonal state linked with overweight and obesity “are unknown,” said Dr. Shaw. However, she and her coworkers followed a few of their subjects with elevated testosterone levels during midpuberty, and several developed signs of early polycystic ovarian syndrome (PCOS) such as irregular menstrual cycles, acne, and hirsutism. “It may be possible to identify girls at high risk for PCOS before menarche,” she suggested.

Dr. Burt Solorzano agreed that delayed breast development in girls with high levels of body fat may reflect inadequate progesterone production, which when coupled with an obesity-related excess level of androgens could put girls at risk for chronic anovulation and later PCOS.

“Weight management during childhood and early puberty may mitigate the adverse effects of obesity on pubertal progression and avoid some of the lifetime complications related to early menarche,” Dr. Burt Solorzano said.

The Body Weight and Puberty Study enrolled 36 girls who were overweight or obese and 54 girls with normal weight. They averaged 11 years of age, with a range of 8.2-14.7 years. Average percent body fat was 41% among the overweight or obese girls and 27% among those with normal weight. The results reported by Ms. Ortega also appeared in a report published Feb 22, 2021 (J Clin Endocrinol Metab. doi: 10.1210/clinem/dgab092).

Dr. Shaw, Ms. Ortega, and Dr. Burt Solorzano had no disclosures.

[email protected]

Girls in late stages of puberty who had elevated levels of body fat showed unusually high levels of several hormones that could contribute to an earlier age of menarche and also slow breast development, according to data from 90 girls who spanned a wide range of body fat in the first longitudinal study to examine links between fat volume, levels of reproductive hormones, and clinical manifestations of hormone action during puberty.

The results showed that girls with greater body fat had higher levels of follicle stimulating hormone, inhibin B, estrone, and certain male-like reproductive hormones, and that this pattern “is specifically tied to body fat,” said Natalie D. Shaw, MD, senior investigator for the study, reported at the annual meeting of the Endocrine Society.

“We found that total body fat is associated with the timing of menarche, as others have reported for body weight,” she noted. The new findings showed that every 1% rise in percent total body fat linked with a significant 3% rise in the likelihood of menarche, menstrual onset. In the new study the average age of menarche was 11.7 years among the overweight or obese girls and 12.8 years among those with normal weights.

But the study’s unique use of an average of about three serial ultrasound breast examinations of each subject during an average 4 years of follow-up also showed that higher levels of body fat linked with slowed breast development in later stages, specifically maturation from stage D to stages D/E and E.

For example, girls with 33% body fat spent an average of 8.2 months in stage D, which stretched to an average of 11.2 months among girls with 38% body fat, reported Madison T. Ortega, a researcher with the Pediatric Endocrinology Group of the National Institute of Environmental Health Sciences in Research Triangle Park, N.C., who presented the report at the meeting.
 

Ultrasound shows what inspection can’t

Results from “several studies have shown earlier breast development in overweight and obese girls by inspection and palpation,” but the new findings from ultrasound examination provide more nuance about the structural breast changes actually occurring in these adolescents, said Dr. Shaw, who heads the Pediatric Endocrinology Group. The current study “was not designed to capture the onset of breast development,” and “it is possible that increased androgens or insulin resistance in girls with higher body fat interferes with normal breast development,” she explained in an interview.

“The authors showed that the timing and progress of early stages of puberty were not earlier in overweight or obese girls. Luteinizing hormone, the indicator of neuroendocrine pubertal onset, and timing of early stages of breast development were the same in all weight groups. The authors also discovered falsely advanced Turner breast stage designations with ultrasonography in some girls with obesity. This might suggest that prior findings in epidemiologic studies of an earlier start to puberty based mostly on breast development stages identified by self-reported inspection and, rarely, palpation, may have been biased by breast adipose tissue,” said Christine M. Burt Solorzano, MD, a pediatric endocrinologist at the University of Virginia in Charlottesville, who was not involved in the study.

“Development of increased follicle-stimulating hormone in late puberty suggests that pubertal tempo, not onset, may be increased in girls with obesity, and goes along with earlier menarche. Their finding of increased androgen levels during mid to late puberty with obesity are consistent with prior findings,” including work published Dr. Burt Solorzano and her associates, she noted. “Delayed timing of advanced breast morphology was unexpected and may reflect relatively lower levels of progesterone in girls with obesity,” a hormone necessary for later stages of breast maturation.

The findings “reinforce that early breast development in the setting of obesity may in fact reflect adipose tissue and not be a true representation of neuroendocrine precocious puberty,” Dr. Burt Solorzano said in an interview. The findings “also suggest that pubertal initiation may not happen earlier in girls with obesity, as has been thought, but rather the tempo of puberty may be more rapid, leading to earlier menarche.”

A possible step toward PCOS

The long-term clinical consequences of the hormonal state linked with overweight and obesity “are unknown,” said Dr. Shaw. However, she and her coworkers followed a few of their subjects with elevated testosterone levels during midpuberty, and several developed signs of early polycystic ovarian syndrome (PCOS) such as irregular menstrual cycles, acne, and hirsutism. “It may be possible to identify girls at high risk for PCOS before menarche,” she suggested.

Dr. Burt Solorzano agreed that delayed breast development in girls with high levels of body fat may reflect inadequate progesterone production, which when coupled with an obesity-related excess level of androgens could put girls at risk for chronic anovulation and later PCOS.

“Weight management during childhood and early puberty may mitigate the adverse effects of obesity on pubertal progression and avoid some of the lifetime complications related to early menarche,” Dr. Burt Solorzano said.

The Body Weight and Puberty Study enrolled 36 girls who were overweight or obese and 54 girls with normal weight. They averaged 11 years of age, with a range of 8.2-14.7 years. Average percent body fat was 41% among the overweight or obese girls and 27% among those with normal weight. The results reported by Ms. Ortega also appeared in a report published Feb 22, 2021 (J Clin Endocrinol Metab. doi: 10.1210/clinem/dgab092).

Dr. Shaw, Ms. Ortega, and Dr. Burt Solorzano had no disclosures.

[email protected]

Girls in late stages of puberty who had elevated levels of body fat showed unusually high levels of several hormones that could contribute to an earlier age of menarche and also slow breast development, according to data from 90 girls who spanned a wide range of body fat in the first longitudinal study to examine links between fat volume, levels of reproductive hormones, and clinical manifestations of hormone action during puberty.

The results showed that girls with greater body fat had higher levels of follicle stimulating hormone, inhibin B, estrone, and certain male-like reproductive hormones, and that this pattern “is specifically tied to body fat,” said Natalie D. Shaw, MD, senior investigator for the study, reported at the annual meeting of the Endocrine Society.

“We found that total body fat is associated with the timing of menarche, as others have reported for body weight,” she noted. The new findings showed that every 1% rise in percent total body fat linked with a significant 3% rise in the likelihood of menarche, menstrual onset. In the new study the average age of menarche was 11.7 years among the overweight or obese girls and 12.8 years among those with normal weights.

