Non–private clinical encounters tied to diagnostic error and delays in delivery of care.

In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.

Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.

Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).

A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.

Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.

Trimethoprim associated with increased risk of AKI and hyperkalemia.

In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.

Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.

Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.

An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.

Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.

Young women with acute myocardial infarction present differently than young men.

Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.

Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.

Non–private clinical encounters tied to diagnostic error and delays in delivery of care.

In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.

Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.

Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).

A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.

Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.

Trimethoprim associated with increased risk of AKI and hyperkalemia.

In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.

Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.

Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.

An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.

Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.

Young women with acute myocardial infarction present differently than young men.

Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.

Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.

Non–private clinical encounters tied to diagnostic error and delays in delivery of care.

In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.

Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.

Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).

A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.

Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.

Trimethoprim associated with increased risk of AKI and hyperkalemia.

In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.

Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.

Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.

An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.

Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.

Young women with acute myocardial infarction present differently than young men.

Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.

Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.

For patients with pancreatic masses, infiltrated lymph nodes, or submucosal tumors, endoscopic ultrasound-guided fine-needle aspirate and fine-needle biopsy produced a comparable diagnostic yield with a similar number of needle passes, according to the results of a multicenter, randomized clinical trial.

Diagnostic yields were 91% for fine-needle aspirate versus 89% for fine-needle biopsy, with a median of one needle pass needed to obtain a diagnostic sample for each technique, reported Satish Nagula, MD, of the Icahn School of Medicine at Mount Sinai, New York, and his associates. The findings were published in the August issue of Clinical Gastroenterology and Hepatology.

Previously, two small, single-center randomized trials yielded conflicting data on whether fine-needle biopsy produces better diagnostic yield than fine-needle aspirate, the investigators noted. The results of four other studies indicated that the two techniques performed similarly. However, “many of these trials had study designs that did not allow for realistic comparisons of needle performance,” they noted. For example, the studies only analyzed the results of the first needle pass or only included specimens with visible core tissue.

The current study included six tertiary care centers that perform high volumes of endoscopic ultrasound. In all, 135 patients were randomly assigned to undergo fine-needle aspirate or fine-needle biopsy. When rapid on-site cytologic evaluation was used, the clinicians made consecutive needle passes until they considered the specimen adequate. Most lesions (77%) were masses, but 17% were lymph nodes, and 7% were submucosal tumors, the researchers said. The endoscopists used a curvilinear array echoendoscope (GF-UC140P or GF-UCT140; Olympus America, Central Valley, Penn.). They performed fine-needle aspirate or biopsy by using either a 22-gauge or 25-gauge needle at their own discretion.

The final diagnosis was malignancy for 70% of lesions, reactive lymphadenopathy for 11% of lesions, and spindle cell tumors in 9% of cases, the investigators said. Diagnostic yield was similar whether or not rapid on-site cytologic evaluation was used. Fine-needle aspiration detected cancer with a sensitivity of 90% and a specificity of 100%. Fine-needle biopsy had a sensitivity of 89% and a specificity of 100%. Adverse events were uncommon (1%), but one patient was hospitalized with pancreatitis for 2 days after undergoing fine-needle biopsy of a pancreatic body lesion.

The researchers noted several study limitations. “Ideally, each patient would undergo both fine-needle aspirate and fine-needle biopsy, allowing each as their own internal control,” they wrote. “It was considered too expensive to use two different needles in this unfunded study.” There also was no central pathology review, which they called “fiscally not feasible.”

There were no funding sources, and the investigators reported having no relevant conflicts of interest.SOURCE: Nagula S et al. Clin Gastroenterol Hepatol. 2017 Jun 14. doi: 10.1016/j.cgh.2017.06.013.

For patients with pancreatic masses, infiltrated lymph nodes, or submucosal tumors, endoscopic ultrasound-guided fine-needle aspirate and fine-needle biopsy produced a comparable diagnostic yield with a similar number of needle passes, according to the results of a multicenter, randomized clinical trial.

Diagnostic yields were 91% for fine-needle aspirate versus 89% for fine-needle biopsy, with a median of one needle pass needed to obtain a diagnostic sample for each technique, reported Satish Nagula, MD, of the Icahn School of Medicine at Mount Sinai, New York, and his associates. The findings were published in the August issue of Clinical Gastroenterology and Hepatology.

Previously, two small, single-center randomized trials yielded conflicting data on whether fine-needle biopsy produces better diagnostic yield than fine-needle aspirate, the investigators noted. The results of four other studies indicated that the two techniques performed similarly. However, “many of these trials had study designs that did not allow for realistic comparisons of needle performance,” they noted. For example, the studies only analyzed the results of the first needle pass or only included specimens with visible core tissue.

The current study included six tertiary care centers that perform high volumes of endoscopic ultrasound. In all, 135 patients were randomly assigned to undergo fine-needle aspirate or fine-needle biopsy. When rapid on-site cytologic evaluation was used, the clinicians made consecutive needle passes until they considered the specimen adequate. Most lesions (77%) were masses, but 17% were lymph nodes, and 7% were submucosal tumors, the researchers said. The endoscopists used a curvilinear array echoendoscope (GF-UC140P or GF-UCT140; Olympus America, Central Valley, Penn.). They performed fine-needle aspirate or biopsy by using either a 22-gauge or 25-gauge needle at their own discretion.

The final diagnosis was malignancy for 70% of lesions, reactive lymphadenopathy for 11% of lesions, and spindle cell tumors in 9% of cases, the investigators said. Diagnostic yield was similar whether or not rapid on-site cytologic evaluation was used. Fine-needle aspiration detected cancer with a sensitivity of 90% and a specificity of 100%. Fine-needle biopsy had a sensitivity of 89% and a specificity of 100%. Adverse events were uncommon (1%), but one patient was hospitalized with pancreatitis for 2 days after undergoing fine-needle biopsy of a pancreatic body lesion.

The researchers noted several study limitations. “Ideally, each patient would undergo both fine-needle aspirate and fine-needle biopsy, allowing each as their own internal control,” they wrote. “It was considered too expensive to use two different needles in this unfunded study.” There also was no central pathology review, which they called “fiscally not feasible.”

There were no funding sources, and the investigators reported having no relevant conflicts of interest.SOURCE: Nagula S et al. Clin Gastroenterol Hepatol. 2017 Jun 14. doi: 10.1016/j.cgh.2017.06.013.

For patients with pancreatic masses, infiltrated lymph nodes, or submucosal tumors, endoscopic ultrasound-guided fine-needle aspirate and fine-needle biopsy produced a comparable diagnostic yield with a similar number of needle passes, according to the results of a multicenter, randomized clinical trial.

Diagnostic yields were 91% for fine-needle aspirate versus 89% for fine-needle biopsy, with a median of one needle pass needed to obtain a diagnostic sample for each technique, reported Satish Nagula, MD, of the Icahn School of Medicine at Mount Sinai, New York, and his associates. The findings were published in the August issue of Clinical Gastroenterology and Hepatology.

Previously, two small, single-center randomized trials yielded conflicting data on whether fine-needle biopsy produces better diagnostic yield than fine-needle aspirate, the investigators noted. The results of four other studies indicated that the two techniques performed similarly. However, “many of these trials had study designs that did not allow for realistic comparisons of needle performance,” they noted. For example, the studies only analyzed the results of the first needle pass or only included specimens with visible core tissue.

The current study included six tertiary care centers that perform high volumes of endoscopic ultrasound. In all, 135 patients were randomly assigned to undergo fine-needle aspirate or fine-needle biopsy. When rapid on-site cytologic evaluation was used, the clinicians made consecutive needle passes until they considered the specimen adequate. Most lesions (77%) were masses, but 17% were lymph nodes, and 7% were submucosal tumors, the researchers said. The endoscopists used a curvilinear array echoendoscope (GF-UC140P or GF-UCT140; Olympus America, Central Valley, Penn.). They performed fine-needle aspirate or biopsy by using either a 22-gauge or 25-gauge needle at their own discretion.

