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Launching into the future
Hospital Medicine: 10 years ago
My first Society of Hospital Medicine Annual Conference was HM08, and it changed the course of my professional career.
I was a first-year hospitalist from an academic program of fewer than 10 physicians. My knowledge about my field did not extend much beyond the clinical practice of hospital medicine. I remember sitting at the airport on my way to HM08 and excitedly looking over the schedule for the meeting. I diligently circled the sessions that I was looking forward to attending, the majority of which focused on the clinical tracks. But by the end of the meeting, in additional to valuable medical knowledge, I walked away with novel insights that launched me into my future.
New ideas in HM: In 2008, comanagement was still a new concept. As I attended sessions and spoke with hospitalists from across the country, it became clear that this was a collaboration that would be core to our specialty. Within a couple of months of returning home from the annual conference, I was approached by the chair of neurosurgery at my institution with a proposal to develop a quality program for his group. While at that time I was considering other competing interests, my experience at HM08 helped me recognize that this was a unique opportunity to build bridges across specialties and to collaborate. I subsequently became the executive director of quality for neurosurgery and over the years was able to create a strong relationship between our departments that led to building a nationally recognized program with exceptional performance in hospital-based quality.
Side note: If you’re interested in resources on comanagement, please check out SHM’s Resources for Effective Co-Management of Hospitalized Patients at https://www.hospitalmedicine.org/comanagement .
Emerging themes and trends in health care: While the quality movement had launched about a decade before HM08, many institutions still did not have robust programs. As I attended sessions during the annual meeting and spoke with thought leaders, one message became clear: Hospitalists would have to lead the quality movement at their institutions. When I returned home, I began learning about quality improvement and started to lead various initiatives. These efforts led to my appointment as associate chief medical officer for the health system. This position enabled me to leverage my knowledge of hospital-based care and collaborate across various specialties to reduce our mortality and readmission rates in the organization.
Side note: If you’re interested in learning more about quality improvement educational and mentorship opportunities, please visit https://www.hospitalmedicine.org/qi and look at the resources for each specific topic.
And, most importantly, friendships: By far the most important thing I took away from HM08 was the friendships that started at that meeting and have developed over the years since. A decade later, I continue to rely on, grow from, and be challenged by the same people I met at that meeting. They are the colleagues I call when I find myself in a tough spot at work and need advice, the collaborators I work with on grants and projects, and the friends I text when I travel to a new town and want to grab a bite to eat.
Side note: If you’re interested in connecting with colleagues who share similar interests, please visit https://www.hospitalmedicine.org/sigs and review SHM’s Special Interest Groups to find ones that are right for you. To connect on a more local level, find an SHM Chapter near you at https://www.hospitalmedicine.org/chapters.
I’ve shared these stories with you because for me my journey with our society has been a deeply personal one. And I feel indebted to SHM and the incredible people who drawn to it for helping me develop and enjoy a rich and rewarding career thus far. So, as I look forward to the next decade, I wanted to share my thoughts on HM and emerging themes in health care with you.
Hospital medicine: The next decade
New ideas in HM: Population health management
Building on our strong culture of collaboration as we move forward into this next decade, we have to define how we deliver value in the context of population health management. As hospitalists, we have to push the boundaries of the hospital and provide high-value care beyond our four walls.
How can we do that? I think technology will play a critical role in extending our reach beyond the hospital. As we move toward delivering greater value to our patients, lower acuity patients will receive care in their homes. Telehealth will enable us to monitor and manage these patients remotely while transferring our bedside management to patients’ bedrooms in their own homes. Virtual hospitals will further enable us to evaluate, triage, monitor, and manage patients remotely. Our active engagement in these efforts is critical to ensure the continued growth and value we bring to our patients, our organizations, and our society.
Emerging themes and trends in health care: Transitioning from quality to value
In the next decade, value will prevail. This is not a novel concept – much like how quality was not a new idea in 2008.
Value has been around for a while: There are some robust programs nationally, there is research around the topic, and there are policies with implications for reimbursements. However, the full potential of value has not yet been realized by health care – it exists in individual programs, not in everything we do. The unprecedented number of mergers and acquisitions in health care in 2018 support the fact that the future will belong to those institutions that can deliver the highest quality of care at the most appropriate cost throughout the entire continuum of care.
What are some of the tools that will help us get there? Artificial intelligence and machine learning will improve the predictive value for the care we deliver to individual patients; some preliminary work in this area has already revealed that factors that we previously associated with higher risk of readmissions are not truly predictive. Another emerging technology is blockchain: By creating a single source of truth for our patients’ medical information, it enables us to have dynamic, high-integrity records regardless of which health systems and EHRs have cared for those patients.
I wish you an energizing journey as you launch your future into the next dynamic decade of health care, and I look forward to connecting with you as we continue to build a society that prepares us for the challenges and opportunities ahead.
Dr. Afsar is the president of the Society of Hospital Medicine and the chief ambulatory officer and chief medical officer for the accountable care organizations at UC Irvine Health.
Hospital Medicine: 10 years ago
My first Society of Hospital Medicine Annual Conference was HM08, and it changed the course of my professional career.
I was a first-year hospitalist from an academic program of fewer than 10 physicians. My knowledge about my field did not extend much beyond the clinical practice of hospital medicine. I remember sitting at the airport on my way to HM08 and excitedly looking over the schedule for the meeting. I diligently circled the sessions that I was looking forward to attending, the majority of which focused on the clinical tracks. But by the end of the meeting, in additional to valuable medical knowledge, I walked away with novel insights that launched me into my future.
New ideas in HM: In 2008, comanagement was still a new concept. As I attended sessions and spoke with hospitalists from across the country, it became clear that this was a collaboration that would be core to our specialty. Within a couple of months of returning home from the annual conference, I was approached by the chair of neurosurgery at my institution with a proposal to develop a quality program for his group. While at that time I was considering other competing interests, my experience at HM08 helped me recognize that this was a unique opportunity to build bridges across specialties and to collaborate. I subsequently became the executive director of quality for neurosurgery and over the years was able to create a strong relationship between our departments that led to building a nationally recognized program with exceptional performance in hospital-based quality.
Side note: If you’re interested in resources on comanagement, please check out SHM’s Resources for Effective Co-Management of Hospitalized Patients at https://www.hospitalmedicine.org/comanagement .
Emerging themes and trends in health care: While the quality movement had launched about a decade before HM08, many institutions still did not have robust programs. As I attended sessions during the annual meeting and spoke with thought leaders, one message became clear: Hospitalists would have to lead the quality movement at their institutions. When I returned home, I began learning about quality improvement and started to lead various initiatives. These efforts led to my appointment as associate chief medical officer for the health system. This position enabled me to leverage my knowledge of hospital-based care and collaborate across various specialties to reduce our mortality and readmission rates in the organization.
Side note: If you’re interested in learning more about quality improvement educational and mentorship opportunities, please visit https://www.hospitalmedicine.org/qi and look at the resources for each specific topic.
And, most importantly, friendships: By far the most important thing I took away from HM08 was the friendships that started at that meeting and have developed over the years since. A decade later, I continue to rely on, grow from, and be challenged by the same people I met at that meeting. They are the colleagues I call when I find myself in a tough spot at work and need advice, the collaborators I work with on grants and projects, and the friends I text when I travel to a new town and want to grab a bite to eat.
Side note: If you’re interested in connecting with colleagues who share similar interests, please visit https://www.hospitalmedicine.org/sigs and review SHM’s Special Interest Groups to find ones that are right for you. To connect on a more local level, find an SHM Chapter near you at https://www.hospitalmedicine.org/chapters.
I’ve shared these stories with you because for me my journey with our society has been a deeply personal one. And I feel indebted to SHM and the incredible people who drawn to it for helping me develop and enjoy a rich and rewarding career thus far. So, as I look forward to the next decade, I wanted to share my thoughts on HM and emerging themes in health care with you.
Hospital medicine: The next decade
New ideas in HM: Population health management
Building on our strong culture of collaboration as we move forward into this next decade, we have to define how we deliver value in the context of population health management. As hospitalists, we have to push the boundaries of the hospital and provide high-value care beyond our four walls.
How can we do that? I think technology will play a critical role in extending our reach beyond the hospital. As we move toward delivering greater value to our patients, lower acuity patients will receive care in their homes. Telehealth will enable us to monitor and manage these patients remotely while transferring our bedside management to patients’ bedrooms in their own homes. Virtual hospitals will further enable us to evaluate, triage, monitor, and manage patients remotely. Our active engagement in these efforts is critical to ensure the continued growth and value we bring to our patients, our organizations, and our society.
Emerging themes and trends in health care: Transitioning from quality to value
In the next decade, value will prevail. This is not a novel concept – much like how quality was not a new idea in 2008.
Value has been around for a while: There are some robust programs nationally, there is research around the topic, and there are policies with implications for reimbursements. However, the full potential of value has not yet been realized by health care – it exists in individual programs, not in everything we do. The unprecedented number of mergers and acquisitions in health care in 2018 support the fact that the future will belong to those institutions that can deliver the highest quality of care at the most appropriate cost throughout the entire continuum of care.
What are some of the tools that will help us get there? Artificial intelligence and machine learning will improve the predictive value for the care we deliver to individual patients; some preliminary work in this area has already revealed that factors that we previously associated with higher risk of readmissions are not truly predictive. Another emerging technology is blockchain: By creating a single source of truth for our patients’ medical information, it enables us to have dynamic, high-integrity records regardless of which health systems and EHRs have cared for those patients.
I wish you an energizing journey as you launch your future into the next dynamic decade of health care, and I look forward to connecting with you as we continue to build a society that prepares us for the challenges and opportunities ahead.
Dr. Afsar is the president of the Society of Hospital Medicine and the chief ambulatory officer and chief medical officer for the accountable care organizations at UC Irvine Health.
Hospital Medicine: 10 years ago
My first Society of Hospital Medicine Annual Conference was HM08, and it changed the course of my professional career.
I was a first-year hospitalist from an academic program of fewer than 10 physicians. My knowledge about my field did not extend much beyond the clinical practice of hospital medicine. I remember sitting at the airport on my way to HM08 and excitedly looking over the schedule for the meeting. I diligently circled the sessions that I was looking forward to attending, the majority of which focused on the clinical tracks. But by the end of the meeting, in additional to valuable medical knowledge, I walked away with novel insights that launched me into my future.