But the study’s unique use of an average of about three serial ultrasound breast examinations of each subject during an average 4 years of follow-up also showed that higher levels of body fat linked with slowed breast development in later stages, specifically maturation from stage D to stages D/E and E.

For example, girls with 33% body fat spent an average of 8.2 months in stage D, which stretched to an average of 11.2 months among girls with 38% body fat, reported Madison T. Ortega, a researcher with the Pediatric Endocrinology Group of the National Institute of Environmental Health Sciences in Research Triangle Park, N.C., who presented the report at the meeting.
 

Ultrasound shows what inspection can’t

Results from “several studies have shown earlier breast development in overweight and obese girls by inspection and palpation,” but the new findings from ultrasound examination provide more nuance about the structural breast changes actually occurring in these adolescents, said Dr. Shaw, who heads the Pediatric Endocrinology Group. The current study “was not designed to capture the onset of breast development,” and “it is possible that increased androgens or insulin resistance in girls with higher body fat interferes with normal breast development,” she explained in an interview.

“The authors showed that the timing and progress of early stages of puberty were not earlier in overweight or obese girls. Luteinizing hormone, the indicator of neuroendocrine pubertal onset, and timing of early stages of breast development were the same in all weight groups. The authors also discovered falsely advanced Turner breast stage designations with ultrasonography in some girls with obesity. This might suggest that prior findings in epidemiologic studies of an earlier start to puberty based mostly on breast development stages identified by self-reported inspection and, rarely, palpation, may have been biased by breast adipose tissue,” said Christine M. Burt Solorzano, MD, a pediatric endocrinologist at the University of Virginia in Charlottesville, who was not involved in the study.

“Development of increased follicle-stimulating hormone in late puberty suggests that pubertal tempo, not onset, may be increased in girls with obesity, and goes along with earlier menarche. Their finding of increased androgen levels during mid to late puberty with obesity are consistent with prior findings,” including work published Dr. Burt Solorzano and her associates, she noted. “Delayed timing of advanced breast morphology was unexpected and may reflect relatively lower levels of progesterone in girls with obesity,” a hormone necessary for later stages of breast maturation.

The findings “reinforce that early breast development in the setting of obesity may in fact reflect adipose tissue and not be a true representation of neuroendocrine precocious puberty,” Dr. Burt Solorzano said in an interview. The findings “also suggest that pubertal initiation may not happen earlier in girls with obesity, as has been thought, but rather the tempo of puberty may be more rapid, leading to earlier menarche.”

A possible step toward PCOS

The long-term clinical consequences of the hormonal state linked with overweight and obesity “are unknown,” said Dr. Shaw. However, she and her coworkers followed a few of their subjects with elevated testosterone levels during midpuberty, and several developed signs of early polycystic ovarian syndrome (PCOS) such as irregular menstrual cycles, acne, and hirsutism. “It may be possible to identify girls at high risk for PCOS before menarche,” she suggested.

Dr. Burt Solorzano agreed that delayed breast development in girls with high levels of body fat may reflect inadequate progesterone production, which when coupled with an obesity-related excess level of androgens could put girls at risk for chronic anovulation and later PCOS.

“Weight management during childhood and early puberty may mitigate the adverse effects of obesity on pubertal progression and avoid some of the lifetime complications related to early menarche,” Dr. Burt Solorzano said.

The Body Weight and Puberty Study enrolled 36 girls who were overweight or obese and 54 girls with normal weight. They averaged 11 years of age, with a range of 8.2-14.7 years. Average percent body fat was 41% among the overweight or obese girls and 27% among those with normal weight. The results reported by Ms. Ortega also appeared in a report published Feb 22, 2021 (J Clin Endocrinol Metab. doi: 10.1210/clinem/dgab092).

Dr. Shaw, Ms. Ortega, and Dr. Burt Solorzano had no disclosures.

[email protected]

Genetic biomarkers for atopic dermatitis (AD) vary from one ethnic group to another, with a mutation in the interleukin-17 receptor A (IL-17RA) gene particularly important in Korean patients, researchers say.

The finding moves researchers another step forward in the effort to figure out which patients are most at risk for the disease and who will respond best to which treatments.

“Because atopic dermatitis is considered a complex trait, we think if there is any method to detect AD gene variations simultaneously, it could be possible to prevent the development of AD and then the atopic march,” said Eung Ho Choi, MD, PhD, a dermatology professor at Yonsei University, Wonju, South Korea.

He presented the finding at the International Society of Atopic Dermatitis (ISAD) 2021 Annual Meeting.

Atopic dermatitis is not caused by a single genetic mutation. But genetic factors play an important role, with about 75% concordance between monozygotic twins versus only 23% for dizygotic twins.

“Genetic biomarkers are needed in predicting the occurrence, severity, and treatment response,” as well as determining the prognosis of atopic dermatitis “and applying it to precision medicine,” Dr. Choi said.

Researchers have identified multiple genetic variations related to atopic dermatitis. One of the most significant genetic contributions found so far is the filaggrin gene variation, which can produce a defective skin barrier, Dr. Choi said. Others are involved in the immune response.

Although variations in the filaggrin gene (FLG ) are the most reliable genetic predictor of atopic dermatitis in Korean patients, they are less common in Korean patients than in Northwestern Europeans, Chinese, and Japanese patients. In Korean patients, the most common reported mutations of this gene are 3321delA and K4022X, Dr. Choi said.

To find out what other gene variants are important in Korean patients with atopic dermatitis, Dr. Choi and his colleagues developed the reverse blot hybridization assay (REBA) to detect skin barrier variations in the FLG, SPINK5 and KLK7 genes, and genes involved in immune response variations, KDR, IL-5RA, IL-9, DEFB1 (Defensin Beta 1), IL-12RB1 (interleukin-12 receptor subunit beta 1), and IL-12RB2.

They compared the prevalence of these variations in 279 Koreans with atopic dermatitis to the prevalence in 224 healthy people without atopic dermatitis and found that the odds ratio for atopic dermatitis increased with the number of these variants: People with three or four variants had a 3.75 times greater risk of AD, and those with 5 or more variants had a 10.3 times greater risk. The number of variants did not correlate to the severity of the disease, however.

The filaggrin variation was present in 13.9% of those with atopic dermatitis. About a quarter (28%) of the patients with AD who had this variation had impetigo, 15% had eczema herpeticum, and 5% had prurigo nodularis. By comparison, 14% of the patients with AD who did not have this variation had impetigo, and 5% had eczema herpeticum, but 19% had prurigo nodularis.

In a separate study, Dr. Choi and his colleagues identified a mutation in IL-17RA, present in 8.1% of 332 patients with AD compared with 3.3% of 245 controls. The patients with IL-17RA mutations all had extrinsic AD.

The variation was associated with longer disease duration, more frequent keratosis pilaris, higher blood eosinophil counts, higher serum total immunoglobulin E (IgE) levels, higher house dust mite allergen-specific IgE levels, and a greater need for systemic treatment than patients without the IL-17RA mutation.