The final diagnosis was malignancy for 70% of lesions, reactive lymphadenopathy for 11% of lesions, and spindle cell tumors in 9% of cases, the investigators said. Diagnostic yield was similar whether or not rapid on-site cytologic evaluation was used. Fine-needle aspiration detected cancer with a sensitivity of 90% and a specificity of 100%. Fine-needle biopsy had a sensitivity of 89% and a specificity of 100%. Adverse events were uncommon (1%), but one patient was hospitalized with pancreatitis for 2 days after undergoing fine-needle biopsy of a pancreatic body lesion.

The researchers noted several study limitations. “Ideally, each patient would undergo both fine-needle aspirate and fine-needle biopsy, allowing each as their own internal control,” they wrote. “It was considered too expensive to use two different needles in this unfunded study.” There also was no central pathology review, which they called “fiscally not feasible.”

There were no funding sources, and the investigators reported having no relevant conflicts of interest.SOURCE: Nagula S et al. Clin Gastroenterol Hepatol. 2017 Jun 14. doi: 10.1016/j.cgh.2017.06.013.

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

Patients at risk of autoimmune connective tissue disease who progressed to actual disease had elevated interferon scores and a family history of autoimmune rheumatic disease, suggesting the interferon scores could be used to predict disease progression, according to results from a prospective, observational study published in Annals of the Rheumatic Diseases.

SOURCE: Yusof MYM et al. Ann Rheum Dis. 21 Jun 2018. doi: 10.1136/annrheumdis-2018-213386.

Patients at risk of autoimmune connective tissue disease who progressed to actual disease had elevated interferon scores and a family history of autoimmune rheumatic disease, suggesting the interferon scores could be used to predict disease progression, according to results from a prospective, observational study published in Annals of the Rheumatic Diseases.

SOURCE: Yusof MYM et al. Ann Rheum Dis. 21 Jun 2018. doi: 10.1136/annrheumdis-2018-213386.

Patients at risk of autoimmune connective tissue disease who progressed to actual disease had elevated interferon scores and a family history of autoimmune rheumatic disease, suggesting the interferon scores could be used to predict disease progression, according to results from a prospective, observational study published in Annals of the Rheumatic Diseases.

SOURCE: Yusof MYM et al. Ann Rheum Dis. 21 Jun 2018. doi: 10.1136/annrheumdis-2018-213386.

In response to alarming racial disparities, New York City announced a new initiative last week to reduce maternal deaths and complications among women of color. Under the new plan, the city will improve the data collection on maternal deaths and complications, fund implicit bias training for medical staff at private and public hospitals, and launch a public awareness campaign.

Over the next three years, the city will spend $12.8 million on the initiative, with the goal of eliminating the black-white racial disparity in deaths related to pregnancy and childbirth and cutting the number of complications in half within five years.

“We recognize these are ambitious goals, but they are not unrealistic,” said Dr. Herminia Palacio, New York City’s deputy mayor for health and human services. “It’s an explicit recognition of the urgency of this issue and puts the goal posts in front of us.”

The city’s health department is targeting nearly two dozen public and private hospitals over four years, focusing on neighborhoods with the highest complication rates, including the South Bronx, North and Central Brooklyn, and East and Central Harlem. Hospital officials will study data from cases that led to bad outcomes, and staff will participate in drills aimed at helping them recognize and treat those complications.

Health department officials approached SUNY Downstate Medical Center in May to serve as a pilot site for many of the new measures.

The Central Brooklyn hospital was featured in the “Lost Mothers” series published by ProPublica and NPR last year as one of the starkest examples of racial disparities among hospitals in three states, according to our analysis of over 1 million births in Florida, Illinois and New York. In the second half of last year, two women, both black, died shortly after delivering at SUNY Downstate from causes that experts have said are preventable. The public, state-run hospital has one of the highest complication rates for hemorrhage in the city.

“We look forward to working with all of our partners to provide quality maternal health care for expectant mothers,” said hospital spokesperson Dawn Skeete-Walker.

“SUNY Downstate serves a unique and diverse population in Brooklyn where many of our expectant mothers are from a variety of different backgrounds, beliefs, and cultures.”

The city will also specifically target its own public hospitals, which are run by NYC Health + Hospitals, training staff on how to better identify and treat hemorrhage and blood clots, two leading causes of maternal death.

The initiative is “aimed at using an approach that encourages folks to have a sense of accountability without finger pointing or blame, and that encourages hospitals to be active participants to identify practices that would benefit from improvement,” said Palacio.

In addition to training, the city’s public hospitals will hire maternal care coordinators who will assist high-risk pregnant women with their appointments, prescriptions and public health benefits. Public hospitals will also work to strengthen prenatal and postpartum care, including conducting hemorrhage assessments, establishing care plans, and providing contraceptive counselling, breastfeeding support and screening for maternal depression.

Starting in 2019, the health department plans to launch a maternal safety public awareness campaign in partnership with grassroots organizations.

“This is a positive first step in really being able to address the concerns of women of color and pregnant women,” said Chanel Porchia-Albert, founder and executive director of Ancient Song Doula Services, which is based in New York City. “There need to be accountability measures that are put in place that stress the community as an active participant and stakeholder.”

The city’s initiative is the latest in a wave of maternal health reforms following the “Lost Mothers” series. Over the past few months, the U.S. Senate has proposed $50 million in funding to reduce maternal deaths, and several states have launched review committees to examine birth outcomes.

As ProPublica and NPR reported, between 700 and 900 women die from causes related to pregnancy and childbirth in the United States every year, and tens of thousands more experience severe complications. The rate of maternal death is substantially higher in the United States than in other affluent nations, and has climbed over the past decade, mostly driven by the outcomes of women of color.

While poverty and inadequate access to health care explain part of the racial disparity in maternal deaths, research has shown that the quality of care at hospitals where black women deliver plays a significant role as well. ProPublica added to research that has found that women who deliver at disproportionately “black-serving” hospitals are more likely to experience serious complications — from emergency hysterectomies to birth-related blood clots — than mothers who deliver at institutions that serve fewer black women.

In New York City, the racial disparity in maternal outcomes is among the largest in the nation, and it’s growing. According to a recent report from New York City’s Department of Health and Mental Hygiene, even as the overall maternal mortality rate across the city has decreased, the gap between black and white mothers has widened.

Regardless of their education, obesity or poverty level, black mothers in New York City are at a higher risk of harm than their white counterparts. Black mothers with a college education fare worse than women of all other races who dropped out of high school. Black women of normal weight have higher rates of harm than obese women of all other races. And black women who reside in the wealthiest neighborhoods have worse outcomes than white, Asian and Hispanic mothers in the poorest ones.

“If you are a poor black woman, you don’t have access to quality OBGYN care, and if you are a wealthy black women, like Serena Williams, you get providers who don’t listen to you when you say you can’t breathe,” said Patricia Loftman, a member of the American College of Nurse Midwives Board of Directors who worked for 30 years as a certified nurse-midwife in Harlem. “The components of this initiative are very aggressive and laudable to the extent that they are forcing hospital departments to talk about implicit bias.”

ProPublica is a Pulitzer Prize-winning investigative newsroom.


 

In response to alarming racial disparities, New York City announced a new initiative last week to reduce maternal deaths and complications among women of color. Under the new plan, the city will improve the data collection on maternal deaths and complications, fund implicit bias training for medical staff at private and public hospitals, and launch a public awareness campaign.