New ideas in HM: In 2008, comanagement was still a new concept. As I attended sessions and spoke with hospitalists from across the country, it became clear that this was a collaboration that would be core to our specialty. Within a couple of months of returning home from the annual conference, I was approached by the chair of neurosurgery at my institution with a proposal to develop a quality program for his group. While at that time I was considering other competing interests, my experience at HM08 helped me recognize that this was a unique opportunity to build bridges across specialties and to collaborate. I subsequently became the executive director of quality for neurosurgery and over the years was able to create a strong relationship between our departments that led to building a nationally recognized program with exceptional performance in hospital-based quality.
Side note: If you’re interested in resources on comanagement, please check out SHM’s Resources for Effective Co-Management of Hospitalized Patients at https://www.hospitalmedicine.org/comanagement .
Emerging themes and trends in health care: While the quality movement had launched about a decade before HM08, many institutions still did not have robust programs. As I attended sessions during the annual meeting and spoke with thought leaders, one message became clear: Hospitalists would have to lead the quality movement at their institutions. When I returned home, I began learning about quality improvement and started to lead various initiatives. These efforts led to my appointment as associate chief medical officer for the health system. This position enabled me to leverage my knowledge of hospital-based care and collaborate across various specialties to reduce our mortality and readmission rates in the organization.
Side note: If you’re interested in learning more about quality improvement educational and mentorship opportunities, please visit https://www.hospitalmedicine.org/qi and look at the resources for each specific topic.
And, most importantly, friendships: By far the most important thing I took away from HM08 was the friendships that started at that meeting and have developed over the years since. A decade later, I continue to rely on, grow from, and be challenged by the same people I met at that meeting. They are the colleagues I call when I find myself in a tough spot at work and need advice, the collaborators I work with on grants and projects, and the friends I text when I travel to a new town and want to grab a bite to eat.
Side note: If you’re interested in connecting with colleagues who share similar interests, please visit https://www.hospitalmedicine.org/sigs and review SHM’s Special Interest Groups to find ones that are right for you. To connect on a more local level, find an SHM Chapter near you at https://www.hospitalmedicine.org/chapters.
I’ve shared these stories with you because for me my journey with our society has been a deeply personal one. And I feel indebted to SHM and the incredible people who drawn to it for helping me develop and enjoy a rich and rewarding career thus far. So, as I look forward to the next decade, I wanted to share my thoughts on HM and emerging themes in health care with you.
Hospital medicine: The next decade
New ideas in HM: Population health management
Building on our strong culture of collaboration as we move forward into this next decade, we have to define how we deliver value in the context of population health management. As hospitalists, we have to push the boundaries of the hospital and provide high-value care beyond our four walls.
How can we do that? I think technology will play a critical role in extending our reach beyond the hospital. As we move toward delivering greater value to our patients, lower acuity patients will receive care in their homes. Telehealth will enable us to monitor and manage these patients remotely while transferring our bedside management to patients’ bedrooms in their own homes. Virtual hospitals will further enable us to evaluate, triage, monitor, and manage patients remotely. Our active engagement in these efforts is critical to ensure the continued growth and value we bring to our patients, our organizations, and our society.
Emerging themes and trends in health care: Transitioning from quality to value
In the next decade, value will prevail. This is not a novel concept – much like how quality was not a new idea in 2008.
Value has been around for a while: There are some robust programs nationally, there is research around the topic, and there are policies with implications for reimbursements. However, the full potential of value has not yet been realized by health care – it exists in individual programs, not in everything we do. The unprecedented number of mergers and acquisitions in health care in 2018 support the fact that the future will belong to those institutions that can deliver the highest quality of care at the most appropriate cost throughout the entire continuum of care.
What are some of the tools that will help us get there? Artificial intelligence and machine learning will improve the predictive value for the care we deliver to individual patients; some preliminary work in this area has already revealed that factors that we previously associated with higher risk of readmissions are not truly predictive. Another emerging technology is blockchain: By creating a single source of truth for our patients’ medical information, it enables us to have dynamic, high-integrity records regardless of which health systems and EHRs have cared for those patients.
I wish you an energizing journey as you launch your future into the next dynamic decade of health care, and I look forward to connecting with you as we continue to build a society that prepares us for the challenges and opportunities ahead.
Dr. Afsar is the president of the Society of Hospital Medicine and the chief ambulatory officer and chief medical officer for the accountable care organizations at UC Irvine Health.
Recently approved SK treatment spares melanocytes in preclinical study
A study using an ex vivo model to evaluate a seborrheic keratosis (SK) treatment shows that a topical application of 40% hydrogen peroxide is gentler on skin than a 5- or 10-second treatment with liquid nitrogen, particularly with respect to melanocytes, suggesting that the former may be less likely to produce disfiguring damage.
The 40% hydrogen peroxide solution (Eskata), also known as A-101, received Food and Drug Administration approval for the treatment of “seborrheic keratoses that are raised” in December, 2017. The study was published online in the Journal of the American Academy of Dermatology.
Melanocyte damage can lead to significant dyschromia, a poor cosmetic outcome that can have a tremendous impact on quality of life for dark-skinned patients, in whom it produces white spots. “A lot of these destructive approaches, especially liquid nitrogen, can leave more disfigurement upon treatment than the lesion itself,” the study’s lead author Adam Friedman, MD, said in an interview.
Melanocytes are particularly vulnerable to the effects of cold, so the destructive potential of liquid nitrogen is no surprise. But Dr. Friedman of the department of dermatology, George Washington University, Washington, wanted to get a better understanding of the impact of the new treatment on different skin cell types and the toxicity profile, so he approached the manufacturer, Aclaris Therapeutics, to do a study.
His team tested 40% hydrogen peroxide treatment and liquid nitrogen cryosurgery on a validated ex vivo human reconstituted full-thickness model derived from Fitzpatrick V skin, with 5 or 10 seconds of cryosurgery or 1 or 2 mcL of 40% hydrogen peroxide.
Using standard a hematoxylin and eosin stain as well as immunohistochemical staining to examine the architecture and cells types of the skin model following both treatments, the researchers found that 5- and 10-second cryosurgery resulted in significant thinning of the epidermis and increased cell death. There was also separation at the dermal-epidermal junction, which was more prominent in the 10-second cryosurgery group, although present even with a 5-second freeze cycle.
The hydrogen peroxide–treated groups showed acanthosis of the epidermis and mild pallor, but this was less noticeable than in the cryosurgery specimens. There was no epidermal clefting in the hydrogen peroxide–treated samples.
Tunel staining revealed 16.4 (plus or minus 0.6424) apoptotic cells per high-powered field in the 5-second cryosurgery experiment and 20.6 (plus or minus 0.6424) in the 10-second procedure. For the hydrogen peroxide treatment, those numbers were 8.65 (plus or minus 0.4122) in the 1 mcL experiment and 12.4 (plus or minus 0.3728) in the 2 mcL experiment.
As expected, melanocytes fared better with the hydrogen peroxide treatment. In the untreated samples, there were 2.5 melanocytes (plus or minus 0.1987) in the untreated sample and 2.0 (plus or minus 0.5000) melanocytes in the vehicle-treated sample. In the 5-second cryosurgery sample, there were 0.45 melanocytes (plus or minus 0.1535), and in the 10 second cryosurgery sample there were 0.2 (plus or minus 0.0918) melanocytes. In contrast, with the 1-mcL hydrogen peroxide-treated sample, there were 1.95 melanocytes in both the 1-mcL and 2-mcL samples (plus or minus 0.1535 for both groups).
“,” Dr. Friedman said. These results, he added, “offer us a lot of insight in terms of how damaging liquid nitrogen is, and it’s good to be reminded of that so that we don’t cause too much harm.”
The authors noted that a clinical trial evaluating the risk of hypopigmentation and hyperpigmentation with 40% hydrogen peroxide in people with darker skin types is underway. In the study, hydrogen peroxide is used to treat dermatosis papulosa nigra.
The study was funded by Aclaris Therapeutics. Senior author Adam Friedman, MD, is a consultant for Aclaris. Dr. Friedman is on the editorial board of Dermatology News.
SOURCE: Kao S et al. J Am Acad Dermatol. 2018 Mar 27. doi: 10.1016/j.jaad.2018.03.034.
A study using an ex vivo model to evaluate a seborrheic keratosis (SK) treatment shows that a topical application of 40% hydrogen peroxide is gentler on skin than a 5- or 10-second treatment with liquid nitrogen, particularly with respect to melanocytes, suggesting that the former may be less likely to produce disfiguring damage.
The 40% hydrogen peroxide solution (Eskata), also known as A-101, received Food and Drug Administration approval for the treatment of “seborrheic keratoses that are raised” in December, 2017. The study was published online in the Journal of the American Academy of Dermatology.
Melanocyte damage can lead to significant dyschromia, a poor cosmetic outcome that can have a tremendous impact on quality of life for dark-skinned patients, in whom it produces white spots. “A lot of these destructive approaches, especially liquid nitrogen, can leave more disfigurement upon treatment than the lesion itself,” the study’s lead author Adam Friedman, MD, said in an interview.
Melanocytes are particularly vulnerable to the effects of cold, so the destructive potential of liquid nitrogen is no surprise. But Dr. Friedman of the department of dermatology, George Washington University, Washington, wanted to get a better understanding of the impact of the new treatment on different skin cell types and the toxicity profile, so he approached the manufacturer, Aclaris Therapeutics, to do a study.
His team tested 40% hydrogen peroxide treatment and liquid nitrogen cryosurgery on a validated ex vivo human reconstituted full-thickness model derived from Fitzpatrick V skin, with 5 or 10 seconds of cryosurgery or 1 or 2 mcL of 40% hydrogen peroxide.
Using standard a hematoxylin and eosin stain as well as immunohistochemical staining to examine the architecture and cells types of the skin model following both treatments, the researchers found that 5- and 10-second cryosurgery resulted in significant thinning of the epidermis and increased cell death. There was also separation at the dermal-epidermal junction, which was more prominent in the 10-second cryosurgery group, although present even with a 5-second freeze cycle.
The hydrogen peroxide–treated groups showed acanthosis of the epidermis and mild pallor, but this was less noticeable than in the cryosurgery specimens. There was no epidermal clefting in the hydrogen peroxide–treated samples.
Tunel staining revealed 16.4 (plus or minus 0.6424) apoptotic cells per high-powered field in the 5-second cryosurgery experiment and 20.6 (plus or minus 0.6424) in the 10-second procedure. For the hydrogen peroxide treatment, those numbers were 8.65 (plus or minus 0.4122) in the 1 mcL experiment and 12.4 (plus or minus 0.3728) in the 2 mcL experiment.