Such findings are important for progress in treating atopic dermatitis because the mechanism differs among patients, said Emma Guttman-Yassky, MD, PhD, director of the Center for Excellence in Eczema and professor and chair of dermatology at the Icahn School of Medicine at Mount Sinai, New York.

“It’s not one size fits all in atopic dermatitis, and we need better biomarkers that will be able to tell us which treatment will work best for each patient,” she said in an interview.

In addition to genetic biomarkers, she and her colleagues are analyzing proteins involved in inflammation. They are using adhesive tape strips to harvest these markers, a less invasive approach than skin biopsies.

A version of this article first appeared on Medscape.com.

Genetic biomarkers for atopic dermatitis (AD) vary from one ethnic group to another, with a mutation in the interleukin-17 receptor A (IL-17RA) gene particularly important in Korean patients, researchers say.

The finding moves researchers another step forward in the effort to figure out which patients are most at risk for the disease and who will respond best to which treatments.

“Because atopic dermatitis is considered a complex trait, we think if there is any method to detect AD gene variations simultaneously, it could be possible to prevent the development of AD and then the atopic march,” said Eung Ho Choi, MD, PhD, a dermatology professor at Yonsei University, Wonju, South Korea.

He presented the finding at the International Society of Atopic Dermatitis (ISAD) 2021 Annual Meeting.

Atopic dermatitis is not caused by a single genetic mutation. But genetic factors play an important role, with about 75% concordance between monozygotic twins versus only 23% for dizygotic twins.

“Genetic biomarkers are needed in predicting the occurrence, severity, and treatment response,” as well as determining the prognosis of atopic dermatitis “and applying it to precision medicine,” Dr. Choi said.

Researchers have identified multiple genetic variations related to atopic dermatitis. One of the most significant genetic contributions found so far is the filaggrin gene variation, which can produce a defective skin barrier, Dr. Choi said. Others are involved in the immune response.

Although variations in the filaggrin gene (FLG ) are the most reliable genetic predictor of atopic dermatitis in Korean patients, they are less common in Korean patients than in Northwestern Europeans, Chinese, and Japanese patients. In Korean patients, the most common reported mutations of this gene are 3321delA and K4022X, Dr. Choi said.

To find out what other gene variants are important in Korean patients with atopic dermatitis, Dr. Choi and his colleagues developed the reverse blot hybridization assay (REBA) to detect skin barrier variations in the FLG, SPINK5 and KLK7 genes, and genes involved in immune response variations, KDR, IL-5RA, IL-9, DEFB1 (Defensin Beta 1), IL-12RB1 (interleukin-12 receptor subunit beta 1), and IL-12RB2.

They compared the prevalence of these variations in 279 Koreans with atopic dermatitis to the prevalence in 224 healthy people without atopic dermatitis and found that the odds ratio for atopic dermatitis increased with the number of these variants: People with three or four variants had a 3.75 times greater risk of AD, and those with 5 or more variants had a 10.3 times greater risk. The number of variants did not correlate to the severity of the disease, however.

The filaggrin variation was present in 13.9% of those with atopic dermatitis. About a quarter (28%) of the patients with AD who had this variation had impetigo, 15% had eczema herpeticum, and 5% had prurigo nodularis. By comparison, 14% of the patients with AD who did not have this variation had impetigo, and 5% had eczema herpeticum, but 19% had prurigo nodularis.

In a separate study, Dr. Choi and his colleagues identified a mutation in IL-17RA, present in 8.1% of 332 patients with AD compared with 3.3% of 245 controls. The patients with IL-17RA mutations all had extrinsic AD.

The variation was associated with longer disease duration, more frequent keratosis pilaris, higher blood eosinophil counts, higher serum total immunoglobulin E (IgE) levels, higher house dust mite allergen-specific IgE levels, and a greater need for systemic treatment than patients without the IL-17RA mutation.

Such findings are important for progress in treating atopic dermatitis because the mechanism differs among patients, said Emma Guttman-Yassky, MD, PhD, director of the Center for Excellence in Eczema and professor and chair of dermatology at the Icahn School of Medicine at Mount Sinai, New York.

“It’s not one size fits all in atopic dermatitis, and we need better biomarkers that will be able to tell us which treatment will work best for each patient,” she said in an interview.

In addition to genetic biomarkers, she and her colleagues are analyzing proteins involved in inflammation. They are using adhesive tape strips to harvest these markers, a less invasive approach than skin biopsies.

A version of this article first appeared on Medscape.com.

Genetic biomarkers for atopic dermatitis (AD) vary from one ethnic group to another, with a mutation in the interleukin-17 receptor A (IL-17RA) gene particularly important in Korean patients, researchers say.

The finding moves researchers another step forward in the effort to figure out which patients are most at risk for the disease and who will respond best to which treatments.

“Because atopic dermatitis is considered a complex trait, we think if there is any method to detect AD gene variations simultaneously, it could be possible to prevent the development of AD and then the atopic march,” said Eung Ho Choi, MD, PhD, a dermatology professor at Yonsei University, Wonju, South Korea.

He presented the finding at the International Society of Atopic Dermatitis (ISAD) 2021 Annual Meeting.

Atopic dermatitis is not caused by a single genetic mutation. But genetic factors play an important role, with about 75% concordance between monozygotic twins versus only 23% for dizygotic twins.

“Genetic biomarkers are needed in predicting the occurrence, severity, and treatment response,” as well as determining the prognosis of atopic dermatitis “and applying it to precision medicine,” Dr. Choi said.

Researchers have identified multiple genetic variations related to atopic dermatitis. One of the most significant genetic contributions found so far is the filaggrin gene variation, which can produce a defective skin barrier, Dr. Choi said. Others are involved in the immune response.

Although variations in the filaggrin gene (FLG ) are the most reliable genetic predictor of atopic dermatitis in Korean patients, they are less common in Korean patients than in Northwestern Europeans, Chinese, and Japanese patients. In Korean patients, the most common reported mutations of this gene are 3321delA and K4022X, Dr. Choi said.

To find out what other gene variants are important in Korean patients with atopic dermatitis, Dr. Choi and his colleagues developed the reverse blot hybridization assay (REBA) to detect skin barrier variations in the FLG, SPINK5 and KLK7 genes, and genes involved in immune response variations, KDR, IL-5RA, IL-9, DEFB1 (Defensin Beta 1), IL-12RB1 (interleukin-12 receptor subunit beta 1), and IL-12RB2.

They compared the prevalence of these variations in 279 Koreans with atopic dermatitis to the prevalence in 224 healthy people without atopic dermatitis and found that the odds ratio for atopic dermatitis increased with the number of these variants: People with three or four variants had a 3.75 times greater risk of AD, and those with 5 or more variants had a 10.3 times greater risk. The number of variants did not correlate to the severity of the disease, however.

The filaggrin variation was present in 13.9% of those with atopic dermatitis. About a quarter (28%) of the patients with AD who had this variation had impetigo, 15% had eczema herpeticum, and 5% had prurigo nodularis. By comparison, 14% of the patients with AD who did not have this variation had impetigo, and 5% had eczema herpeticum, but 19% had prurigo nodularis.