Over the next three years, the city will spend $12.8 million on the initiative, with the goal of eliminating the black-white racial disparity in deaths related to pregnancy and childbirth and cutting the number of complications in half within five years.

“We recognize these are ambitious goals, but they are not unrealistic,” said Dr. Herminia Palacio, New York City’s deputy mayor for health and human services. “It’s an explicit recognition of the urgency of this issue and puts the goal posts in front of us.”

The city’s health department is targeting nearly two dozen public and private hospitals over four years, focusing on neighborhoods with the highest complication rates, including the South Bronx, North and Central Brooklyn, and East and Central Harlem. Hospital officials will study data from cases that led to bad outcomes, and staff will participate in drills aimed at helping them recognize and treat those complications.

Health department officials approached SUNY Downstate Medical Center in May to serve as a pilot site for many of the new measures.

The Central Brooklyn hospital was featured in the “Lost Mothers” series published by ProPublica and NPR last year as one of the starkest examples of racial disparities among hospitals in three states, according to our analysis of over 1 million births in Florida, Illinois and New York. In the second half of last year, two women, both black, died shortly after delivering at SUNY Downstate from causes that experts have said are preventable. The public, state-run hospital has one of the highest complication rates for hemorrhage in the city.

“We look forward to working with all of our partners to provide quality maternal health care for expectant mothers,” said hospital spokesperson Dawn Skeete-Walker.

“SUNY Downstate serves a unique and diverse population in Brooklyn where many of our expectant mothers are from a variety of different backgrounds, beliefs, and cultures.”

The city will also specifically target its own public hospitals, which are run by NYC Health + Hospitals, training staff on how to better identify and treat hemorrhage and blood clots, two leading causes of maternal death.

The initiative is “aimed at using an approach that encourages folks to have a sense of accountability without finger pointing or blame, and that encourages hospitals to be active participants to identify practices that would benefit from improvement,” said Palacio.

In addition to training, the city’s public hospitals will hire maternal care coordinators who will assist high-risk pregnant women with their appointments, prescriptions and public health benefits. Public hospitals will also work to strengthen prenatal and postpartum care, including conducting hemorrhage assessments, establishing care plans, and providing contraceptive counselling, breastfeeding support and screening for maternal depression.

Starting in 2019, the health department plans to launch a maternal safety public awareness campaign in partnership with grassroots organizations.

“This is a positive first step in really being able to address the concerns of women of color and pregnant women,” said Chanel Porchia-Albert, founder and executive director of Ancient Song Doula Services, which is based in New York City. “There need to be accountability measures that are put in place that stress the community as an active participant and stakeholder.”

The city’s initiative is the latest in a wave of maternal health reforms following the “Lost Mothers” series. Over the past few months, the U.S. Senate has proposed $50 million in funding to reduce maternal deaths, and several states have launched review committees to examine birth outcomes.

As ProPublica and NPR reported, between 700 and 900 women die from causes related to pregnancy and childbirth in the United States every year, and tens of thousands more experience severe complications. The rate of maternal death is substantially higher in the United States than in other affluent nations, and has climbed over the past decade, mostly driven by the outcomes of women of color.

While poverty and inadequate access to health care explain part of the racial disparity in maternal deaths, research has shown that the quality of care at hospitals where black women deliver plays a significant role as well. ProPublica added to research that has found that women who deliver at disproportionately “black-serving” hospitals are more likely to experience serious complications — from emergency hysterectomies to birth-related blood clots — than mothers who deliver at institutions that serve fewer black women.

In New York City, the racial disparity in maternal outcomes is among the largest in the nation, and it’s growing. According to a recent report from New York City’s Department of Health and Mental Hygiene, even as the overall maternal mortality rate across the city has decreased, the gap between black and white mothers has widened.

Regardless of their education, obesity or poverty level, black mothers in New York City are at a higher risk of harm than their white counterparts. Black mothers with a college education fare worse than women of all other races who dropped out of high school. Black women of normal weight have higher rates of harm than obese women of all other races. And black women who reside in the wealthiest neighborhoods have worse outcomes than white, Asian and Hispanic mothers in the poorest ones.

“If you are a poor black woman, you don’t have access to quality OBGYN care, and if you are a wealthy black women, like Serena Williams, you get providers who don’t listen to you when you say you can’t breathe,” said Patricia Loftman, a member of the American College of Nurse Midwives Board of Directors who worked for 30 years as a certified nurse-midwife in Harlem. “The components of this initiative are very aggressive and laudable to the extent that they are forcing hospital departments to talk about implicit bias.”

ProPublica is a Pulitzer Prize-winning investigative newsroom.


 

In response to alarming racial disparities, New York City announced a new initiative last week to reduce maternal deaths and complications among women of color. Under the new plan, the city will improve the data collection on maternal deaths and complications, fund implicit bias training for medical staff at private and public hospitals, and launch a public awareness campaign.

Over the next three years, the city will spend $12.8 million on the initiative, with the goal of eliminating the black-white racial disparity in deaths related to pregnancy and childbirth and cutting the number of complications in half within five years.

“We recognize these are ambitious goals, but they are not unrealistic,” said Dr. Herminia Palacio, New York City’s deputy mayor for health and human services. “It’s an explicit recognition of the urgency of this issue and puts the goal posts in front of us.”

The city’s health department is targeting nearly two dozen public and private hospitals over four years, focusing on neighborhoods with the highest complication rates, including the South Bronx, North and Central Brooklyn, and East and Central Harlem. Hospital officials will study data from cases that led to bad outcomes, and staff will participate in drills aimed at helping them recognize and treat those complications.

Health department officials approached SUNY Downstate Medical Center in May to serve as a pilot site for many of the new measures.

The Central Brooklyn hospital was featured in the “Lost Mothers” series published by ProPublica and NPR last year as one of the starkest examples of racial disparities among hospitals in three states, according to our analysis of over 1 million births in Florida, Illinois and New York. In the second half of last year, two women, both black, died shortly after delivering at SUNY Downstate from causes that experts have said are preventable. The public, state-run hospital has one of the highest complication rates for hemorrhage in the city.

“We look forward to working with all of our partners to provide quality maternal health care for expectant mothers,” said hospital spokesperson Dawn Skeete-Walker.

“SUNY Downstate serves a unique and diverse population in Brooklyn where many of our expectant mothers are from a variety of different backgrounds, beliefs, and cultures.”

The city will also specifically target its own public hospitals, which are run by NYC Health + Hospitals, training staff on how to better identify and treat hemorrhage and blood clots, two leading causes of maternal death.

The initiative is “aimed at using an approach that encourages folks to have a sense of accountability without finger pointing or blame, and that encourages hospitals to be active participants to identify practices that would benefit from improvement,” said Palacio.

In addition to training, the city’s public hospitals will hire maternal care coordinators who will assist high-risk pregnant women with their appointments, prescriptions and public health benefits. Public hospitals will also work to strengthen prenatal and postpartum care, including conducting hemorrhage assessments, establishing care plans, and providing contraceptive counselling, breastfeeding support and screening for maternal depression.

Starting in 2019, the health department plans to launch a maternal safety public awareness campaign in partnership with grassroots organizations.

“This is a positive first step in really being able to address the concerns of women of color and pregnant women,” said Chanel Porchia-Albert, founder and executive director of Ancient Song Doula Services, which is based in New York City. “There need to be accountability measures that are put in place that stress the community as an active participant and stakeholder.”

The city’s initiative is the latest in a wave of maternal health reforms following the “Lost Mothers” series. Over the past few months, the U.S. Senate has proposed $50 million in funding to reduce maternal deaths, and several states have launched review committees to examine birth outcomes.