As expected, melanocytes fared better with the hydrogen peroxide treatment. In the untreated samples, there were 2.5 melanocytes (plus or minus 0.1987) in the untreated sample and 2.0 (plus or minus 0.5000) melanocytes in the vehicle-treated sample. In the 5-second cryosurgery sample, there were 0.45 melanocytes (plus or minus 0.1535), and in the 10 second cryosurgery sample there were 0.2 (plus or minus 0.0918) melanocytes. In contrast, with the 1-mcL hydrogen peroxide-treated sample, there were 1.95 melanocytes in both the 1-mcL and 2-mcL samples (plus or minus 0.1535 for both groups).
“,” Dr. Friedman said. These results, he added, “offer us a lot of insight in terms of how damaging liquid nitrogen is, and it’s good to be reminded of that so that we don’t cause too much harm.”
The authors noted that a clinical trial evaluating the risk of hypopigmentation and hyperpigmentation with 40% hydrogen peroxide in people with darker skin types is underway. In the study, hydrogen peroxide is used to treat dermatosis papulosa nigra.
The study was funded by Aclaris Therapeutics. Senior author Adam Friedman, MD, is a consultant for Aclaris. Dr. Friedman is on the editorial board of Dermatology News.
SOURCE: Kao S et al. J Am Acad Dermatol. 2018 Mar 27. doi: 10.1016/j.jaad.2018.03.034.
A study using an ex vivo model to evaluate a seborrheic keratosis (SK) treatment shows that a topical application of 40% hydrogen peroxide is gentler on skin than a 5- or 10-second treatment with liquid nitrogen, particularly with respect to melanocytes, suggesting that the former may be less likely to produce disfiguring damage.
The 40% hydrogen peroxide solution (Eskata), also known as A-101, received Food and Drug Administration approval for the treatment of “seborrheic keratoses that are raised” in December, 2017. The study was published online in the Journal of the American Academy of Dermatology.
Melanocyte damage can lead to significant dyschromia, a poor cosmetic outcome that can have a tremendous impact on quality of life for dark-skinned patients, in whom it produces white spots. “A lot of these destructive approaches, especially liquid nitrogen, can leave more disfigurement upon treatment than the lesion itself,” the study’s lead author Adam Friedman, MD, said in an interview.
Melanocytes are particularly vulnerable to the effects of cold, so the destructive potential of liquid nitrogen is no surprise. But Dr. Friedman of the department of dermatology, George Washington University, Washington, wanted to get a better understanding of the impact of the new treatment on different skin cell types and the toxicity profile, so he approached the manufacturer, Aclaris Therapeutics, to do a study.
His team tested 40% hydrogen peroxide treatment and liquid nitrogen cryosurgery on a validated ex vivo human reconstituted full-thickness model derived from Fitzpatrick V skin, with 5 or 10 seconds of cryosurgery or 1 or 2 mcL of 40% hydrogen peroxide.
Using standard a hematoxylin and eosin stain as well as immunohistochemical staining to examine the architecture and cells types of the skin model following both treatments, the researchers found that 5- and 10-second cryosurgery resulted in significant thinning of the epidermis and increased cell death. There was also separation at the dermal-epidermal junction, which was more prominent in the 10-second cryosurgery group, although present even with a 5-second freeze cycle.
The hydrogen peroxide–treated groups showed acanthosis of the epidermis and mild pallor, but this was less noticeable than in the cryosurgery specimens. There was no epidermal clefting in the hydrogen peroxide–treated samples.
Tunel staining revealed 16.4 (plus or minus 0.6424) apoptotic cells per high-powered field in the 5-second cryosurgery experiment and 20.6 (plus or minus 0.6424) in the 10-second procedure. For the hydrogen peroxide treatment, those numbers were 8.65 (plus or minus 0.4122) in the 1 mcL experiment and 12.4 (plus or minus 0.3728) in the 2 mcL experiment.
As expected, melanocytes fared better with the hydrogen peroxide treatment. In the untreated samples, there were 2.5 melanocytes (plus or minus 0.1987) in the untreated sample and 2.0 (plus or minus 0.5000) melanocytes in the vehicle-treated sample. In the 5-second cryosurgery sample, there were 0.45 melanocytes (plus or minus 0.1535), and in the 10 second cryosurgery sample there were 0.2 (plus or minus 0.0918) melanocytes. In contrast, with the 1-mcL hydrogen peroxide-treated sample, there were 1.95 melanocytes in both the 1-mcL and 2-mcL samples (plus or minus 0.1535 for both groups).
“,” Dr. Friedman said. These results, he added, “offer us a lot of insight in terms of how damaging liquid nitrogen is, and it’s good to be reminded of that so that we don’t cause too much harm.”
The authors noted that a clinical trial evaluating the risk of hypopigmentation and hyperpigmentation with 40% hydrogen peroxide in people with darker skin types is underway. In the study, hydrogen peroxide is used to treat dermatosis papulosa nigra.
The study was funded by Aclaris Therapeutics. Senior author Adam Friedman, MD, is a consultant for Aclaris. Dr. Friedman is on the editorial board of Dermatology News.
SOURCE: Kao S et al. J Am Acad Dermatol. 2018 Mar 27. doi: 10.1016/j.jaad.2018.03.034.
FROM JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Key clinical point: The results of a preclinical study using an ex vivo model of darker skin found that a 40% hydrogen peroxide solution for treating SKs was less damaging to the skin.
Major finding: The topical hydrogen peroxide treatment left 1.95 melanocytes in place, compared with 0.2-0.4 in the liquid nitrogen samples. As expected, melanocytes fared better with the hydrogen peroxide treatment. In the untreated samples, there were 2.5 melanocytes (plus or minus 0.1987) in the untreated sample and 2.0 (plus or minus 0.5000) melanocytes in the vehicle-treated sample. In the 5-second cryosurgery sample, there were 0.45 melanocytes (plus or minus 0.1535), and in the 10-second cryosurgery sample there were 0.2 (plus or minus 0.0918) melanocytes.
Study details: The study compared the cytotoxic effects and impact on melanocytes of liquid nitrogen and 40% hydrogen peroxide solution using ex vivo human reconstituted full-thickness model.
Disclosures: The study was funded by Aclaris Therapeutics. Senior author Adam Friedman, MD, is a consultant for Aclaris.
Source: Kao S. et al. J Am Acad Dermatol. 2018 Mar 27. doi: 10.1016/j.jaad.2018.03.034.
PDPK1 could be novel target in MCL
Researchers may have found a new therapeutic approach for treating mantle cell lymphoma (MCL) by targeting 3-phosphoinositide-dependent protein kinase 1 (PDPK1).
Saori Maegawa and colleagues at Kyoto Prefectural University of Medicine in Japan, evaluated PDPK1 activity in patient-derived primary B-cell lymphoma cells by immunohistochemical staining of p-PDPK1Ser241 (p-PDPK1) in tissue specimens from seven patients with MCL, six patients with diffuse large B-cell lymphoma, and five patients with follicular lymphoma. All specimens were biopsied at initial diagnosis, before starting treatment.
“Our study showed that PDPK1 inhibition caused inactivation of RSK2-NTKD, as well as the decrease of total RSK2 protein, but not of AKT, in MCL-derived cells,” the researchers wrote in Experimental Hematology. “This implies that RSK2 activity is mainly regulated by PDPK1 at both the transcriptional expression and post-translational levels, but AKT activity is regulated by a signaling pathway that does not interact with a PDPK1-mediated pathway in MCL.”
If a PDPK1 inhibitor is pursued as clinical target, the researchers said careful monitoring for hyperglycemia may be required since impaired glucose metabolism is commonly seen with AKT inhibitors. Future research in MCL could also be directed toward the targeting of RSK2-NTKD, the researchers wrote.
SOURCE: Maegawa S et al. Exp Hematol. 2018 Mar;59:72-81.e2.
Researchers may have found a new therapeutic approach for treating mantle cell lymphoma (MCL) by targeting 3-phosphoinositide-dependent protein kinase 1 (PDPK1).
Saori Maegawa and colleagues at Kyoto Prefectural University of Medicine in Japan, evaluated PDPK1 activity in patient-derived primary B-cell lymphoma cells by immunohistochemical staining of p-PDPK1Ser241 (p-PDPK1) in tissue specimens from seven patients with MCL, six patients with diffuse large B-cell lymphoma, and five patients with follicular lymphoma. All specimens were biopsied at initial diagnosis, before starting treatment.
“Our study showed that PDPK1 inhibition caused inactivation of RSK2-NTKD, as well as the decrease of total RSK2 protein, but not of AKT, in MCL-derived cells,” the researchers wrote in Experimental Hematology. “This implies that RSK2 activity is mainly regulated by PDPK1 at both the transcriptional expression and post-translational levels, but AKT activity is regulated by a signaling pathway that does not interact with a PDPK1-mediated pathway in MCL.”
If a PDPK1 inhibitor is pursued as clinical target, the researchers said careful monitoring for hyperglycemia may be required since impaired glucose metabolism is commonly seen with AKT inhibitors. Future research in MCL could also be directed toward the targeting of RSK2-NTKD, the researchers wrote.
SOURCE: Maegawa S et al. Exp Hematol. 2018 Mar;59:72-81.e2.
Researchers may have found a new therapeutic approach for treating mantle cell lymphoma (MCL) by targeting 3-phosphoinositide-dependent protein kinase 1 (PDPK1).
Saori Maegawa and colleagues at Kyoto Prefectural University of Medicine in Japan, evaluated PDPK1 activity in patient-derived primary B-cell lymphoma cells by immunohistochemical staining of p-PDPK1Ser241 (p-PDPK1) in tissue specimens from seven patients with MCL, six patients with diffuse large B-cell lymphoma, and five patients with follicular lymphoma. All specimens were biopsied at initial diagnosis, before starting treatment.
“Our study showed that PDPK1 inhibition caused inactivation of RSK2-NTKD, as well as the decrease of total RSK2 protein, but not of AKT, in MCL-derived cells,” the researchers wrote in Experimental Hematology. “This implies that RSK2 activity is mainly regulated by PDPK1 at both the transcriptional expression and post-translational levels, but AKT activity is regulated by a signaling pathway that does not interact with a PDPK1-mediated pathway in MCL.”