In a separate study, Dr. Choi and his colleagues identified a mutation in IL-17RA, present in 8.1% of 332 patients with AD compared with 3.3% of 245 controls. The patients with IL-17RA mutations all had extrinsic AD.

The variation was associated with longer disease duration, more frequent keratosis pilaris, higher blood eosinophil counts, higher serum total immunoglobulin E (IgE) levels, higher house dust mite allergen-specific IgE levels, and a greater need for systemic treatment than patients without the IL-17RA mutation.

Such findings are important for progress in treating atopic dermatitis because the mechanism differs among patients, said Emma Guttman-Yassky, MD, PhD, director of the Center for Excellence in Eczema and professor and chair of dermatology at the Icahn School of Medicine at Mount Sinai, New York.

“It’s not one size fits all in atopic dermatitis, and we need better biomarkers that will be able to tell us which treatment will work best for each patient,” she said in an interview.

In addition to genetic biomarkers, she and her colleagues are analyzing proteins involved in inflammation. They are using adhesive tape strips to harvest these markers, a less invasive approach than skin biopsies.

A version of this article first appeared on Medscape.com.

Personalized nutritional support for adults hospitalized with chronic heart failure and deemed to be at high nutritional risk reduced the risk of death or adverse cardiovascular events, compared with standard hospital food, new research indicates.
 

The Swiss EFFORT trial focused on patients with chronic heart failure and high risk of malnutrition defined by low body mass index, weight loss, and low food intake upon hospital admission.

“This high-risk group of chronic heart failure patients showed a significant improvement in mortality over 30 and 180 days, as well as other clinical outcomes, when individualized nutritional support interventions were offered to patients,” Philipp Schuetz, MD, MPH, Kantonsspital Aarau, Switzerland, said in an interview.

“While monitoring the nutritional status should be done also in outpatient settings by [general practitioners], malnutrition screening upon hospital admission may help to identify high-risk patients with high risk for nutritional status deterioration during the hospital stay who will benefit from nutritional assessment and treatment,” said Dr. Schuetz.

The study was published online May 3 in the Journal of the American College of Cardiology.
 

It’s not all about salt

The findings are based on a prespecified secondary analysis of outcomes in 645 patients (median age, 78.8 years, 52% men) hospitalized with chronic heart failure who participated in the open-label EFFORT study.  

One-third of patients were hospitalized for acute decompensated heart failure and two-thirds had chronic heart failure and other acute medical illnesses requiring hospitalization.

All patients were at risk of malnutrition based on a Nutritional Risk Screening (NRS) score of 3 points or higher. They were randomly allocated 1:1 to individualized nutritional support to reach energy, protein, and micronutrient goals or usual hospital food (control group). 

By 30 days, 27 of 321 patients (8.4%) receiving nutritional support had died compared with 48 of 324 patients (14.8%) in the control group (adjusted odds ratio [OR]: 0.44; 95% confidence interval, 0.26-0.75; P = .002)

Patients with high nutritional risk (NRS >4 points) showed the most benefit from nutritional support.

Compared with patients with moderate nutritional risk scores (NRS score 3-4), those with high nutritional risk (NRS >4) had a highly significant 65% increased mortality risk over 180 days.

The individual component of the NRS with the strongest association with mortality was low food intake in the week before hospitalization.

Patients who received nutritional support in the hospital also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; OR, 0.50; 95% CI, 0.34-0.75; P = .001).

“Historically, cardiologists and internists caring for patients with heart failure have mainly focused on salt-restrictive diets to reduce blood volume and thus optimize heart function. Yet, reduction of salt intake has not been shown to effectively improve clinical outcome but may, on the contrary, increase the risk of malnutrition as low-salt diets are often not tasty,” Dr. Schuetz said.

“Our data suggest that we should move our focus away from salt-restrictive diets to high-protein diets to cover individual nutritional goals in this high-risk group of patients, which includes screening, assessment, and nutritional support by dietitians,” Dr. Schuetz said.

In a linked editorial, Sheldon Gottlieb, MD, Johns Hopkins University, Baltimore, said there has been “relatively little attention” paid to the role of diet in heart failure other than recommending reduced salt intake. 

In fact, in the 2021 American College of Cardiology expert consensus recommendations for optimizing heart failure treatment, roughly five words are devoted to diet and exercise and there is no mention of nutrition assessment by a dietitian, he points out.

“This study adds another tile to the still-fragmentary mosaic picture of the patient with heart failure at nutritional risk who might benefit from nutritional support,” Dr. Dr. Gottlieb wrote.

“ ‘Good medical care’ dictates that all hospitalized patients deserve to have a standardized nutritional assessment; the challenge remains: how to determine which patient with heart failure at nutritional risk will benefit by medical nutrition therapy,” Dr. Gottlieb said.

The Swiss National Science Foundation and the Research Council of the Kantonsspital Aarau provided funding for the trial. Dr. Schuetz’s institution has previously received unrestricted grant money unrelated to this project from Nestle Health Science and Abbott Nutrition. Dr. Gottlieb owns a federal trademark for the “Greens, Beans, and Leans” diet, and has a pending federal trademark for “FLOATS”: flax + oats cereal.

A version of this article first appeared on Medscape.com.

Personalized nutritional support for adults hospitalized with chronic heart failure and deemed to be at high nutritional risk reduced the risk of death or adverse cardiovascular events, compared with standard hospital food, new research indicates.
 

The Swiss EFFORT trial focused on patients with chronic heart failure and high risk of malnutrition defined by low body mass index, weight loss, and low food intake upon hospital admission.

“This high-risk group of chronic heart failure patients showed a significant improvement in mortality over 30 and 180 days, as well as other clinical outcomes, when individualized nutritional support interventions were offered to patients,” Philipp Schuetz, MD, MPH, Kantonsspital Aarau, Switzerland, said in an interview.

“While monitoring the nutritional status should be done also in outpatient settings by [general practitioners], malnutrition screening upon hospital admission may help to identify high-risk patients with high risk for nutritional status deterioration during the hospital stay who will benefit from nutritional assessment and treatment,” said Dr. Schuetz.

The study was published online May 3 in the Journal of the American College of Cardiology.
 

It’s not all about salt

The findings are based on a prespecified secondary analysis of outcomes in 645 patients (median age, 78.8 years, 52% men) hospitalized with chronic heart failure who participated in the open-label EFFORT study.  

One-third of patients were hospitalized for acute decompensated heart failure and two-thirds had chronic heart failure and other acute medical illnesses requiring hospitalization.

All patients were at risk of malnutrition based on a Nutritional Risk Screening (NRS) score of 3 points or higher. They were randomly allocated 1:1 to individualized nutritional support to reach energy, protein, and micronutrient goals or usual hospital food (control group). 

By 30 days, 27 of 321 patients (8.4%) receiving nutritional support had died compared with 48 of 324 patients (14.8%) in the control group (adjusted odds ratio [OR]: 0.44; 95% confidence interval, 0.26-0.75; P = .002)

Patients with high nutritional risk (NRS >4 points) showed the most benefit from nutritional support.