As ProPublica and NPR reported, between 700 and 900 women die from causes related to pregnancy and childbirth in the United States every year, and tens of thousands more experience severe complications. The rate of maternal death is substantially higher in the United States than in other affluent nations, and has climbed over the past decade, mostly driven by the outcomes of women of color.

While poverty and inadequate access to health care explain part of the racial disparity in maternal deaths, research has shown that the quality of care at hospitals where black women deliver plays a significant role as well. ProPublica added to research that has found that women who deliver at disproportionately “black-serving” hospitals are more likely to experience serious complications — from emergency hysterectomies to birth-related blood clots — than mothers who deliver at institutions that serve fewer black women.

In New York City, the racial disparity in maternal outcomes is among the largest in the nation, and it’s growing. According to a recent report from New York City’s Department of Health and Mental Hygiene, even as the overall maternal mortality rate across the city has decreased, the gap between black and white mothers has widened.

Regardless of their education, obesity or poverty level, black mothers in New York City are at a higher risk of harm than their white counterparts. Black mothers with a college education fare worse than women of all other races who dropped out of high school. Black women of normal weight have higher rates of harm than obese women of all other races. And black women who reside in the wealthiest neighborhoods have worse outcomes than white, Asian and Hispanic mothers in the poorest ones.

“If you are a poor black woman, you don’t have access to quality OBGYN care, and if you are a wealthy black women, like Serena Williams, you get providers who don’t listen to you when you say you can’t breathe,” said Patricia Loftman, a member of the American College of Nurse Midwives Board of Directors who worked for 30 years as a certified nurse-midwife in Harlem. “The components of this initiative are very aggressive and laudable to the extent that they are forcing hospital departments to talk about implicit bias.”

ProPublica is a Pulitzer Prize-winning investigative newsroom.


 

The Centers for Medicare & Medicaid Services has resumed the risk adjustment payment program from calendar year 2017 and is taking steps to ensure the program’s operation for 2018 and beyond.

CMS posted a final rule on July 24 that reissues, with additional explanation, the risk adjustment methodology that was used to calculate payments made to insurers for 2017.

The risk adjustment payment program uses statewide average premiums to draw money from health insurance plans within a state that have low levels of high-need patients and funnels that money to plans in that state with high amounts of high-need patients as a way to minimize adverse selection and to spread risk.

CMS halted the risk adjustment program earlier in the month following legal action. In January 2018, the U.S. District Court for the District of Massachusetts ruled that the CMS was acting within its authority in promulgating its methodology based on statewide average premiums. A month later, the U.S. District Court for the District of New Mexico ruled that the methodology was invalid and barred the CMS from collecting or making payments, which prompted the agency to temporarily halt the program.

“This final rule will restore operation of the risk adjustment program and mitigate some of the uncertainty caused by the New Mexico litigation,” CMS Administrator Seema Verma said in a statement. “Issuers that had expressed concern about having to withdraw from markets or becoming insolvent should be assured by our actions today.”

CMS said the final rule provides a fuller explanation to support the 2017 risk adjustment methodology. The agency dispensed with the normal notice and comment period before issuing the final rule to help ensure timely payments are made by the program while working to resolve the legal questions. A motion to reconsider was filed in New Mexico on June 21, but a ruling on that is not expected until early September, which prompted the unusual move to issue a final rule without any notice or comment period.

CMS added that there will be a notice of proposed rule making with the normal comment period related to the risk adjustment payments for the 2018 calendar year. The existing rule was also vacated by the New Mexico court. The risk adjustment methodology for 2019 and beyond was finalized in a rule issued on April 17.

[email protected]

The Centers for Medicare & Medicaid Services has resumed the risk adjustment payment program from calendar year 2017 and is taking steps to ensure the program’s operation for 2018 and beyond.

CMS posted a final rule on July 24 that reissues, with additional explanation, the risk adjustment methodology that was used to calculate payments made to insurers for 2017.

The risk adjustment payment program uses statewide average premiums to draw money from health insurance plans within a state that have low levels of high-need patients and funnels that money to plans in that state with high amounts of high-need patients as a way to minimize adverse selection and to spread risk.

CMS halted the risk adjustment program earlier in the month following legal action. In January 2018, the U.S. District Court for the District of Massachusetts ruled that the CMS was acting within its authority in promulgating its methodology based on statewide average premiums. A month later, the U.S. District Court for the District of New Mexico ruled that the methodology was invalid and barred the CMS from collecting or making payments, which prompted the agency to temporarily halt the program.

“This final rule will restore operation of the risk adjustment program and mitigate some of the uncertainty caused by the New Mexico litigation,” CMS Administrator Seema Verma said in a statement. “Issuers that had expressed concern about having to withdraw from markets or becoming insolvent should be assured by our actions today.”

CMS said the final rule provides a fuller explanation to support the 2017 risk adjustment methodology. The agency dispensed with the normal notice and comment period before issuing the final rule to help ensure timely payments are made by the program while working to resolve the legal questions. A motion to reconsider was filed in New Mexico on June 21, but a ruling on that is not expected until early September, which prompted the unusual move to issue a final rule without any notice or comment period.

CMS added that there will be a notice of proposed rule making with the normal comment period related to the risk adjustment payments for the 2018 calendar year. The existing rule was also vacated by the New Mexico court. The risk adjustment methodology for 2019 and beyond was finalized in a rule issued on April 17.

[email protected]

The Centers for Medicare & Medicaid Services has resumed the risk adjustment payment program from calendar year 2017 and is taking steps to ensure the program’s operation for 2018 and beyond.

CMS posted a final rule on July 24 that reissues, with additional explanation, the risk adjustment methodology that was used to calculate payments made to insurers for 2017.

The risk adjustment payment program uses statewide average premiums to draw money from health insurance plans within a state that have low levels of high-need patients and funnels that money to plans in that state with high amounts of high-need patients as a way to minimize adverse selection and to spread risk.

CMS halted the risk adjustment program earlier in the month following legal action. In January 2018, the U.S. District Court for the District of Massachusetts ruled that the CMS was acting within its authority in promulgating its methodology based on statewide average premiums. A month later, the U.S. District Court for the District of New Mexico ruled that the methodology was invalid and barred the CMS from collecting or making payments, which prompted the agency to temporarily halt the program.

“This final rule will restore operation of the risk adjustment program and mitigate some of the uncertainty caused by the New Mexico litigation,” CMS Administrator Seema Verma said in a statement. “Issuers that had expressed concern about having to withdraw from markets or becoming insolvent should be assured by our actions today.”

CMS said the final rule provides a fuller explanation to support the 2017 risk adjustment methodology. The agency dispensed with the normal notice and comment period before issuing the final rule to help ensure timely payments are made by the program while working to resolve the legal questions. A motion to reconsider was filed in New Mexico on June 21, but a ruling on that is not expected until early September, which prompted the unusual move to issue a final rule without any notice or comment period.

CMS added that there will be a notice of proposed rule making with the normal comment period related to the risk adjustment payments for the 2018 calendar year. The existing rule was also vacated by the New Mexico court. The risk adjustment methodology for 2019 and beyond was finalized in a rule issued on April 17.

[email protected]

MALMO, SWEDEN – Four doses of hexavalent diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus/Haemophilus influenza type b vaccine given in infancy provides reassuringly long-lasting immune memory against hepatitis B among 14- to 15-year-olds, Tino F. Schwarz, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

He presented the fourth and final study in a series evaluating the antibody persistence and immune memory against hepatitis B (HBV) in recipients of the complete four-dose series of hexavalent DTPa-HBV-IPV/Hib vaccine in infancy. Because exposure to HBV can increase during adolescence, it was essential to determine whether antibody persistence is maintained, explained Dr. Schwarz of Juliusspital Hospital in Wurzburg, Germany.