If a PDPK1 inhibitor is pursued as clinical target, the researchers said careful monitoring for hyperglycemia may be required since impaired glucose metabolism is commonly seen with AKT inhibitors. Future research in MCL could also be directed toward the targeting of RSK2-NTKD, the researchers wrote.
SOURCE: Maegawa S et al. Exp Hematol. 2018 Mar;59:72-81.e2.
FROM EXPERIMENTAL HEMATOLOGY
Closing the gender gap
It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.
“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”
That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.1
Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”2
In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.
“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.
Fueling the conversation
When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.” 
“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”
Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.
“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”
A 2015 study in the Journal of Hospital Medicine found that just 16% of university hospital medicine divisions were led by women, and women made up just 28% of those physicians leading general internal medicine divisions. Meanwhile, female hospitalists gave just 26% of presentations at national meetings, were first authors on only 33% of publications, and were senior authors on only 21% of manuscripts.3
In addition, Dr. Farnan and Dr. Arora wrote in their review, another recent survey of female physicians – primarily internists – found that 36% reported discrimination based on pregnancy, maternity leave, or breastfeeding. This was – at least in part, Dr. Farnan said – because “physician-mothers were not present at the table when discussions were held about scheduling.”
And while hospitalists have relatively flexible schedules, they can be unforgiving when it comes to traditional child care arrangements, Dr. Arora said.
But, there is hope, particularly within the Society of Hospital Medicine, Dr. Arora and Dr. Farnan wrote. The organization has seen an increase in female leadership – including its president-elect Nasim Afsar, MD, MBA, SFHM – and a board of directors that is split evenly between men and women. Mentorship of junior women is also on the rise, which allows opportunities for senior female physicians to teach younger women how to better negotiate and advocate for themselves.
“I think it has to come from both sides. Leadership does need to recognize that women may be less aggressive in their negotiating skills,” said Dr. Farnan. “But I think there also needs to be some recognition by women that it is okay to ask for more money.”
But it isn’t all about money, she said. “It can be negotiating for anything important in career development, career opportunities, research opportunities.” This also extends to schedule flexibility, training and more.
Leadership in hospitalist groups can help, Dr. Arora and Dr. Farnan wrote in their Annals article, by providing schedule flexibility, support for training, and structured on-boarding for new faculty. Citing efforts in other specialties such as cardiology and general surgery, female hospitalists may benefit from negotiation skills training, structured mentorship, and education around personal and professional development.
However, both physicians recognize the challenges of implicit bias and stereotype threat that may confront many women. For example, women who exert more stereotypically “male” traits such as assertiveness and confidence may face a “harsh likability penalty because they are going against gender norms,” said Dr. Arora.
Being taken seriously
Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.4
“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”
In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.
“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.
“If patients don’t trust the care they are given, it can impact outcomes,” she added. “There is a lot to being a hospitalist that is diagnostic, such as finding the correct diagnosis and implementing the appropriate treatment. However, beyond that, a huge part of this role is to be a knowledgeable caregiver, someone who guides a patient through the experience of being ill in a complex medical system. This requires immense trust.”
Dr. Reiff-Pasarew also believes better mentoring and feedback opportunities would benefit female physicians and trainees. “I often see that equally knowledgeable female trainees and medical students are much more self-deprecating when presenting research,” she said. “They give disclaimers that they don’t know enough, while their male peers are more confident.”
She is quick, however, not to blame women, largely because the same social pressures that Dr. Arora and Dr. Farnan acknowledged may have molded their behaviors. “I meet with residents to talk explicitly about situations where they are treated inappropriately by patients or other staff,” Dr. Reiff-Pasarew said. “We discuss how they might react in those situations in the future and how they can process these challenges.”
Modern American culture equips men and women with “different essential skill sets,” Dr. Reiff-Pasarew noted, but she suggested men and women can learn from one another. “We should be teaching men to be more empathetic listeners, a skill that is generally taught to girls. Similarly, we need to teach women confidence, a skill predominantly taught to boys.”
Just as important, male clinicians should believe in and trust the experiences that women report having, Dr. Reiff-Pasarew said. “It’s very difficult to understand the subtleties of how people are treated differently in patient interactions if you’ve never been in that situation.”
Equal compensation for equal work
Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.
“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”
Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”
Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.5
“Here is evidence that women may be doing a modestly better job than men in terms of outcomes,” Dr. Jena said. “If we are in the business of underpaying and underrewarding females, we are disincentivizing female physicians from entering the field, and in certain specialties female physicians see better patient outcomes.”
Dr. Arora and Dr. Farnan are optimistic that as more studies like those by Dr. Jena and colleagues are published – utilizing large data sets never before available, which account for many of the factors that have been used to justify pay and leadership disparities in the past – times will change for the better.
“There comes a time when everyone realizes a group has been wronged and it’s time to right it. I think now is the time for women. It’s tragic it’s come so late but I’m glad it’s here,” Dr. Arora said. “A lot of work is being done on the ground and in institutions to promote women leaders, to include women in search committees, and improve pay. These are always difficult discussions but now we can have transparency in salaries and we can we discuss them.”
However, Dr. Arora is also concerned about blowback, particularly as issues of sexual harassment of women in the workplace finally emerge from the shadows. “The blowback may be that more people tiptoe around women and are more cautious around them,” she said. “This could end up hurting women in the workplace. Something so deeply cemented like this doesn’t die easily and I think it requires culture change. I do think we’re on that journey and starting to see things change.”
But the real measure of that, said Dr. Farnan, is when these conversations are no longer taking place.
“We will know we’ve achieved what we want to achieve when we don’t have to discuss this anymore,” she said. “We will know we’ve achieved parity when we stop talking about it.”
References
1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.
2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.
4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.
5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.
It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.
“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”
That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.1
Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”2
In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.
“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.
Fueling the conversation
When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.”
“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”
Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.
“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”
A 2015 study in the Journal of Hospital Medicine found that just 16% of university hospital medicine divisions were led by women, and women made up just 28% of those physicians leading general internal medicine divisions. Meanwhile, female hospitalists gave just 26% of presentations at national meetings, were first authors on only 33% of publications, and were senior authors on only 21% of manuscripts.3
In addition, Dr. Farnan and Dr. Arora wrote in their review, another recent survey of female physicians – primarily internists – found that 36% reported discrimination based on pregnancy, maternity leave, or breastfeeding. This was – at least in part, Dr. Farnan said – because “physician-mothers were not present at the table when discussions were held about scheduling.”
And while hospitalists have relatively flexible schedules, they can be unforgiving when it comes to traditional child care arrangements, Dr. Arora said.
But, there is hope, particularly within the Society of Hospital Medicine, Dr. Arora and Dr. Farnan wrote. The organization has seen an increase in female leadership – including its president-elect Nasim Afsar, MD, MBA, SFHM – and a board of directors that is split evenly between men and women. Mentorship of junior women is also on the rise, which allows opportunities for senior female physicians to teach younger women how to better negotiate and advocate for themselves.
“I think it has to come from both sides. Leadership does need to recognize that women may be less aggressive in their negotiating skills,” said Dr. Farnan. “But I think there also needs to be some recognition by women that it is okay to ask for more money.”
But it isn’t all about money, she said. “It can be negotiating for anything important in career development, career opportunities, research opportunities.” This also extends to schedule flexibility, training and more.
Leadership in hospitalist groups can help, Dr. Arora and Dr. Farnan wrote in their Annals article, by providing schedule flexibility, support for training, and structured on-boarding for new faculty. Citing efforts in other specialties such as cardiology and general surgery, female hospitalists may benefit from negotiation skills training, structured mentorship, and education around personal and professional development.
However, both physicians recognize the challenges of implicit bias and stereotype threat that may confront many women. For example, women who exert more stereotypically “male” traits such as assertiveness and confidence may face a “harsh likability penalty because they are going against gender norms,” said Dr. Arora.
Being taken seriously
Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.4
“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”
In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.
“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.
“If patients don’t trust the care they are given, it can impact outcomes,” she added. “There is a lot to being a hospitalist that is diagnostic, such as finding the correct diagnosis and implementing the appropriate treatment. However, beyond that, a huge part of this role is to be a knowledgeable caregiver, someone who guides a patient through the experience of being ill in a complex medical system. This requires immense trust.”
Dr. Reiff-Pasarew also believes better mentoring and feedback opportunities would benefit female physicians and trainees. “I often see that equally knowledgeable female trainees and medical students are much more self-deprecating when presenting research,” she said. “They give disclaimers that they don’t know enough, while their male peers are more confident.”
She is quick, however, not to blame women, largely because the same social pressures that Dr. Arora and Dr. Farnan acknowledged may have molded their behaviors. “I meet with residents to talk explicitly about situations where they are treated inappropriately by patients or other staff,” Dr. Reiff-Pasarew said. “We discuss how they might react in those situations in the future and how they can process these challenges.”
Modern American culture equips men and women with “different essential skill sets,” Dr. Reiff-Pasarew noted, but she suggested men and women can learn from one another. “We should be teaching men to be more empathetic listeners, a skill that is generally taught to girls. Similarly, we need to teach women confidence, a skill predominantly taught to boys.”
Just as important, male clinicians should believe in and trust the experiences that women report having, Dr. Reiff-Pasarew said. “It’s very difficult to understand the subtleties of how people are treated differently in patient interactions if you’ve never been in that situation.”
Equal compensation for equal work
Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.
“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”
Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”
Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.5
“Here is evidence that women may be doing a modestly better job than men in terms of outcomes,” Dr. Jena said. “If we are in the business of underpaying and underrewarding females, we are disincentivizing female physicians from entering the field, and in certain specialties female physicians see better patient outcomes.”
Dr. Arora and Dr. Farnan are optimistic that as more studies like those by Dr. Jena and colleagues are published – utilizing large data sets never before available, which account for many of the factors that have been used to justify pay and leadership disparities in the past – times will change for the better.
“There comes a time when everyone realizes a group has been wronged and it’s time to right it. I think now is the time for women. It’s tragic it’s come so late but I’m glad it’s here,” Dr. Arora said. “A lot of work is being done on the ground and in institutions to promote women leaders, to include women in search committees, and improve pay. These are always difficult discussions but now we can have transparency in salaries and we can we discuss them.”
However, Dr. Arora is also concerned about blowback, particularly as issues of sexual harassment of women in the workplace finally emerge from the shadows. “The blowback may be that more people tiptoe around women and are more cautious around them,” she said. “This could end up hurting women in the workplace. Something so deeply cemented like this doesn’t die easily and I think it requires culture change. I do think we’re on that journey and starting to see things change.”