Compared with patients with moderate nutritional risk scores (NRS score 3-4), those with high nutritional risk (NRS >4) had a highly significant 65% increased mortality risk over 180 days.

The individual component of the NRS with the strongest association with mortality was low food intake in the week before hospitalization.

Patients who received nutritional support in the hospital also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; OR, 0.50; 95% CI, 0.34-0.75; P = .001).

“Historically, cardiologists and internists caring for patients with heart failure have mainly focused on salt-restrictive diets to reduce blood volume and thus optimize heart function. Yet, reduction of salt intake has not been shown to effectively improve clinical outcome but may, on the contrary, increase the risk of malnutrition as low-salt diets are often not tasty,” Dr. Schuetz said.

“Our data suggest that we should move our focus away from salt-restrictive diets to high-protein diets to cover individual nutritional goals in this high-risk group of patients, which includes screening, assessment, and nutritional support by dietitians,” Dr. Schuetz said.

In a linked editorial, Sheldon Gottlieb, MD, Johns Hopkins University, Baltimore, said there has been “relatively little attention” paid to the role of diet in heart failure other than recommending reduced salt intake. 

In fact, in the 2021 American College of Cardiology expert consensus recommendations for optimizing heart failure treatment, roughly five words are devoted to diet and exercise and there is no mention of nutrition assessment by a dietitian, he points out.

“This study adds another tile to the still-fragmentary mosaic picture of the patient with heart failure at nutritional risk who might benefit from nutritional support,” Dr. Dr. Gottlieb wrote.

“ ‘Good medical care’ dictates that all hospitalized patients deserve to have a standardized nutritional assessment; the challenge remains: how to determine which patient with heart failure at nutritional risk will benefit by medical nutrition therapy,” Dr. Gottlieb said.

The Swiss National Science Foundation and the Research Council of the Kantonsspital Aarau provided funding for the trial. Dr. Schuetz’s institution has previously received unrestricted grant money unrelated to this project from Nestle Health Science and Abbott Nutrition. Dr. Gottlieb owns a federal trademark for the “Greens, Beans, and Leans” diet, and has a pending federal trademark for “FLOATS”: flax + oats cereal.

A version of this article first appeared on Medscape.com.

Personalized nutritional support for adults hospitalized with chronic heart failure and deemed to be at high nutritional risk reduced the risk of death or adverse cardiovascular events, compared with standard hospital food, new research indicates.
 

The Swiss EFFORT trial focused on patients with chronic heart failure and high risk of malnutrition defined by low body mass index, weight loss, and low food intake upon hospital admission.

“This high-risk group of chronic heart failure patients showed a significant improvement in mortality over 30 and 180 days, as well as other clinical outcomes, when individualized nutritional support interventions were offered to patients,” Philipp Schuetz, MD, MPH, Kantonsspital Aarau, Switzerland, said in an interview.

“While monitoring the nutritional status should be done also in outpatient settings by [general practitioners], malnutrition screening upon hospital admission may help to identify high-risk patients with high risk for nutritional status deterioration during the hospital stay who will benefit from nutritional assessment and treatment,” said Dr. Schuetz.

The study was published online May 3 in the Journal of the American College of Cardiology.
 

It’s not all about salt

The findings are based on a prespecified secondary analysis of outcomes in 645 patients (median age, 78.8 years, 52% men) hospitalized with chronic heart failure who participated in the open-label EFFORT study.  

One-third of patients were hospitalized for acute decompensated heart failure and two-thirds had chronic heart failure and other acute medical illnesses requiring hospitalization.

All patients were at risk of malnutrition based on a Nutritional Risk Screening (NRS) score of 3 points or higher. They were randomly allocated 1:1 to individualized nutritional support to reach energy, protein, and micronutrient goals or usual hospital food (control group). 

By 30 days, 27 of 321 patients (8.4%) receiving nutritional support had died compared with 48 of 324 patients (14.8%) in the control group (adjusted odds ratio [OR]: 0.44; 95% confidence interval, 0.26-0.75; P = .002)

Patients with high nutritional risk (NRS >4 points) showed the most benefit from nutritional support.

Compared with patients with moderate nutritional risk scores (NRS score 3-4), those with high nutritional risk (NRS >4) had a highly significant 65% increased mortality risk over 180 days.

The individual component of the NRS with the strongest association with mortality was low food intake in the week before hospitalization.

Patients who received nutritional support in the hospital also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; OR, 0.50; 95% CI, 0.34-0.75; P = .001).

“Historically, cardiologists and internists caring for patients with heart failure have mainly focused on salt-restrictive diets to reduce blood volume and thus optimize heart function. Yet, reduction of salt intake has not been shown to effectively improve clinical outcome but may, on the contrary, increase the risk of malnutrition as low-salt diets are often not tasty,” Dr. Schuetz said.

“Our data suggest that we should move our focus away from salt-restrictive diets to high-protein diets to cover individual nutritional goals in this high-risk group of patients, which includes screening, assessment, and nutritional support by dietitians,” Dr. Schuetz said.

In a linked editorial, Sheldon Gottlieb, MD, Johns Hopkins University, Baltimore, said there has been “relatively little attention” paid to the role of diet in heart failure other than recommending reduced salt intake. 

In fact, in the 2021 American College of Cardiology expert consensus recommendations for optimizing heart failure treatment, roughly five words are devoted to diet and exercise and there is no mention of nutrition assessment by a dietitian, he points out.

“This study adds another tile to the still-fragmentary mosaic picture of the patient with heart failure at nutritional risk who might benefit from nutritional support,” Dr. Dr. Gottlieb wrote.

“ ‘Good medical care’ dictates that all hospitalized patients deserve to have a standardized nutritional assessment; the challenge remains: how to determine which patient with heart failure at nutritional risk will benefit by medical nutrition therapy,” Dr. Gottlieb said.

The Swiss National Science Foundation and the Research Council of the Kantonsspital Aarau provided funding for the trial. Dr. Schuetz’s institution has previously received unrestricted grant money unrelated to this project from Nestle Health Science and Abbott Nutrition. Dr. Gottlieb owns a federal trademark for the “Greens, Beans, and Leans” diet, and has a pending federal trademark for “FLOATS”: flax + oats cereal.

A version of this article first appeared on Medscape.com.

The use of neoadjuvant endocrine therapy (NET) increased significantly during the first 8 months of the COVID-19 pandemic for women with estrogen receptor–positive (ER+) breast cancer. These patients would normally undergo surgery first, but because of operating room restrictions, those surgeries were delayed because of the pandemic, according to a new study.
 

“We hypothesized that by offering a nontoxic therapy, we would be able to ‘hold over’ patients until such time when personal protective equipment supplies were renewed and we could get into the operating room,” lead author Lee Wilke, MD, professor of surgery, University of Wisconsin, Madison, said in an interview.