“As expected, we saw a decrease in anti-HBs [hepatitis B surface antigen] antibody levels over the years, with persistent seroprotection in 85% of children at age 4-5 years, 72% at 7-8 years, 61% at 12-13 years, and now 54% of adolescents at 14-15 years. But we could demonstrate a very strong anamnestic response in the trial. This is good information. It clearly shows that, in patients who are exposed to hepatitis B, we can certainly guarantee that they are protected. It’s a good result for public health. The vaccine is a very robust vaccine which induces a very strong response over the years. It can be boosted, but from an immunologic point of view it is not required,” he said.

The multicenter study included 268 adolescents aged 14-15 years who had received the four-dose hexavalent vaccine series in infancy. Their antibody persistence against anti-HBs was measured, then measured once again 1 month after receiving a challenge dose of monovalent HBV vaccine.

Prechallenge, 105 of the teens were seronegative, 144 were seroprotected as defined by an anti-HBs concentration of at least 10 mIU/mL, and 19 had low seropositivity marked by an antibody level of 6 to less than 10 mIU/mL. Yet 1 month after the booster, which was intended to mimic the impact of real-world exposure to HBV, 83% of the initially seronegative subjects had an anti-HBs concentration of 10 mIU/mL or more, and 67% of them had a level of at least 100 mIU/mL.

“We saw a clear fantastic anamnestic response,” Dr. Schwarz declared.

Overall, 93% of study participants seroconverted, and 87% of them had anti-HBs titers of 100 mIU/mL, “which is the level we’d like to achieve in vaccinees,” he observed.

The booster monovalent HBV vaccine was well tolerated, with one-third of subjects complaining of mild local injection site pain and 30% noting fatigue. But in response to a question posed by session chair Ronald de Groot, MD, emeritus professor of pediatrics at Radboud University in Nijmegen, the Netherlands, Dr. Schwarz said these study results indicate there’s no need for routine boosting in healthy adolescents such as those in the trial. Immunocompromised individuals might be a different story, but they weren’t investigated.

But what about in physicians and surgeons, where protection against HBV infection is essential? Dr. de Groot asked.

“In Germany, we require a titer of 100 mIU/mL or more in medical staff, but we’re quite alone in Europe. Other countries do not require booster vaccination for medical staff. The data we’ve shown here is quite reassuring: If you get exposed, you in effect get a booster. It’s complicated to test surgeons in their offices; better to just rely on the anamnestic response that we’ve demonstrated,” Dr. Schwarz replied.

He reported serving as a consultant to GlaxoSmithKline, which funded the study, as well as to Pfizer and Sanofi Pasteur.

[email protected]

MALMO, SWEDEN – Four doses of hexavalent diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus/Haemophilus influenza type b vaccine given in infancy provides reassuringly long-lasting immune memory against hepatitis B among 14- to 15-year-olds, Tino F. Schwarz, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

He presented the fourth and final study in a series evaluating the antibody persistence and immune memory against hepatitis B (HBV) in recipients of the complete four-dose series of hexavalent DTPa-HBV-IPV/Hib vaccine in infancy. Because exposure to HBV can increase during adolescence, it was essential to determine whether antibody persistence is maintained, explained Dr. Schwarz of Juliusspital Hospital in Wurzburg, Germany.

“As expected, we saw a decrease in anti-HBs [hepatitis B surface antigen] antibody levels over the years, with persistent seroprotection in 85% of children at age 4-5 years, 72% at 7-8 years, 61% at 12-13 years, and now 54% of adolescents at 14-15 years. But we could demonstrate a very strong anamnestic response in the trial. This is good information. It clearly shows that, in patients who are exposed to hepatitis B, we can certainly guarantee that they are protected. It’s a good result for public health. The vaccine is a very robust vaccine which induces a very strong response over the years. It can be boosted, but from an immunologic point of view it is not required,” he said.

The multicenter study included 268 adolescents aged 14-15 years who had received the four-dose hexavalent vaccine series in infancy. Their antibody persistence against anti-HBs was measured, then measured once again 1 month after receiving a challenge dose of monovalent HBV vaccine.

Prechallenge, 105 of the teens were seronegative, 144 were seroprotected as defined by an anti-HBs concentration of at least 10 mIU/mL, and 19 had low seropositivity marked by an antibody level of 6 to less than 10 mIU/mL. Yet 1 month after the booster, which was intended to mimic the impact of real-world exposure to HBV, 83% of the initially seronegative subjects had an anti-HBs concentration of 10 mIU/mL or more, and 67% of them had a level of at least 100 mIU/mL.

“We saw a clear fantastic anamnestic response,” Dr. Schwarz declared.

Overall, 93% of study participants seroconverted, and 87% of them had anti-HBs titers of 100 mIU/mL, “which is the level we’d like to achieve in vaccinees,” he observed.

The booster monovalent HBV vaccine was well tolerated, with one-third of subjects complaining of mild local injection site pain and 30% noting fatigue. But in response to a question posed by session chair Ronald de Groot, MD, emeritus professor of pediatrics at Radboud University in Nijmegen, the Netherlands, Dr. Schwarz said these study results indicate there’s no need for routine boosting in healthy adolescents such as those in the trial. Immunocompromised individuals might be a different story, but they weren’t investigated.

But what about in physicians and surgeons, where protection against HBV infection is essential? Dr. de Groot asked.

“In Germany, we require a titer of 100 mIU/mL or more in medical staff, but we’re quite alone in Europe. Other countries do not require booster vaccination for medical staff. The data we’ve shown here is quite reassuring: If you get exposed, you in effect get a booster. It’s complicated to test surgeons in their offices; better to just rely on the anamnestic response that we’ve demonstrated,” Dr. Schwarz replied.

He reported serving as a consultant to GlaxoSmithKline, which funded the study, as well as to Pfizer and Sanofi Pasteur.

[email protected]

MALMO, SWEDEN – Four doses of hexavalent diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus/Haemophilus influenza type b vaccine given in infancy provides reassuringly long-lasting immune memory against hepatitis B among 14- to 15-year-olds, Tino F. Schwarz, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

He presented the fourth and final study in a series evaluating the antibody persistence and immune memory against hepatitis B (HBV) in recipients of the complete four-dose series of hexavalent DTPa-HBV-IPV/Hib vaccine in infancy. Because exposure to HBV can increase during adolescence, it was essential to determine whether antibody persistence is maintained, explained Dr. Schwarz of Juliusspital Hospital in Wurzburg, Germany.

“As expected, we saw a decrease in anti-HBs [hepatitis B surface antigen] antibody levels over the years, with persistent seroprotection in 85% of children at age 4-5 years, 72% at 7-8 years, 61% at 12-13 years, and now 54% of adolescents at 14-15 years. But we could demonstrate a very strong anamnestic response in the trial. This is good information. It clearly shows that, in patients who are exposed to hepatitis B, we can certainly guarantee that they are protected. It’s a good result for public health. The vaccine is a very robust vaccine which induces a very strong response over the years. It can be boosted, but from an immunologic point of view it is not required,” he said.

The multicenter study included 268 adolescents aged 14-15 years who had received the four-dose hexavalent vaccine series in infancy. Their antibody persistence against anti-HBs was measured, then measured once again 1 month after receiving a challenge dose of monovalent HBV vaccine.