But the real measure of that, said Dr. Farnan, is when these conversations are no longer taking place.
“We will know we’ve achieved what we want to achieve when we don’t have to discuss this anymore,” she said. “We will know we’ve achieved parity when we stop talking about it.”
References
1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.
2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.
4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.
5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.
It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.
“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”
That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.1
Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”2
In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.
“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.
Fueling the conversation
When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.”
“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”
Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.
“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”
A 2015 study in the Journal of Hospital Medicine found that just 16% of university hospital medicine divisions were led by women, and women made up just 28% of those physicians leading general internal medicine divisions. Meanwhile, female hospitalists gave just 26% of presentations at national meetings, were first authors on only 33% of publications, and were senior authors on only 21% of manuscripts.3
In addition, Dr. Farnan and Dr. Arora wrote in their review, another recent survey of female physicians – primarily internists – found that 36% reported discrimination based on pregnancy, maternity leave, or breastfeeding. This was – at least in part, Dr. Farnan said – because “physician-mothers were not present at the table when discussions were held about scheduling.”
And while hospitalists have relatively flexible schedules, they can be unforgiving when it comes to traditional child care arrangements, Dr. Arora said.
But, there is hope, particularly within the Society of Hospital Medicine, Dr. Arora and Dr. Farnan wrote. The organization has seen an increase in female leadership – including its president-elect Nasim Afsar, MD, MBA, SFHM – and a board of directors that is split evenly between men and women. Mentorship of junior women is also on the rise, which allows opportunities for senior female physicians to teach younger women how to better negotiate and advocate for themselves.
“I think it has to come from both sides. Leadership does need to recognize that women may be less aggressive in their negotiating skills,” said Dr. Farnan. “But I think there also needs to be some recognition by women that it is okay to ask for more money.”
But it isn’t all about money, she said. “It can be negotiating for anything important in career development, career opportunities, research opportunities.” This also extends to schedule flexibility, training and more.
Leadership in hospitalist groups can help, Dr. Arora and Dr. Farnan wrote in their Annals article, by providing schedule flexibility, support for training, and structured on-boarding for new faculty. Citing efforts in other specialties such as cardiology and general surgery, female hospitalists may benefit from negotiation skills training, structured mentorship, and education around personal and professional development.
However, both physicians recognize the challenges of implicit bias and stereotype threat that may confront many women. For example, women who exert more stereotypically “male” traits such as assertiveness and confidence may face a “harsh likability penalty because they are going against gender norms,” said Dr. Arora.
Being taken seriously
Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.4
“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”
In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.
“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.
“If patients don’t trust the care they are given, it can impact outcomes,” she added. “There is a lot to being a hospitalist that is diagnostic, such as finding the correct diagnosis and implementing the appropriate treatment. However, beyond that, a huge part of this role is to be a knowledgeable caregiver, someone who guides a patient through the experience of being ill in a complex medical system. This requires immense trust.”
Dr. Reiff-Pasarew also believes better mentoring and feedback opportunities would benefit female physicians and trainees. “I often see that equally knowledgeable female trainees and medical students are much more self-deprecating when presenting research,” she said. “They give disclaimers that they don’t know enough, while their male peers are more confident.”
She is quick, however, not to blame women, largely because the same social pressures that Dr. Arora and Dr. Farnan acknowledged may have molded their behaviors. “I meet with residents to talk explicitly about situations where they are treated inappropriately by patients or other staff,” Dr. Reiff-Pasarew said. “We discuss how they might react in those situations in the future and how they can process these challenges.”
Modern American culture equips men and women with “different essential skill sets,” Dr. Reiff-Pasarew noted, but she suggested men and women can learn from one another. “We should be teaching men to be more empathetic listeners, a skill that is generally taught to girls. Similarly, we need to teach women confidence, a skill predominantly taught to boys.”
Just as important, male clinicians should believe in and trust the experiences that women report having, Dr. Reiff-Pasarew said. “It’s very difficult to understand the subtleties of how people are treated differently in patient interactions if you’ve never been in that situation.”
Equal compensation for equal work
Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.
“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”
Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”
Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.5
“Here is evidence that women may be doing a modestly better job than men in terms of outcomes,” Dr. Jena said. “If we are in the business of underpaying and underrewarding females, we are disincentivizing female physicians from entering the field, and in certain specialties female physicians see better patient outcomes.”
Dr. Arora and Dr. Farnan are optimistic that as more studies like those by Dr. Jena and colleagues are published – utilizing large data sets never before available, which account for many of the factors that have been used to justify pay and leadership disparities in the past – times will change for the better.
“There comes a time when everyone realizes a group has been wronged and it’s time to right it. I think now is the time for women. It’s tragic it’s come so late but I’m glad it’s here,” Dr. Arora said. “A lot of work is being done on the ground and in institutions to promote women leaders, to include women in search committees, and improve pay. These are always difficult discussions but now we can have transparency in salaries and we can we discuss them.”
However, Dr. Arora is also concerned about blowback, particularly as issues of sexual harassment of women in the workplace finally emerge from the shadows. “The blowback may be that more people tiptoe around women and are more cautious around them,” she said. “This could end up hurting women in the workplace. Something so deeply cemented like this doesn’t die easily and I think it requires culture change. I do think we’re on that journey and starting to see things change.”
But the real measure of that, said Dr. Farnan, is when these conversations are no longer taking place.
“We will know we’ve achieved what we want to achieve when we don’t have to discuss this anymore,” she said. “We will know we’ve achieved parity when we stop talking about it.”
References
1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.
2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.
4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.
5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.
The ‘holy grail’ of thrombosis prevention
SAN DIEGO – The “holy grail” of thrombosis prevention is the ability to determine the risk of recurrence with or without continuation of anticoagulant treatment, according to Philip S. Wells, MD.
“Very little data exists for the comparison of active treatment to placebo in the acute and long-term phases of treatment,” he said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “With low molecular weight heparin, vitamin K antagonists, and direct-acting oral anticoagulants, the relative risk reduction is about 90% in the acute phase and 80%-85% in the extended phase. After discontinuing anticoagulants, the absolute risk of recurrence varies depending on VTE category.”
Dr. Wells, chair and chief of the department of medicine at The Ottawa Hospital and the University of Ottawa, said that after 3 months of anticoagulation the chance of recurrence in postsurgical VTE patients is less than 1% per year. After 3 months of anticoagulant use in nonsurgical patients with provoked risk factors, it is around 4%. This includes medical patients, trauma victims, pregnant women, and patients wearing a plaster cast.
In patients who survive an unprovoked VTE, after 3-6 months of anticoagulant therapy their overall recurrence risk is 10% in the first year and 30% after 5 years. The risk of recurrence is 50% higher if a patient experiences a second unprovoked VTE, and the risk of fatality is 50% higher if the initial event was a pulmonary embolism (PE), he said.
According to the ongoing prospective Austrian Study on Recurrent Venous Thromboembolism, the risk of recurrent VTE is 20% in men and 6% in women (N Engl J Med. 2004 Jun 17;350[25]:2558-63). A multicenter prospective study in Canada yielded similar results. It found that the risk of recurrent VTE is 19% in men versus 9% in women (CMAJ 2008;179[5]:417-26).
That Canadian prospective study, led by Marc Rodger, MD, described the development of the HERDOO2 clinical decision rule for determining a patient’s risk for a recurrent VTE. This includes hyperpigmentation, edema, or redness in either leg (signs of postthrombotic syndrome), D-dimer level of 250 mcg/L or greater while on warfarin, body mass index of 30 kg/m2 or greater, and age of 65 years or older.
If patients have zero or one risk factor, the annual risk of VTE after 6 months of treatment is 1.6%, while two or more risk factors bumps the annual risk of VTE to 14.1%, according to the researchers.
In a subsequent study to validate the HERDOO2, researchers found that the risk of recurrent major VTE was 3.0% in low-risk women who discontinued oral anticoagulants (OACs), 8.1% in high-risk women and men who discontinued OACs, 1.6% in high-risk women and men who continued OACs, and 7.4% in high-risk women who discontinued OACs (BMJ 2017;356:j1065).
“I think the HERDOO2 rule is working pretty well to determine a low-risk group of women, and it’s not an unreasonable tool to be using,” Dr. Wells said.
Other variables that might help clinicians predict a patient’s VTE recurrence include the presence of recurrent venous obstruction (adjusted HR 1.32), and older age (HR 1.01 for every 1 year increase).
D-dimer levels can also be helpful. “If the serial D-dimers are positive, stay on anticoagulants,” Dr. Wells advised. “If they’re negative, discontinue anticoagulants and have the D-dimer levels repeated monthly for 3 months. If positive or positive conversions, return to OAC therapy.”
In one study, the annual risk of a VTE was 3% in the negative D-dimer patients, compared with 6.1% in those who had a history of an unprovoked VTE (Blood 2014;124:196-203).
In a separate study of 319 patients with two negative D-dimer results who did not restart anticoagulation therapy, the rate of recurrent VTE was 6.7% per patient-year (Ann Intern Med 2015;162:27-34). It was 9.7% per patient-year in men, compared with 5.4% per patient-year in women.
Dr. Wells emphasized the importance of shared decision-making with the patient when devising a strategy for long-term anticoagulation following a VTE. “We don’t have a lot of good tools, but [trying to elicit] patient preference is the right thing to try and do,” he said. “Physicians should present an unbiased perspective to patients regarding their treatment, including the benefits and harms, effect on quality of life, and cost.”
Dr. Wells also shared his current clinical approach. In women with an unprovoked VTE, he applies the HERDOO2 rule. If there’s a low recurrence risk, he discontinues the anticoagulant. If there’s a non-low recurrence risk he continues with the anticoagulant unless there’s a high risk for bleeding. Men with an unprovoked VTE receive indefinite anticoagulant therapy, but if the index event is a deep vein thrombosis (DVT), Dr. Wells applies a bleeding risk tool to help him determine management going forward. If the patient has a high risk of bleeding, he does not use an anticoagulant.
“If there is a high risk of bleeding it’s best of stay off anticoagulant therapy,” he said. “If there is an intermediate risk of bleeding and the index event was a DVT, the patient could stay off anticoagulants. I think we have a long way to go to developing tools that actually enable us to reach these points with each patient in discussions we have with them about continuing anticoagulants.”
Dr. Wells reported having received research support from BMS/Pfizer and honoraria from Bayer AG, Janssen, Pfizer, and Daiichi Sankyo. He is a member of the scientific advisory board for Bayer AG and Pfizer.