“And while a small number of women with ER+ tumors get NET anyway, we found over one-third of patients with ER+ breast cancer were treated with NET due to COVID-19 during the first 8 months of last year,” she said.

“One year later, 31% of the same patient population is still getting NET,” she added.

The study was presented during the online annual meeting of the American Society of Breast Surgeons (ASBrS).
 

COVID-specific registry

Dr. Wilke believes that this study presents an accurate snapshot of changes in treatment caused by the pandemic.

She and her colleagues compared data collected in the ASBrS Mastery Program registry to data collected in an embedded but separate COVID-19 segment. The data were for the period from March 1 to Oct. 28, 2020.

Almost three-quarters of the surgeons who entered patients into the COVID-19 segment were from urban areas; 95% reported stopping mammographic screening during part of this period.

The preliminary analysis focused on data collected from 2,476 patients in the COVID-19 segment and 2,303 patients within the Mastery registry.

For patients with ER+/HER2- breast cancer, NET was described as a usual approach in 6.5% of patients in the COVID-19 registry. In the Mastery registry, 7.8% of patients received NET.

Compared with surgery first/usual practice, which served as the reference, older patients were more likely to receive NET first because of the COVID-19 pandemic than younger patients, and they were more likely to receive NET first if they lived in the Northeast or the Southeast compared to other regions of the United States. Dr. Wilke pointed out that the Northeast and the Southeast were hardest hit by COVID-19 early on in the pandemic.

Genomic testing was carried out in a small subgroup of patients; 24% of those patients underwent testing on the core biopsy specimen because of COVID-19, the investigators noted. Genomic testing on a core biopsy specimen helps determine whether it’s feasible to forgo chemotherapy and use NET instead or whether the patient should proceed directly to surgery. The authors noted that almost 11% of patients required a change in the usual surgical approach because of COVID-19. Such changes were made primarily to avoid hospitalizations during the early phase of the pandemic for patients who were to undergo mastectomy or reconstruction.

“Patients who needed standard approaches still got them,” Dr. Wilke emphasized in a statement. For example, women with aggressive triple-negative and HER2+ tumors were treated with neoadjuvant chemotherapy, she added. “However, NET is a very good approach for a moderate subset of patients, and we think we will see it being used more often in the U.S. now,” Dr. Wilke observed.

“But especially early during the pandemic, these revised treatments were necessary because access to hospital ORs was limited or unavailable, so our algorithmic-based treatment guidelines allowed us to offer high-quality, evidence-based care fine-tuned for a patient’s specific cancer profile,” she affirmed.

Dr. Wilke has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The use of neoadjuvant endocrine therapy (NET) increased significantly during the first 8 months of the COVID-19 pandemic for women with estrogen receptor–positive (ER+) breast cancer. These patients would normally undergo surgery first, but because of operating room restrictions, those surgeries were delayed because of the pandemic, according to a new study.
 

“We hypothesized that by offering a nontoxic therapy, we would be able to ‘hold over’ patients until such time when personal protective equipment supplies were renewed and we could get into the operating room,” lead author Lee Wilke, MD, professor of surgery, University of Wisconsin, Madison, said in an interview.

“And while a small number of women with ER+ tumors get NET anyway, we found over one-third of patients with ER+ breast cancer were treated with NET due to COVID-19 during the first 8 months of last year,” she said.

“One year later, 31% of the same patient population is still getting NET,” she added.

The study was presented during the online annual meeting of the American Society of Breast Surgeons (ASBrS).
 

COVID-specific registry

Dr. Wilke believes that this study presents an accurate snapshot of changes in treatment caused by the pandemic.

She and her colleagues compared data collected in the ASBrS Mastery Program registry to data collected in an embedded but separate COVID-19 segment. The data were for the period from March 1 to Oct. 28, 2020.

Almost three-quarters of the surgeons who entered patients into the COVID-19 segment were from urban areas; 95% reported stopping mammographic screening during part of this period.

The preliminary analysis focused on data collected from 2,476 patients in the COVID-19 segment and 2,303 patients within the Mastery registry.

For patients with ER+/HER2- breast cancer, NET was described as a usual approach in 6.5% of patients in the COVID-19 registry. In the Mastery registry, 7.8% of patients received NET.

Compared with surgery first/usual practice, which served as the reference, older patients were more likely to receive NET first because of the COVID-19 pandemic than younger patients, and they were more likely to receive NET first if they lived in the Northeast or the Southeast compared to other regions of the United States. Dr. Wilke pointed out that the Northeast and the Southeast were hardest hit by COVID-19 early on in the pandemic.

Genomic testing was carried out in a small subgroup of patients; 24% of those patients underwent testing on the core biopsy specimen because of COVID-19, the investigators noted. Genomic testing on a core biopsy specimen helps determine whether it’s feasible to forgo chemotherapy and use NET instead or whether the patient should proceed directly to surgery. The authors noted that almost 11% of patients required a change in the usual surgical approach because of COVID-19. Such changes were made primarily to avoid hospitalizations during the early phase of the pandemic for patients who were to undergo mastectomy or reconstruction.

“Patients who needed standard approaches still got them,” Dr. Wilke emphasized in a statement. For example, women with aggressive triple-negative and HER2+ tumors were treated with neoadjuvant chemotherapy, she added. “However, NET is a very good approach for a moderate subset of patients, and we think we will see it being used more often in the U.S. now,” Dr. Wilke observed.

“But especially early during the pandemic, these revised treatments were necessary because access to hospital ORs was limited or unavailable, so our algorithmic-based treatment guidelines allowed us to offer high-quality, evidence-based care fine-tuned for a patient’s specific cancer profile,” she affirmed.

Dr. Wilke has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The use of neoadjuvant endocrine therapy (NET) increased significantly during the first 8 months of the COVID-19 pandemic for women with estrogen receptor–positive (ER+) breast cancer. These patients would normally undergo surgery first, but because of operating room restrictions, those surgeries were delayed because of the pandemic, according to a new study.
 

“We hypothesized that by offering a nontoxic therapy, we would be able to ‘hold over’ patients until such time when personal protective equipment supplies were renewed and we could get into the operating room,” lead author Lee Wilke, MD, professor of surgery, University of Wisconsin, Madison, said in an interview.

“And while a small number of women with ER+ tumors get NET anyway, we found over one-third of patients with ER+ breast cancer were treated with NET due to COVID-19 during the first 8 months of last year,” she said.

“One year later, 31% of the same patient population is still getting NET,” she added.

The study was presented during the online annual meeting of the American Society of Breast Surgeons (ASBrS).
 

COVID-specific registry

Dr. Wilke believes that this study presents an accurate snapshot of changes in treatment caused by the pandemic.

She and her colleagues compared data collected in the ASBrS Mastery Program registry to data collected in an embedded but separate COVID-19 segment. The data were for the period from March 1 to Oct. 28, 2020.

Almost three-quarters of the surgeons who entered patients into the COVID-19 segment were from urban areas; 95% reported stopping mammographic screening during part of this period.

The preliminary analysis focused on data collected from 2,476 patients in the COVID-19 segment and 2,303 patients within the Mastery registry.