Prechallenge, 105 of the teens were seronegative, 144 were seroprotected as defined by an anti-HBs concentration of at least 10 mIU/mL, and 19 had low seropositivity marked by an antibody level of 6 to less than 10 mIU/mL. Yet 1 month after the booster, which was intended to mimic the impact of real-world exposure to HBV, 83% of the initially seronegative subjects had an anti-HBs concentration of 10 mIU/mL or more, and 67% of them had a level of at least 100 mIU/mL.

“We saw a clear fantastic anamnestic response,” Dr. Schwarz declared.

Overall, 93% of study participants seroconverted, and 87% of them had anti-HBs titers of 100 mIU/mL, “which is the level we’d like to achieve in vaccinees,” he observed.

The booster monovalent HBV vaccine was well tolerated, with one-third of subjects complaining of mild local injection site pain and 30% noting fatigue. But in response to a question posed by session chair Ronald de Groot, MD, emeritus professor of pediatrics at Radboud University in Nijmegen, the Netherlands, Dr. Schwarz said these study results indicate there’s no need for routine boosting in healthy adolescents such as those in the trial. Immunocompromised individuals might be a different story, but they weren’t investigated.

But what about in physicians and surgeons, where protection against HBV infection is essential? Dr. de Groot asked.

“In Germany, we require a titer of 100 mIU/mL or more in medical staff, but we’re quite alone in Europe. Other countries do not require booster vaccination for medical staff. The data we’ve shown here is quite reassuring: If you get exposed, you in effect get a booster. It’s complicated to test surgeons in their offices; better to just rely on the anamnestic response that we’ve demonstrated,” Dr. Schwarz replied.

He reported serving as a consultant to GlaxoSmithKline, which funded the study, as well as to Pfizer and Sanofi Pasteur.

[email protected]

ORLANDO – Widespread implementation of enhanced recovery protocols at the state level resulted in a significant reduction in length of stay and complications in patients undergoing elective colectomy, an analysis shows.

The benefits were particularly pronounced in the subset of patients undergoing laparoscopic colectomy in the retrospective analysis, which included data for treated at four institutions in the Virginia Surgical Quality Collaborative Workgroup.

While the benefits of enhanced recovery after surgery (ERAS) are well known, most of the published data has come from single-institution experiences, according to investigator Traci L. Hedrick, MD, FACS, of the University of Virginia, Charlottesville.

At the American College of Surgeons Quality and Safety Conference, Dr. Hedrick presented risk-adjusted National Surgical Quality Improvement Program (NSQIP) data for 2,971 consecutive procedures during 2012-2016 at the University of Virginia, Winchester Medical Center, Carilion Clinic, and Inova Fairfax.

“Institutions came and went from the collaborative during this time period, so we focused on those institutions that maintained in the collaborative throughout the entire study protocol,” Dr. Hedrick said in her presentation.

Of the 2,971 procedures, about half (1,460) were performed after implementation of enhanced recovery protocols. Laparoscopic and open procedures were analyzed separately due to a substantial shift toward laparoscopic procedures, mainly during the 2012-2014 period, Dr. Hedrick said.

Among laparoscopic cases, there was a significant 1-day reduction in median length of stay, dropping from 4 days for pre–enhanced recovery protocol cases to 3 days for post–enhanced recovery protocol cases, Dr. Hedrick reported.

Observed morbidity also dropped significantly from 14.8% to 8.9% for the pre– and post–enhanced recovery cases, and the readmission rate fell significantly from 13% to 8.8%.

For open cases, there was a significant 1-day drop in median length of stay, from 4 to 3 days, but no significant differences in observed morbidity or readmission rates, according to Dr. Hedrick.

“As more of the patients were done laparoscopically, that really selected out the more complicated patients that were undergoing open procedures,” she said.

The protocols implemented by institutions in the Virginia collaborative group were generally uniform in important tenants of enhanced recovery, such as opioid minimization and avoidance of fasting, but specific elements were left up to each institution to improve buy-in, according to Dr. Hedrick.

“A lot of our protocols are very similar, particularly with regards to the order set,” Dr. Hedrick explained, “[but] I really am a firm believer in not being very strict about exactly what to use, because it’s so dependent on preference at the local level.”

The Virginia Surgical Quality Collaborative Workgroup is one of 20 regional ACS NSQIP collaboratives with the objective of improving surgical outcomes through multi-institutional collaboration, Dr. Hedrick said.

Dr. Hedrick and her coinvestigators had no relevant disclosures to report.

ORLANDO – Widespread implementation of enhanced recovery protocols at the state level resulted in a significant reduction in length of stay and complications in patients undergoing elective colectomy, an analysis shows.

The benefits were particularly pronounced in the subset of patients undergoing laparoscopic colectomy in the retrospective analysis, which included data for treated at four institutions in the Virginia Surgical Quality Collaborative Workgroup.

While the benefits of enhanced recovery after surgery (ERAS) are well known, most of the published data has come from single-institution experiences, according to investigator Traci L. Hedrick, MD, FACS, of the University of Virginia, Charlottesville.

At the American College of Surgeons Quality and Safety Conference, Dr. Hedrick presented risk-adjusted National Surgical Quality Improvement Program (NSQIP) data for 2,971 consecutive procedures during 2012-2016 at the University of Virginia, Winchester Medical Center, Carilion Clinic, and Inova Fairfax.

“Institutions came and went from the collaborative during this time period, so we focused on those institutions that maintained in the collaborative throughout the entire study protocol,” Dr. Hedrick said in her presentation.

Of the 2,971 procedures, about half (1,460) were performed after implementation of enhanced recovery protocols. Laparoscopic and open procedures were analyzed separately due to a substantial shift toward laparoscopic procedures, mainly during the 2012-2014 period, Dr. Hedrick said.

Among laparoscopic cases, there was a significant 1-day reduction in median length of stay, dropping from 4 days for pre–enhanced recovery protocol cases to 3 days for post–enhanced recovery protocol cases, Dr. Hedrick reported.

Observed morbidity also dropped significantly from 14.8% to 8.9% for the pre– and post–enhanced recovery cases, and the readmission rate fell significantly from 13% to 8.8%.

For open cases, there was a significant 1-day drop in median length of stay, from 4 to 3 days, but no significant differences in observed morbidity or readmission rates, according to Dr. Hedrick.

“As more of the patients were done laparoscopically, that really selected out the more complicated patients that were undergoing open procedures,” she said.

The protocols implemented by institutions in the Virginia collaborative group were generally uniform in important tenants of enhanced recovery, such as opioid minimization and avoidance of fasting, but specific elements were left up to each institution to improve buy-in, according to Dr. Hedrick.

“A lot of our protocols are very similar, particularly with regards to the order set,” Dr. Hedrick explained, “[but] I really am a firm believer in not being very strict about exactly what to use, because it’s so dependent on preference at the local level.”

The Virginia Surgical Quality Collaborative Workgroup is one of 20 regional ACS NSQIP collaboratives with the objective of improving surgical outcomes through multi-institutional collaboration, Dr. Hedrick said.

Dr. Hedrick and her coinvestigators had no relevant disclosures to report.

ORLANDO – Widespread implementation of enhanced recovery protocols at the state level resulted in a significant reduction in length of stay and complications in patients undergoing elective colectomy, an analysis shows.

The benefits were particularly pronounced in the subset of patients undergoing laparoscopic colectomy in the retrospective analysis, which included data for treated at four institutions in the Virginia Surgical Quality Collaborative Workgroup.

While the benefits of enhanced recovery after surgery (ERAS) are well known, most of the published data has come from single-institution experiences, according to investigator Traci L. Hedrick, MD, FACS, of the University of Virginia, Charlottesville.

At the American College of Surgeons Quality and Safety Conference, Dr. Hedrick presented risk-adjusted National Surgical Quality Improvement Program (NSQIP) data for 2,971 consecutive procedures during 2012-2016 at the University of Virginia, Winchester Medical Center, Carilion Clinic, and Inova Fairfax.