SAN DIEGO – The “holy grail” of thrombosis prevention is the ability to determine the risk of recurrence with or without continuation of anticoagulant treatment, according to Philip S. Wells, MD.
“Very little data exists for the comparison of active treatment to placebo in the acute and long-term phases of treatment,” he said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “With low molecular weight heparin, vitamin K antagonists, and direct-acting oral anticoagulants, the relative risk reduction is about 90% in the acute phase and 80%-85% in the extended phase. After discontinuing anticoagulants, the absolute risk of recurrence varies depending on VTE category.”
Dr. Wells, chair and chief of the department of medicine at The Ottawa Hospital and the University of Ottawa, said that after 3 months of anticoagulation the chance of recurrence in postsurgical VTE patients is less than 1% per year. After 3 months of anticoagulant use in nonsurgical patients with provoked risk factors, it is around 4%. This includes medical patients, trauma victims, pregnant women, and patients wearing a plaster cast.
In patients who survive an unprovoked VTE, after 3-6 months of anticoagulant therapy their overall recurrence risk is 10% in the first year and 30% after 5 years. The risk of recurrence is 50% higher if a patient experiences a second unprovoked VTE, and the risk of fatality is 50% higher if the initial event was a pulmonary embolism (PE), he said.
According to the ongoing prospective Austrian Study on Recurrent Venous Thromboembolism, the risk of recurrent VTE is 20% in men and 6% in women (N Engl J Med. 2004 Jun 17;350[25]:2558-63). A multicenter prospective study in Canada yielded similar results. It found that the risk of recurrent VTE is 19% in men versus 9% in women (CMAJ 2008;179[5]:417-26).
That Canadian prospective study, led by Marc Rodger, MD, described the development of the HERDOO2 clinical decision rule for determining a patient’s risk for a recurrent VTE. This includes hyperpigmentation, edema, or redness in either leg (signs of postthrombotic syndrome), D-dimer level of 250 mcg/L or greater while on warfarin, body mass index of 30 kg/m2 or greater, and age of 65 years or older.
If patients have zero or one risk factor, the annual risk of VTE after 6 months of treatment is 1.6%, while two or more risk factors bumps the annual risk of VTE to 14.1%, according to the researchers.
In a subsequent study to validate the HERDOO2, researchers found that the risk of recurrent major VTE was 3.0% in low-risk women who discontinued oral anticoagulants (OACs), 8.1% in high-risk women and men who discontinued OACs, 1.6% in high-risk women and men who continued OACs, and 7.4% in high-risk women who discontinued OACs (BMJ 2017;356:j1065).
“I think the HERDOO2 rule is working pretty well to determine a low-risk group of women, and it’s not an unreasonable tool to be using,” Dr. Wells said.
Other variables that might help clinicians predict a patient’s VTE recurrence include the presence of recurrent venous obstruction (adjusted HR 1.32), and older age (HR 1.01 for every 1 year increase).
D-dimer levels can also be helpful. “If the serial D-dimers are positive, stay on anticoagulants,” Dr. Wells advised. “If they’re negative, discontinue anticoagulants and have the D-dimer levels repeated monthly for 3 months. If positive or positive conversions, return to OAC therapy.”
In one study, the annual risk of a VTE was 3% in the negative D-dimer patients, compared with 6.1% in those who had a history of an unprovoked VTE (Blood 2014;124:196-203).
In a separate study of 319 patients with two negative D-dimer results who did not restart anticoagulation therapy, the rate of recurrent VTE was 6.7% per patient-year (Ann Intern Med 2015;162:27-34). It was 9.7% per patient-year in men, compared with 5.4% per patient-year in women.
Dr. Wells emphasized the importance of shared decision-making with the patient when devising a strategy for long-term anticoagulation following a VTE. “We don’t have a lot of good tools, but [trying to elicit] patient preference is the right thing to try and do,” he said. “Physicians should present an unbiased perspective to patients regarding their treatment, including the benefits and harms, effect on quality of life, and cost.”
Dr. Wells also shared his current clinical approach. In women with an unprovoked VTE, he applies the HERDOO2 rule. If there’s a low recurrence risk, he discontinues the anticoagulant. If there’s a non-low recurrence risk he continues with the anticoagulant unless there’s a high risk for bleeding. Men with an unprovoked VTE receive indefinite anticoagulant therapy, but if the index event is a deep vein thrombosis (DVT), Dr. Wells applies a bleeding risk tool to help him determine management going forward. If the patient has a high risk of bleeding, he does not use an anticoagulant.
“If there is a high risk of bleeding it’s best of stay off anticoagulant therapy,” he said. “If there is an intermediate risk of bleeding and the index event was a DVT, the patient could stay off anticoagulants. I think we have a long way to go to developing tools that actually enable us to reach these points with each patient in discussions we have with them about continuing anticoagulants.”
Dr. Wells reported having received research support from BMS/Pfizer and honoraria from Bayer AG, Janssen, Pfizer, and Daiichi Sankyo. He is a member of the scientific advisory board for Bayer AG and Pfizer.
SAN DIEGO – The “holy grail” of thrombosis prevention is the ability to determine the risk of recurrence with or without continuation of anticoagulant treatment, according to Philip S. Wells, MD.
“Very little data exists for the comparison of active treatment to placebo in the acute and long-term phases of treatment,” he said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “With low molecular weight heparin, vitamin K antagonists, and direct-acting oral anticoagulants, the relative risk reduction is about 90% in the acute phase and 80%-85% in the extended phase. After discontinuing anticoagulants, the absolute risk of recurrence varies depending on VTE category.”
Dr. Wells, chair and chief of the department of medicine at The Ottawa Hospital and the University of Ottawa, said that after 3 months of anticoagulation the chance of recurrence in postsurgical VTE patients is less than 1% per year. After 3 months of anticoagulant use in nonsurgical patients with provoked risk factors, it is around 4%. This includes medical patients, trauma victims, pregnant women, and patients wearing a plaster cast.
In patients who survive an unprovoked VTE, after 3-6 months of anticoagulant therapy their overall recurrence risk is 10% in the first year and 30% after 5 years. The risk of recurrence is 50% higher if a patient experiences a second unprovoked VTE, and the risk of fatality is 50% higher if the initial event was a pulmonary embolism (PE), he said.
According to the ongoing prospective Austrian Study on Recurrent Venous Thromboembolism, the risk of recurrent VTE is 20% in men and 6% in women (N Engl J Med. 2004 Jun 17;350[25]:2558-63). A multicenter prospective study in Canada yielded similar results. It found that the risk of recurrent VTE is 19% in men versus 9% in women (CMAJ 2008;179[5]:417-26).
That Canadian prospective study, led by Marc Rodger, MD, described the development of the HERDOO2 clinical decision rule for determining a patient’s risk for a recurrent VTE. This includes hyperpigmentation, edema, or redness in either leg (signs of postthrombotic syndrome), D-dimer level of 250 mcg/L or greater while on warfarin, body mass index of 30 kg/m2 or greater, and age of 65 years or older.
If patients have zero or one risk factor, the annual risk of VTE after 6 months of treatment is 1.6%, while two or more risk factors bumps the annual risk of VTE to 14.1%, according to the researchers.
In a subsequent study to validate the HERDOO2, researchers found that the risk of recurrent major VTE was 3.0% in low-risk women who discontinued oral anticoagulants (OACs), 8.1% in high-risk women and men who discontinued OACs, 1.6% in high-risk women and men who continued OACs, and 7.4% in high-risk women who discontinued OACs (BMJ 2017;356:j1065).
“I think the HERDOO2 rule is working pretty well to determine a low-risk group of women, and it’s not an unreasonable tool to be using,” Dr. Wells said.
Other variables that might help clinicians predict a patient’s VTE recurrence include the presence of recurrent venous obstruction (adjusted HR 1.32), and older age (HR 1.01 for every 1 year increase).
D-dimer levels can also be helpful. “If the serial D-dimers are positive, stay on anticoagulants,” Dr. Wells advised. “If they’re negative, discontinue anticoagulants and have the D-dimer levels repeated monthly for 3 months. If positive or positive conversions, return to OAC therapy.”
In one study, the annual risk of a VTE was 3% in the negative D-dimer patients, compared with 6.1% in those who had a history of an unprovoked VTE (Blood 2014;124:196-203).
In a separate study of 319 patients with two negative D-dimer results who did not restart anticoagulation therapy, the rate of recurrent VTE was 6.7% per patient-year (Ann Intern Med 2015;162:27-34). It was 9.7% per patient-year in men, compared with 5.4% per patient-year in women.
Dr. Wells emphasized the importance of shared decision-making with the patient when devising a strategy for long-term anticoagulation following a VTE. “We don’t have a lot of good tools, but [trying to elicit] patient preference is the right thing to try and do,” he said. “Physicians should present an unbiased perspective to patients regarding their treatment, including the benefits and harms, effect on quality of life, and cost.”
Dr. Wells also shared his current clinical approach. In women with an unprovoked VTE, he applies the HERDOO2 rule. If there’s a low recurrence risk, he discontinues the anticoagulant. If there’s a non-low recurrence risk he continues with the anticoagulant unless there’s a high risk for bleeding. Men with an unprovoked VTE receive indefinite anticoagulant therapy, but if the index event is a deep vein thrombosis (DVT), Dr. Wells applies a bleeding risk tool to help him determine management going forward. If the patient has a high risk of bleeding, he does not use an anticoagulant.
“If there is a high risk of bleeding it’s best of stay off anticoagulant therapy,” he said. “If there is an intermediate risk of bleeding and the index event was a DVT, the patient could stay off anticoagulants. I think we have a long way to go to developing tools that actually enable us to reach these points with each patient in discussions we have with them about continuing anticoagulants.”
Dr. Wells reported having received research support from BMS/Pfizer and honoraria from Bayer AG, Janssen, Pfizer, and Daiichi Sankyo. He is a member of the scientific advisory board for Bayer AG and Pfizer.
EXPERT ANALYSIS FROM THSNA 2018
Liability claims from cutaneous laser surgery continue to rise
DALLAS – , and the average indemnity claim is close to $320,000, results from an analysis of national data have shown.