For patients with ER+/HER2- breast cancer, NET was described as a usual approach in 6.5% of patients in the COVID-19 registry. In the Mastery registry, 7.8% of patients received NET.

Compared with surgery first/usual practice, which served as the reference, older patients were more likely to receive NET first because of the COVID-19 pandemic than younger patients, and they were more likely to receive NET first if they lived in the Northeast or the Southeast compared to other regions of the United States. Dr. Wilke pointed out that the Northeast and the Southeast were hardest hit by COVID-19 early on in the pandemic.

Genomic testing was carried out in a small subgroup of patients; 24% of those patients underwent testing on the core biopsy specimen because of COVID-19, the investigators noted. Genomic testing on a core biopsy specimen helps determine whether it’s feasible to forgo chemotherapy and use NET instead or whether the patient should proceed directly to surgery. The authors noted that almost 11% of patients required a change in the usual surgical approach because of COVID-19. Such changes were made primarily to avoid hospitalizations during the early phase of the pandemic for patients who were to undergo mastectomy or reconstruction.

“Patients who needed standard approaches still got them,” Dr. Wilke emphasized in a statement. For example, women with aggressive triple-negative and HER2+ tumors were treated with neoadjuvant chemotherapy, she added. “However, NET is a very good approach for a moderate subset of patients, and we think we will see it being used more often in the U.S. now,” Dr. Wilke observed.

“But especially early during the pandemic, these revised treatments were necessary because access to hospital ORs was limited or unavailable, so our algorithmic-based treatment guidelines allowed us to offer high-quality, evidence-based care fine-tuned for a patient’s specific cancer profile,” she affirmed.

Dr. Wilke has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Physicians and nonphysicians clearly differ in whether or not a PhD or EdD should be able to call themselves ‘doctor,’ a new Medscape poll Who Should Get to Be Called ‘Doctor’? shows. The topic has clearly struck a nerve, since a record number of respondents – over 12,000 – voted in the poll.

Most physicians think it’s appropriate for people with other doctorate degrees such as a PhD or EdD to call themselves ‘doctor,’ although slightly more than half said it depends on the context.

The controversy over who gets to be called a doctor was reignited when a Wall Street Journal opinion piece criticized First Lady Jill Biden, EdD, for wanting to be called “Dr Biden.” The piece also challenged the idea that having a PhD is worth the honorific of ‘doctor.’

Medical ethicist Arthur Caplan, PhD, disagreed with that viewpoint, saying the context matters. For example, he prefers to be called “professor” when he’s introduced to the public rather than “doctor” to avoid any confusion about his professional status.

More than 12,000 clinicians including physicians, medical students, nurses, pharmacists, and other health care professionals responded to the poll. The non-MD clinicians were the most likely to say it was always appropriate to be called “doctor” while physicians were the least likely.
 

Context matters

Large percentages of clinicians – 54% of doctors, 62% of medical students, and 41% of nurses – said that the context matters for being called “doctor.’’

“I earned my PhD in 1995 and my MD in 2000. I think it is contextual. In a research or University setting, “Dr.” seems appropriate for a PhD. That same person in public should probably not hold themselves out as “Dr.” So, maybe MDs and DOs can choose, while others maintain the title in their specific setting.” 

Some readers proposed that people with MDs call themselves physicians rather than doctors. Said one: “Anyone with a terminal doctorate degree has the right to use the word doctor.  As a physician when someone asks what I do, I say: ‘I am a physician.’ Problem solved. There can only be one physician but there are many types of doctors.”

Physicians and nurses differed most in their views. Just 24% of physicians said it was always appropriate for people with other doctorate degrees to call themselves doctor whereas about an equal number (22%) thought it was never appropriate.

In contrast, 43% of nurses (including advance practice nurses) said it was always appropriate for people with non-MD doctorates to be called doctor. Only 16% said it’s never appropriate. 

This difference may reflect the growing number of nurses with doctorate degrees, either a DNP or PhD, who want to be called doctor in clinical settings.

Age made a difference too. Only 16% of physicians younger than age 45 said it was always appropriate for people with non-MD doctorate degrees to be called doctor, compared with 27% of physicians aged 45 and up.

Medical students (31%) were also more likely than physicians to say it was always appropriate for non-MD doctorates to use the title “doctor” and 64% said it depends on the context. This was noteworthy because twice as many medical students as physicians (16% vs. 8%) said they work in academia, research, or military government settings.
 

Too many ‘doctors’ confuse the public

Physicians (70%) were also more likely to say it was always or often confusing for the public to hear someone without a medical degree addressed as “doctor.” Only 6% of physicians thought it was never or rarely confusing.

Nurses disagreed. Just 45% said that it was always or often confusing while 16% said it was never or rarely confusing.

Medical students were more aligned with physicians on this issue – 60% said it was always or often confusing to the public and just 10% said it was never or rarely confusing.  

One reader commented, “The problem is the confusion the ‘doctor’ title causes for patients, especially in a hospital setting. Is the ‘doctor’ a physician, a pharmacist, a psychologist, a nurse, etc., etc.? We need to think not of our own egos but if and how  the confusion about this plethora of titles may be hindering good patient care.”

These concerns are not unfounded. The American Medical Association reported in its Truth in Advertising campaign that “patients mistake physicians with nonphysician providers” based on an online survey of 802 adults in 2018. The participants thought these specialists were MDs: dentists (61%), podiatrists (67%), optometrists (47%), psychologists (43%), doctors of nursing (39%), and chiropractors (27%).

The AMA has advocated that states pass the “Health Care Professional Transparency Act,” which New Jersey has enacted. The law requires all health care professionals dealing with patients to wear a name tag that clearly identifies their licensure. Health care professionals must also display their education, training, and licensure in their office.

A version of this article first appeared on Medscape.com.

Physicians and nonphysicians clearly differ in whether or not a PhD or EdD should be able to call themselves ‘doctor,’ a new Medscape poll Who Should Get to Be Called ‘Doctor’? shows. The topic has clearly struck a nerve, since a record number of respondents – over 12,000 – voted in the poll.

Most physicians think it’s appropriate for people with other doctorate degrees such as a PhD or EdD to call themselves ‘doctor,’ although slightly more than half said it depends on the context.

The controversy over who gets to be called a doctor was reignited when a Wall Street Journal opinion piece criticized First Lady Jill Biden, EdD, for wanting to be called “Dr Biden.” The piece also challenged the idea that having a PhD is worth the honorific of ‘doctor.’

Medical ethicist Arthur Caplan, PhD, disagreed with that viewpoint, saying the context matters. For example, he prefers to be called “professor” when he’s introduced to the public rather than “doctor” to avoid any confusion about his professional status.

More than 12,000 clinicians including physicians, medical students, nurses, pharmacists, and other health care professionals responded to the poll. The non-MD clinicians were the most likely to say it was always appropriate to be called “doctor” while physicians were the least likely.
 

Context matters

Large percentages of clinicians – 54% of doctors, 62% of medical students, and 41% of nurses – said that the context matters for being called “doctor.’’