“Institutions came and went from the collaborative during this time period, so we focused on those institutions that maintained in the collaborative throughout the entire study protocol,” Dr. Hedrick said in her presentation.

Of the 2,971 procedures, about half (1,460) were performed after implementation of enhanced recovery protocols. Laparoscopic and open procedures were analyzed separately due to a substantial shift toward laparoscopic procedures, mainly during the 2012-2014 period, Dr. Hedrick said.

Among laparoscopic cases, there was a significant 1-day reduction in median length of stay, dropping from 4 days for pre–enhanced recovery protocol cases to 3 days for post–enhanced recovery protocol cases, Dr. Hedrick reported.

Observed morbidity also dropped significantly from 14.8% to 8.9% for the pre– and post–enhanced recovery cases, and the readmission rate fell significantly from 13% to 8.8%.

For open cases, there was a significant 1-day drop in median length of stay, from 4 to 3 days, but no significant differences in observed morbidity or readmission rates, according to Dr. Hedrick.

“As more of the patients were done laparoscopically, that really selected out the more complicated patients that were undergoing open procedures,” she said.

The protocols implemented by institutions in the Virginia collaborative group were generally uniform in important tenants of enhanced recovery, such as opioid minimization and avoidance of fasting, but specific elements were left up to each institution to improve buy-in, according to Dr. Hedrick.

“A lot of our protocols are very similar, particularly with regards to the order set,” Dr. Hedrick explained, “[but] I really am a firm believer in not being very strict about exactly what to use, because it’s so dependent on preference at the local level.”

The Virginia Surgical Quality Collaborative Workgroup is one of 20 regional ACS NSQIP collaboratives with the objective of improving surgical outcomes through multi-institutional collaboration, Dr. Hedrick said.

Dr. Hedrick and her coinvestigators had no relevant disclosures to report.

ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.

jacoblund/Thinkstock

Among patients with right-sided cancers, the rate of survival improved when 22 or more lymph nodes were harvested during operations, according to the study results presented at the American College of Surgeons Quality and Safety Conference.

“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.

This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.

Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.

Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.

In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.

The difference was most pronounced in stage III of the disease, he added.

Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”

Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.

Help your patients better prepare for their colonoscopy by using AGA patient education materials: https://www.gastro.org/practice-guidance/gi-patient-center/topic/colonoscopy.

ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.

jacoblund/Thinkstock

Among patients with right-sided cancers, the rate of survival improved when 22 or more lymph nodes were harvested during operations, according to the study results presented at the American College of Surgeons Quality and Safety Conference.

“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.

This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.

Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.

Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.

In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.

The difference was most pronounced in stage III of the disease, he added.

Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”

Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.

Help your patients better prepare for their colonoscopy by using AGA patient education materials: https://www.gastro.org/practice-guidance/gi-patient-center/topic/colonoscopy.

ORLANDO – The inferior outcomes associated with right-sided colon cancers might be mitigated if a higher lymph node harvest is obtained, a retrospective study suggested.

jacoblund/Thinkstock

Among patients with right-sided cancers, the rate of survival improved when 22 or more lymph nodes were harvested during operations, according to the study results presented at the American College of Surgeons Quality and Safety Conference.

“These data may provide indirect evidence for complete mesocolic excision to obtain a higher lymph node harvest to improve survival,” said investigator Arman Erkan, MD, of the Center for Colon and Rectal Surgery at Florida Hospital Orlando, in an oral abstract presentation.

This study adds new perspective on recent studies that have also demonstrated worse outcomes for right-sided versus left-sided tumors, which may be related to differences in levels of vascular ligation and nodal harvest. In addition, many studies to date have been limited in their ability to evaluate that hypothesis because of small sample size or other factors, he said in his presentation.

Accordingly, Dr. Erkan and his colleagues queried the National Cancer Database for colectomies for nonmetastatic colon adenocarcinoma occurring between 2004 and 2014, evaluating a total of 504,958 patient records, of which 273,198 were for right-sided tumors. To minimize bias, they used propensity score matching, leaving 148,540 patients in each group for the primary analysis.

Right-sided tumors were associated with inferior 5-year survival for patients with stage II and III disease (P less than .001 for right vs. left in both analyses), the investigators found.

In multivariate analysis, they found a significant interaction between right-sided tumors and a lymph node harvest of greater than 22 nodes toward increased survival, with a hazard ratio of 0.87 (95% confidence interval, 0.84-0.90). “This indicates that survival after right-sided resections can be improved if more than 22 nodes are harvested during the surgery,” Dr. Erkan said.

The difference was most pronounced in stage III of the disease, he added.

Study coauthor Lawrence Lee, MD, a colorectal surgeon at McGill University, said in a related press release that the study findings might prompt surgeons to reevaluate the types of procedures they perform in patients with right-sided tumors. “These patients may need a more extensive resection than is considered to be standard for them.”

Dr. Erkan, Dr. Lee, and other coinvestigators reported no conflicts of interest related to their research.

Help your patients better prepare for their colonoscopy by using AGA patient education materials: https://www.gastro.org/practice-guidance/gi-patient-center/topic/colonoscopy.

CHICAGO – A dendritic cell vaccine improved progression-free survival when administered sequentially after chemotherapy in patients with epithelial ovarian carcinoma who have undergone primary debulking surgery, according to interim findings from a randomized, phase 2, open-label trial.

Of 99 patients enrolled in the international, multicenter trial between November 2013 and March 2016, 92 received at least one dose of therapy and had a postbaseline endpoint assessment (the modified intention-to-treat population). Median progression-free survival was 18.3 months in the 31 patients who received autologous dendritic cell vaccine (DCVAC) given concomitantly with chemotherapy (group A), 24.3 months in the 30 patients who received DCVAC given sequentially as maintenance therapy after chemotherapy (group B), and 18.6 months in the 31 controls who received chemotherapy alone (group C), Lukas Rob, MD, reported at the annual meeting of the American Society of Clinical Oncology.

“When DCVAC was administered as maintenance [therapy] after the chemotherapy, the time to disease progression was prolonged by almost 6 months. Based on the hazard ratio, there was a 57% decrease in the hazard of progression in favor of arm B,” said Dr. Rob, of University Hospital Kralovske Vinohrady, Prague.

Compared with group C, progression-free survival hazard ratios were 0.64 and 0.43 in the modified intention-to-treat population in groups A and B, respectively, he said.

“These results are statistically significant and the clinical benefit is even more significant in patients who received more doses of DCVAC,” he added, explaining that the hazard ratios for patients in groups A and B who received at least eight doses of DCVAC and/or three cycles of chemotherapy (the per protocol population, including 87 patients) were 1.01 and 0.32, respectively.

Although the overall survival data in this study is immature, there is “a strong trend in favor of DCVAC in the maintenance treatment arm,” he said.

Study participants had FIGO stage III epithelial ovarian cancer (EOC) and a performance status score of 0-2. All had undergone primary debulking surgery and had less than 1 cm maximal residuum and no prior systemic therapy. Patients were randomized up to 6 weeks after surgery. Chemotherapy in all three groups included six cycles of carboplatin and paclitaxel, and DCVAC was given at doses of 1 x 107 dendritic cells per dose for a planned 10 doses.

Most patients with EOC – about 70% of those with stage III/IV disease – relapse after optimal debulking surgery and chemotherapy.