“Physicians seeking to undertake laser surgery in their practice should ensure they have proper training in the physics, safety, and techniques of each procedure,” study author Saami Khalifian, MD, said in an interview in advance of the annual meeting of the American Society for Laser Medicine and Surgery. “Legal precedent has demonstrated that nonphysicians performing laser surgery will likely be held to a standard of care and training corresponding to a physician with appropriate training. Therefore, physicians who delegate laser operations to their nonphysician agents are ultimately responsible for the actions of their agents.”
For the period between June 2012 and December 2017, Dr. Khalifian and his colleagues identified 32 cases with public decision related to injury secondary to cutaneous laser surgery. The incidence of litigation related to laser surgery demonstrates an increasing trend since 1985, with peak occurrence in 2010 (total of 22 cases, which represents 10.7% of 206 cases reported in the entire data set since 1985). Laser hair removal was the most common litigated procedure prior to 2012, but since then has been surpassed by laser rejuvenation, which includes ablative and nonablative resurfacing, fractionated lasers, and intense pulsed light (47% of cases since mid-2012). Nonphysician operators accounted for a substantial subset of these cases (66% of all cases since mid-2012), with their physician supervisors named as defendants, despite not performing the procedure.
Dr. Khalifian noted that medical spas in the study “uniformly had unsupervised nonphysician operators in nonmedical office settings,” and therefore “had one of the highest litigation rates and number of cases. What is interesting about this, however, is that medical spas that are run by nonphysicians are also less likely to have medical liability insurance to satisfy a potential malpractice claim and therefore would be less likely to be pursued by a plaintiff’s attorney. Despite this, they had one of the highest patient injury rates, which is likely underrepresented based on the lack of malpractice insurance to be pursued in a legal claim.”
The researchers also found that delegated procedures were most frequently litigated against regardless of subspecialty of supervising physician (66%). Of the preventable causes of action, the most common was failure to obtain an informed consent (34%) and negligence (50%). Of the 32 cases with public decisions, 17 (53.1%) resulted in decisions in favor of the plaintiff. The mean indemnity payment was $318,832.
“Our current work evaluating data from 2012-2017 is consistent with our prior work dating back to 1985 and demonstrates again that nonphysician operators account for the majority of cases of legal action,” Dr. Khalifian said. “In fact, there is an increasing trend since about 2008 for a higher proportion of cases being performed by physician extenders and nonphysician operators. Despite physicians acting as supervisors and not the actual laser operator they are nonetheless named as defendants in legal claims,” he added.
The data on allegations and causes of legal action “should serve as a guide to help improve patient safety and decrease professional liability,” he pointed out. “It is critical that physicians take steps to mitigate risk to patients by ensuring robust and adequate training for their agents and by directly supervising procedures. However, the data clearly show that the safest treatments are performed directly by physicians who have had such dedicated training in laser and light sources.”
Dr. Khalifian acknowledged certain limitations of the study, including the fact that the data were extracted from only one legal database and did not include cases settled outside of the justice system through third-party arbitration or other means. “It is also limited by search terms in our query,” he said. “It is possible that some cases did not include the terms we used. Finally, only incomplete information was available for some cases even when supplemented through other resources and additional research.”
He reported having no financial disclosures. Study coauthor Mathew M. Avram, MD, JD, serves on the medical advisory board of Sciton and on the scientific advisory boards of Sienna Biopharmaceuticals, Cytrellis, and Allergan. He is also consultant for Merz Aesthetics, Allergan, Soliton, Invasix, and Revance, and has intellectual property with Cytrellis. He also holds stock options with Cytrellis, Invasix, and Zalea.
SOURCE: Khalifian et al. ASLMS 2018.
DALLAS – , and the average indemnity claim is close to $320,000, results from an analysis of national data have shown.
“Physicians seeking to undertake laser surgery in their practice should ensure they have proper training in the physics, safety, and techniques of each procedure,” study author Saami Khalifian, MD, said in an interview in advance of the annual meeting of the American Society for Laser Medicine and Surgery. “Legal precedent has demonstrated that nonphysicians performing laser surgery will likely be held to a standard of care and training corresponding to a physician with appropriate training. Therefore, physicians who delegate laser operations to their nonphysician agents are ultimately responsible for the actions of their agents.”
For the period between June 2012 and December 2017, Dr. Khalifian and his colleagues identified 32 cases with public decision related to injury secondary to cutaneous laser surgery. The incidence of litigation related to laser surgery demonstrates an increasing trend since 1985, with peak occurrence in 2010 (total of 22 cases, which represents 10.7% of 206 cases reported in the entire data set since 1985). Laser hair removal was the most common litigated procedure prior to 2012, but since then has been surpassed by laser rejuvenation, which includes ablative and nonablative resurfacing, fractionated lasers, and intense pulsed light (47% of cases since mid-2012). Nonphysician operators accounted for a substantial subset of these cases (66% of all cases since mid-2012), with their physician supervisors named as defendants, despite not performing the procedure.
Dr. Khalifian noted that medical spas in the study “uniformly had unsupervised nonphysician operators in nonmedical office settings,” and therefore “had one of the highest litigation rates and number of cases. What is interesting about this, however, is that medical spas that are run by nonphysicians are also less likely to have medical liability insurance to satisfy a potential malpractice claim and therefore would be less likely to be pursued by a plaintiff’s attorney. Despite this, they had one of the highest patient injury rates, which is likely underrepresented based on the lack of malpractice insurance to be pursued in a legal claim.”
The researchers also found that delegated procedures were most frequently litigated against regardless of subspecialty of supervising physician (66%). Of the preventable causes of action, the most common was failure to obtain an informed consent (34%) and negligence (50%). Of the 32 cases with public decisions, 17 (53.1%) resulted in decisions in favor of the plaintiff. The mean indemnity payment was $318,832.
“Our current work evaluating data from 2012-2017 is consistent with our prior work dating back to 1985 and demonstrates again that nonphysician operators account for the majority of cases of legal action,” Dr. Khalifian said. “In fact, there is an increasing trend since about 2008 for a higher proportion of cases being performed by physician extenders and nonphysician operators. Despite physicians acting as supervisors and not the actual laser operator they are nonetheless named as defendants in legal claims,” he added.
The data on allegations and causes of legal action “should serve as a guide to help improve patient safety and decrease professional liability,” he pointed out. “It is critical that physicians take steps to mitigate risk to patients by ensuring robust and adequate training for their agents and by directly supervising procedures. However, the data clearly show that the safest treatments are performed directly by physicians who have had such dedicated training in laser and light sources.”
Dr. Khalifian acknowledged certain limitations of the study, including the fact that the data were extracted from only one legal database and did not include cases settled outside of the justice system through third-party arbitration or other means. “It is also limited by search terms in our query,” he said. “It is possible that some cases did not include the terms we used. Finally, only incomplete information was available for some cases even when supplemented through other resources and additional research.”
He reported having no financial disclosures. Study coauthor Mathew M. Avram, MD, JD, serves on the medical advisory board of Sciton and on the scientific advisory boards of Sienna Biopharmaceuticals, Cytrellis, and Allergan. He is also consultant for Merz Aesthetics, Allergan, Soliton, Invasix, and Revance, and has intellectual property with Cytrellis. He also holds stock options with Cytrellis, Invasix, and Zalea.
SOURCE: Khalifian et al. ASLMS 2018.
DALLAS – , and the average indemnity claim is close to $320,000, results from an analysis of national data have shown.
“Physicians seeking to undertake laser surgery in their practice should ensure they have proper training in the physics, safety, and techniques of each procedure,” study author Saami Khalifian, MD, said in an interview in advance of the annual meeting of the American Society for Laser Medicine and Surgery. “Legal precedent has demonstrated that nonphysicians performing laser surgery will likely be held to a standard of care and training corresponding to a physician with appropriate training. Therefore, physicians who delegate laser operations to their nonphysician agents are ultimately responsible for the actions of their agents.”
For the period between June 2012 and December 2017, Dr. Khalifian and his colleagues identified 32 cases with public decision related to injury secondary to cutaneous laser surgery. The incidence of litigation related to laser surgery demonstrates an increasing trend since 1985, with peak occurrence in 2010 (total of 22 cases, which represents 10.7% of 206 cases reported in the entire data set since 1985). Laser hair removal was the most common litigated procedure prior to 2012, but since then has been surpassed by laser rejuvenation, which includes ablative and nonablative resurfacing, fractionated lasers, and intense pulsed light (47% of cases since mid-2012). Nonphysician operators accounted for a substantial subset of these cases (66% of all cases since mid-2012), with their physician supervisors named as defendants, despite not performing the procedure.
Dr. Khalifian noted that medical spas in the study “uniformly had unsupervised nonphysician operators in nonmedical office settings,” and therefore “had one of the highest litigation rates and number of cases. What is interesting about this, however, is that medical spas that are run by nonphysicians are also less likely to have medical liability insurance to satisfy a potential malpractice claim and therefore would be less likely to be pursued by a plaintiff’s attorney. Despite this, they had one of the highest patient injury rates, which is likely underrepresented based on the lack of malpractice insurance to be pursued in a legal claim.”
The researchers also found that delegated procedures were most frequently litigated against regardless of subspecialty of supervising physician (66%). Of the preventable causes of action, the most common was failure to obtain an informed consent (34%) and negligence (50%). Of the 32 cases with public decisions, 17 (53.1%) resulted in decisions in favor of the plaintiff. The mean indemnity payment was $318,832.
“Our current work evaluating data from 2012-2017 is consistent with our prior work dating back to 1985 and demonstrates again that nonphysician operators account for the majority of cases of legal action,” Dr. Khalifian said. “In fact, there is an increasing trend since about 2008 for a higher proportion of cases being performed by physician extenders and nonphysician operators. Despite physicians acting as supervisors and not the actual laser operator they are nonetheless named as defendants in legal claims,” he added.
The data on allegations and causes of legal action “should serve as a guide to help improve patient safety and decrease professional liability,” he pointed out. “It is critical that physicians take steps to mitigate risk to patients by ensuring robust and adequate training for their agents and by directly supervising procedures. However, the data clearly show that the safest treatments are performed directly by physicians who have had such dedicated training in laser and light sources.”
Dr. Khalifian acknowledged certain limitations of the study, including the fact that the data were extracted from only one legal database and did not include cases settled outside of the justice system through third-party arbitration or other means. “It is also limited by search terms in our query,” he said. “It is possible that some cases did not include the terms we used. Finally, only incomplete information was available for some cases even when supplemented through other resources and additional research.”