“I earned my PhD in 1995 and my MD in 2000. I think it is contextual. In a research or University setting, “Dr.” seems appropriate for a PhD. That same person in public should probably not hold themselves out as “Dr.” So, maybe MDs and DOs can choose, while others maintain the title in their specific setting.” 

Some readers proposed that people with MDs call themselves physicians rather than doctors. Said one: “Anyone with a terminal doctorate degree has the right to use the word doctor.  As a physician when someone asks what I do, I say: ‘I am a physician.’ Problem solved. There can only be one physician but there are many types of doctors.”

Physicians and nurses differed most in their views. Just 24% of physicians said it was always appropriate for people with other doctorate degrees to call themselves doctor whereas about an equal number (22%) thought it was never appropriate.

In contrast, 43% of nurses (including advance practice nurses) said it was always appropriate for people with non-MD doctorates to be called doctor. Only 16% said it’s never appropriate. 

This difference may reflect the growing number of nurses with doctorate degrees, either a DNP or PhD, who want to be called doctor in clinical settings.

Age made a difference too. Only 16% of physicians younger than age 45 said it was always appropriate for people with non-MD doctorate degrees to be called doctor, compared with 27% of physicians aged 45 and up.

Medical students (31%) were also more likely than physicians to say it was always appropriate for non-MD doctorates to use the title “doctor” and 64% said it depends on the context. This was noteworthy because twice as many medical students as physicians (16% vs. 8%) said they work in academia, research, or military government settings.
 

Too many ‘doctors’ confuse the public

Physicians (70%) were also more likely to say it was always or often confusing for the public to hear someone without a medical degree addressed as “doctor.” Only 6% of physicians thought it was never or rarely confusing.

Nurses disagreed. Just 45% said that it was always or often confusing while 16% said it was never or rarely confusing.

Medical students were more aligned with physicians on this issue – 60% said it was always or often confusing to the public and just 10% said it was never or rarely confusing.  

One reader commented, “The problem is the confusion the ‘doctor’ title causes for patients, especially in a hospital setting. Is the ‘doctor’ a physician, a pharmacist, a psychologist, a nurse, etc., etc.? We need to think not of our own egos but if and how  the confusion about this plethora of titles may be hindering good patient care.”

These concerns are not unfounded. The American Medical Association reported in its Truth in Advertising campaign that “patients mistake physicians with nonphysician providers” based on an online survey of 802 adults in 2018. The participants thought these specialists were MDs: dentists (61%), podiatrists (67%), optometrists (47%), psychologists (43%), doctors of nursing (39%), and chiropractors (27%).

The AMA has advocated that states pass the “Health Care Professional Transparency Act,” which New Jersey has enacted. The law requires all health care professionals dealing with patients to wear a name tag that clearly identifies their licensure. Health care professionals must also display their education, training, and licensure in their office.

A version of this article first appeared on Medscape.com.

Physicians and nonphysicians clearly differ in whether or not a PhD or EdD should be able to call themselves ‘doctor,’ a new Medscape poll Who Should Get to Be Called ‘Doctor’? shows. The topic has clearly struck a nerve, since a record number of respondents – over 12,000 – voted in the poll.

Most physicians think it’s appropriate for people with other doctorate degrees such as a PhD or EdD to call themselves ‘doctor,’ although slightly more than half said it depends on the context.

The controversy over who gets to be called a doctor was reignited when a Wall Street Journal opinion piece criticized First Lady Jill Biden, EdD, for wanting to be called “Dr Biden.” The piece also challenged the idea that having a PhD is worth the honorific of ‘doctor.’

Medical ethicist Arthur Caplan, PhD, disagreed with that viewpoint, saying the context matters. For example, he prefers to be called “professor” when he’s introduced to the public rather than “doctor” to avoid any confusion about his professional status.

More than 12,000 clinicians including physicians, medical students, nurses, pharmacists, and other health care professionals responded to the poll. The non-MD clinicians were the most likely to say it was always appropriate to be called “doctor” while physicians were the least likely.
 

Context matters

Large percentages of clinicians – 54% of doctors, 62% of medical students, and 41% of nurses – said that the context matters for being called “doctor.’’

“I earned my PhD in 1995 and my MD in 2000. I think it is contextual. In a research or University setting, “Dr.” seems appropriate for a PhD. That same person in public should probably not hold themselves out as “Dr.” So, maybe MDs and DOs can choose, while others maintain the title in their specific setting.” 

Some readers proposed that people with MDs call themselves physicians rather than doctors. Said one: “Anyone with a terminal doctorate degree has the right to use the word doctor.  As a physician when someone asks what I do, I say: ‘I am a physician.’ Problem solved. There can only be one physician but there are many types of doctors.”

Physicians and nurses differed most in their views. Just 24% of physicians said it was always appropriate for people with other doctorate degrees to call themselves doctor whereas about an equal number (22%) thought it was never appropriate.

In contrast, 43% of nurses (including advance practice nurses) said it was always appropriate for people with non-MD doctorates to be called doctor. Only 16% said it’s never appropriate. 

This difference may reflect the growing number of nurses with doctorate degrees, either a DNP or PhD, who want to be called doctor in clinical settings.

Age made a difference too. Only 16% of physicians younger than age 45 said it was always appropriate for people with non-MD doctorate degrees to be called doctor, compared with 27% of physicians aged 45 and up.

Medical students (31%) were also more likely than physicians to say it was always appropriate for non-MD doctorates to use the title “doctor” and 64% said it depends on the context. This was noteworthy because twice as many medical students as physicians (16% vs. 8%) said they work in academia, research, or military government settings.
 

Too many ‘doctors’ confuse the public

Physicians (70%) were also more likely to say it was always or often confusing for the public to hear someone without a medical degree addressed as “doctor.” Only 6% of physicians thought it was never or rarely confusing.

Nurses disagreed. Just 45% said that it was always or often confusing while 16% said it was never or rarely confusing.

Medical students were more aligned with physicians on this issue – 60% said it was always or often confusing to the public and just 10% said it was never or rarely confusing.  

One reader commented, “The problem is the confusion the ‘doctor’ title causes for patients, especially in a hospital setting. Is the ‘doctor’ a physician, a pharmacist, a psychologist, a nurse, etc., etc.? We need to think not of our own egos but if and how  the confusion about this plethora of titles may be hindering good patient care.”

These concerns are not unfounded. The American Medical Association reported in its Truth in Advertising campaign that “patients mistake physicians with nonphysician providers” based on an online survey of 802 adults in 2018. The participants thought these specialists were MDs: dentists (61%), podiatrists (67%), optometrists (47%), psychologists (43%), doctors of nursing (39%), and chiropractors (27%).

The AMA has advocated that states pass the “Health Care Professional Transparency Act,” which New Jersey has enacted. The law requires all health care professionals dealing with patients to wear a name tag that clearly identifies their licensure. Health care professionals must also display their education, training, and licensure in their office.

A version of this article first appeared on Medscape.com.