“There is no doubt that we need a new treatment modality,” he said. Because autologous DCVAC can present tumor antigens to elicit a durable immune response, he and his colleagues hypothesized that adding DCVAC to chemotherapy could improve outcomes – either when used concomitantly to target tumor-induced immune suppression and allowing for partial recovery of the immune system after each cycle, or when used sequentially as maintenance therapy, as minimal tumor burden after chemotherapy would provide optimal conditions for immune stimulation and the immune system would be fully recovered after completing cytotoxic therapy.

The treatments in this study were well tolerated; no grade 3 or greater adverse events were related solely to DCVAC, and the vaccine did not worsen the side effects of chemotherapy, Dr. Rob said.

The findings suggested that sequential DCVAC after chemotherapy in patients with EOC is a promising maintenance treatment option that can delay disease progression, he concluded, noting that “due to the excellent result in the maintenance arm we decided ... to enroll more patients in arms B and C to increase the power of this study.”

Additionally, a phase 3 trial is planned and enrollment should begin in early 2019, he said.

Dr. Rob reported having no disclosures.

SOURCE: Rob L et al. ASCO 2018, Abstract 5509.

CHICAGO – A dendritic cell vaccine improved progression-free survival when administered sequentially after chemotherapy in patients with epithelial ovarian carcinoma who have undergone primary debulking surgery, according to interim findings from a randomized, phase 2, open-label trial.

Of 99 patients enrolled in the international, multicenter trial between November 2013 and March 2016, 92 received at least one dose of therapy and had a postbaseline endpoint assessment (the modified intention-to-treat population). Median progression-free survival was 18.3 months in the 31 patients who received autologous dendritic cell vaccine (DCVAC) given concomitantly with chemotherapy (group A), 24.3 months in the 30 patients who received DCVAC given sequentially as maintenance therapy after chemotherapy (group B), and 18.6 months in the 31 controls who received chemotherapy alone (group C), Lukas Rob, MD, reported at the annual meeting of the American Society of Clinical Oncology.

“When DCVAC was administered as maintenance [therapy] after the chemotherapy, the time to disease progression was prolonged by almost 6 months. Based on the hazard ratio, there was a 57% decrease in the hazard of progression in favor of arm B,” said Dr. Rob, of University Hospital Kralovske Vinohrady, Prague.

Compared with group C, progression-free survival hazard ratios were 0.64 and 0.43 in the modified intention-to-treat population in groups A and B, respectively, he said.

“These results are statistically significant and the clinical benefit is even more significant in patients who received more doses of DCVAC,” he added, explaining that the hazard ratios for patients in groups A and B who received at least eight doses of DCVAC and/or three cycles of chemotherapy (the per protocol population, including 87 patients) were 1.01 and 0.32, respectively.

Although the overall survival data in this study is immature, there is “a strong trend in favor of DCVAC in the maintenance treatment arm,” he said.

Study participants had FIGO stage III epithelial ovarian cancer (EOC) and a performance status score of 0-2. All had undergone primary debulking surgery and had less than 1 cm maximal residuum and no prior systemic therapy. Patients were randomized up to 6 weeks after surgery. Chemotherapy in all three groups included six cycles of carboplatin and paclitaxel, and DCVAC was given at doses of 1 x 107 dendritic cells per dose for a planned 10 doses.

Most patients with EOC – about 70% of those with stage III/IV disease – relapse after optimal debulking surgery and chemotherapy.

“There is no doubt that we need a new treatment modality,” he said. Because autologous DCVAC can present tumor antigens to elicit a durable immune response, he and his colleagues hypothesized that adding DCVAC to chemotherapy could improve outcomes – either when used concomitantly to target tumor-induced immune suppression and allowing for partial recovery of the immune system after each cycle, or when used sequentially as maintenance therapy, as minimal tumor burden after chemotherapy would provide optimal conditions for immune stimulation and the immune system would be fully recovered after completing cytotoxic therapy.

The treatments in this study were well tolerated; no grade 3 or greater adverse events were related solely to DCVAC, and the vaccine did not worsen the side effects of chemotherapy, Dr. Rob said.

The findings suggested that sequential DCVAC after chemotherapy in patients with EOC is a promising maintenance treatment option that can delay disease progression, he concluded, noting that “due to the excellent result in the maintenance arm we decided ... to enroll more patients in arms B and C to increase the power of this study.”

Additionally, a phase 3 trial is planned and enrollment should begin in early 2019, he said.

Dr. Rob reported having no disclosures.

SOURCE: Rob L et al. ASCO 2018, Abstract 5509.

CHICAGO – A dendritic cell vaccine improved progression-free survival when administered sequentially after chemotherapy in patients with epithelial ovarian carcinoma who have undergone primary debulking surgery, according to interim findings from a randomized, phase 2, open-label trial.

Of 99 patients enrolled in the international, multicenter trial between November 2013 and March 2016, 92 received at least one dose of therapy and had a postbaseline endpoint assessment (the modified intention-to-treat population). Median progression-free survival was 18.3 months in the 31 patients who received autologous dendritic cell vaccine (DCVAC) given concomitantly with chemotherapy (group A), 24.3 months in the 30 patients who received DCVAC given sequentially as maintenance therapy after chemotherapy (group B), and 18.6 months in the 31 controls who received chemotherapy alone (group C), Lukas Rob, MD, reported at the annual meeting of the American Society of Clinical Oncology.

“When DCVAC was administered as maintenance [therapy] after the chemotherapy, the time to disease progression was prolonged by almost 6 months. Based on the hazard ratio, there was a 57% decrease in the hazard of progression in favor of arm B,” said Dr. Rob, of University Hospital Kralovske Vinohrady, Prague.

Compared with group C, progression-free survival hazard ratios were 0.64 and 0.43 in the modified intention-to-treat population in groups A and B, respectively, he said.

“These results are statistically significant and the clinical benefit is even more significant in patients who received more doses of DCVAC,” he added, explaining that the hazard ratios for patients in groups A and B who received at least eight doses of DCVAC and/or three cycles of chemotherapy (the per protocol population, including 87 patients) were 1.01 and 0.32, respectively.

Although the overall survival data in this study is immature, there is “a strong trend in favor of DCVAC in the maintenance treatment arm,” he said.

Study participants had FIGO stage III epithelial ovarian cancer (EOC) and a performance status score of 0-2. All had undergone primary debulking surgery and had less than 1 cm maximal residuum and no prior systemic therapy. Patients were randomized up to 6 weeks after surgery. Chemotherapy in all three groups included six cycles of carboplatin and paclitaxel, and DCVAC was given at doses of 1 x 107 dendritic cells per dose for a planned 10 doses.

Most patients with EOC – about 70% of those with stage III/IV disease – relapse after optimal debulking surgery and chemotherapy.

“There is no doubt that we need a new treatment modality,” he said. Because autologous DCVAC can present tumor antigens to elicit a durable immune response, he and his colleagues hypothesized that adding DCVAC to chemotherapy could improve outcomes – either when used concomitantly to target tumor-induced immune suppression and allowing for partial recovery of the immune system after each cycle, or when used sequentially as maintenance therapy, as minimal tumor burden after chemotherapy would provide optimal conditions for immune stimulation and the immune system would be fully recovered after completing cytotoxic therapy.

The treatments in this study were well tolerated; no grade 3 or greater adverse events were related solely to DCVAC, and the vaccine did not worsen the side effects of chemotherapy, Dr. Rob said.

The findings suggested that sequential DCVAC after chemotherapy in patients with EOC is a promising maintenance treatment option that can delay disease progression, he concluded, noting that “due to the excellent result in the maintenance arm we decided ... to enroll more patients in arms B and C to increase the power of this study.”

Additionally, a phase 3 trial is planned and enrollment should begin in early 2019, he said.

Dr. Rob reported having no disclosures.

SOURCE: Rob L et al. ASCO 2018, Abstract 5509.