He reported having no financial disclosures. Study coauthor Mathew M. Avram, MD, JD, serves on the medical advisory board of Sciton and on the scientific advisory boards of Sienna Biopharmaceuticals, Cytrellis, and Allergan. He is also consultant for Merz Aesthetics, Allergan, Soliton, Invasix, and Revance, and has intellectual property with Cytrellis. He also holds stock options with Cytrellis, Invasix, and Zalea.
SOURCE: Khalifian et al. ASLMS 2018.
REPORTING FROM ASLMS 2018
Key clinical point: Claims related to cutaneous laser surgery are steadily increasing, as are the average indemnity payments.
Major finding: Among cases with public decision related to injury secondary to cutaneous laser surgery, nearly half since mid-2012 (47%) have been due to laser rejuvenation.
Study details: An analysis of 32 medical professional liability claims related to cutaneous laser surgery June 2012 through December 2017.
Disclosures: Dr. Khalifian reported having no financial disclosures. Study coauthor Mathew Avram, MD, serves on the medical advisory board of Sciton and on the scientific advisory boards of Sienna Biopharmaceuticals, Cytrellis, and Allergan. He is also consultant for Merz Aesthetics, Allergan, Soliton, Invasix, and Revance, and has intellectual property with Cytrellis. He also holds stock options with Cytrellis, Invasix, and Zalea.
Source: Khalifian et al. ASLMS 2018.
Psychiatric subspecialty is changing its name
Constantine G. Lyketsos, MD, remembers when the Academy of Psychosomatic Medicine held annual meetings that attracted 200. Now, the subspecialty organization’s meeting attracts about 1,000 people, and is getting a new name to reflect that growth.
“The field has grown substantially, and I think it will grow further with this name change,” said Dr. Lyketsos, who along with James L. Levenson, MD, spearheaded the effort to have the subspecialty recognized almost 20 years ago. “The field is the same. [But the] name change is going to change the way we are perceived by our primary customers – the patients. It will probably be a positive development for our trainees.”
The organization will be rebranded as the Academy of Consultation-Liaison Psychiatry. The name change, aimed in part at shedding the ambiguity around the word “psychosomatic” and better capturing the mission of consultation-liaison psychiatry, will be reflected across the group’s platforms. The tagline on the group’s journal, Psychosomatics, will become “The Journal of Consultation-Liaison Psychiatry,” and the theme of the group’s November 2018 annual meeting in Orlando will focus on the rebranding.
“I’m a consultation-liaison psychiatrist, and I think that clears the air from the very beginning,” said Dr. Lyketsos, professor and chair of psychiatry at Johns Hopkins Bayview in Baltimore.
Consultation-liaison psychiatrists work collaboratively with four groups of “complex medically ill” patients, Dr. Lyketsos, Dr. Levenson, and associates wrote a few years ago while advocating on behalf of the subspecialty. They treat patients with comorbid psychiatric and general medical illness; those with psychiatric illness directly tied to a primary medical condition, such as dementia or delirium; those with “complex illness behavior such as ‘somatoform’ disorders”; and those admitted to medical-surgical units after incidents such as attempted suicide. Consultation-liaison psychiatrists, who typically work in teaching hospitals, tend to provide services that are reactive – emergent or urgent (Eur J Psychiatry. 2006;20[3]:165-71).
Some think the field is limited to inpatient consultations, but it encompasses a “spectrum of physicians working at the interface between psychiatry and the other medical specialties, including many outpatient settings,” wrote Robert J. Boland, MD, academy President James R. Rundell, MD, and their associates (Psychosomatics. 2017. doi: 10.1016/j.psym.2017.11.006).
“Clinicians in consultation-liaison psychiatry face a wide breadth of conundrums and controversies in all areas of practice,” Dr. Rundell wrote in a recent newsletter. In addition to raising awareness among patients and medical-surgical colleagues, Dr. Rundell said, the academy hopes to educate other psychiatrists about the scope of consultation-liaison psychiatry.
The change will go into effect April 15.
Constantine G. Lyketsos, MD, remembers when the Academy of Psychosomatic Medicine held annual meetings that attracted 200. Now, the subspecialty organization’s meeting attracts about 1,000 people, and is getting a new name to reflect that growth.
“The field has grown substantially, and I think it will grow further with this name change,” said Dr. Lyketsos, who along with James L. Levenson, MD, spearheaded the effort to have the subspecialty recognized almost 20 years ago. “The field is the same. [But the] name change is going to change the way we are perceived by our primary customers – the patients. It will probably be a positive development for our trainees.”
The organization will be rebranded as the Academy of Consultation-Liaison Psychiatry. The name change, aimed in part at shedding the ambiguity around the word “psychosomatic” and better capturing the mission of consultation-liaison psychiatry, will be reflected across the group’s platforms. The tagline on the group’s journal, Psychosomatics, will become “The Journal of Consultation-Liaison Psychiatry,” and the theme of the group’s November 2018 annual meeting in Orlando will focus on the rebranding.
“I’m a consultation-liaison psychiatrist, and I think that clears the air from the very beginning,” said Dr. Lyketsos, professor and chair of psychiatry at Johns Hopkins Bayview in Baltimore.
Consultation-liaison psychiatrists work collaboratively with four groups of “complex medically ill” patients, Dr. Lyketsos, Dr. Levenson, and associates wrote a few years ago while advocating on behalf of the subspecialty. They treat patients with comorbid psychiatric and general medical illness; those with psychiatric illness directly tied to a primary medical condition, such as dementia or delirium; those with “complex illness behavior such as ‘somatoform’ disorders”; and those admitted to medical-surgical units after incidents such as attempted suicide. Consultation-liaison psychiatrists, who typically work in teaching hospitals, tend to provide services that are reactive – emergent or urgent (Eur J Psychiatry. 2006;20[3]:165-71).
Some think the field is limited to inpatient consultations, but it encompasses a “spectrum of physicians working at the interface between psychiatry and the other medical specialties, including many outpatient settings,” wrote Robert J. Boland, MD, academy President James R. Rundell, MD, and their associates (Psychosomatics. 2017. doi: 10.1016/j.psym.2017.11.006).
“Clinicians in consultation-liaison psychiatry face a wide breadth of conundrums and controversies in all areas of practice,” Dr. Rundell wrote in a recent newsletter. In addition to raising awareness among patients and medical-surgical colleagues, Dr. Rundell said, the academy hopes to educate other psychiatrists about the scope of consultation-liaison psychiatry.
The change will go into effect April 15.
Constantine G. Lyketsos, MD, remembers when the Academy of Psychosomatic Medicine held annual meetings that attracted 200. Now, the subspecialty organization’s meeting attracts about 1,000 people, and is getting a new name to reflect that growth.
“The field has grown substantially, and I think it will grow further with this name change,” said Dr. Lyketsos, who along with James L. Levenson, MD, spearheaded the effort to have the subspecialty recognized almost 20 years ago. “The field is the same. [But the] name change is going to change the way we are perceived by our primary customers – the patients. It will probably be a positive development for our trainees.”
The organization will be rebranded as the Academy of Consultation-Liaison Psychiatry. The name change, aimed in part at shedding the ambiguity around the word “psychosomatic” and better capturing the mission of consultation-liaison psychiatry, will be reflected across the group’s platforms. The tagline on the group’s journal, Psychosomatics, will become “The Journal of Consultation-Liaison Psychiatry,” and the theme of the group’s November 2018 annual meeting in Orlando will focus on the rebranding.
“I’m a consultation-liaison psychiatrist, and I think that clears the air from the very beginning,” said Dr. Lyketsos, professor and chair of psychiatry at Johns Hopkins Bayview in Baltimore.
Consultation-liaison psychiatrists work collaboratively with four groups of “complex medically ill” patients, Dr. Lyketsos, Dr. Levenson, and associates wrote a few years ago while advocating on behalf of the subspecialty. They treat patients with comorbid psychiatric and general medical illness; those with psychiatric illness directly tied to a primary medical condition, such as dementia or delirium; those with “complex illness behavior such as ‘somatoform’ disorders”; and those admitted to medical-surgical units after incidents such as attempted suicide. Consultation-liaison psychiatrists, who typically work in teaching hospitals, tend to provide services that are reactive – emergent or urgent (Eur J Psychiatry. 2006;20[3]:165-71).
Some think the field is limited to inpatient consultations, but it encompasses a “spectrum of physicians working at the interface between psychiatry and the other medical specialties, including many outpatient settings,” wrote Robert J. Boland, MD, academy President James R. Rundell, MD, and their associates (Psychosomatics. 2017. doi: 10.1016/j.psym.2017.11.006).
“Clinicians in consultation-liaison psychiatry face a wide breadth of conundrums and controversies in all areas of practice,” Dr. Rundell wrote in a recent newsletter. In addition to raising awareness among patients and medical-surgical colleagues, Dr. Rundell said, the academy hopes to educate other psychiatrists about the scope of consultation-liaison psychiatry.
The change will go into effect April 15.
Americans don’t know about cancer drug shortages – but want to be told
Most Americans are unaware of cancer drug shortages, according to the results of a nationally representative survey.
But most would want to know about drug substitutions with differences in efficacy or safety, reported Zachary A.K. Frosch, MD, of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, with his associates. Most also would transfer care to avoid receiving a substitution with substantially lower efficacy or safety, the researchers wrote in Cancer.
Drug shortages have plagued oncology for years. In a recent survey of U.S. oncologists who treated lung or colorectal cancer, 74% had experienced a shortage of at least one injectable therapy in the prior year, and 28% had used a less effective alternative as a result (J Oncol Pract. 2015;11:e152-62). However, little is known about public awareness and response to these shortages.
Therefore, the investigators used a 13-item instrument to survey 420 U.S. adults about their personal cancer history, as well as their knowledge and preferences regarding drug shortages and substitutions. Respondents were chosen randomly from a demographically representative online sample.
Only 16% of respondents said they were aware of drug shortages (including 31% of those with a personal cancer history and 14% of those without one), but more than 80% would want to be told about resultant substitutions with major or minor differences in safety or efficacy.
Furthermore, most respondents said they would transfer care to avoid a substitution: 72% for major efficacy differences and 61% for major safety differences. Respondents who were black, of low educational or socioeconomic level, uninsured, or unemployed were less likely to transfer care because of substitutions.
The findings show the need for more clinician-patient counseling about drug shortages, Dr. Frosch said in a media release.
“It can be stressful for patients with cancer to learn that their care may be impacted by drug shortages, but it’s important for oncologists to engage patients in these discussions,” he said. “Our data suggest that people expect disclosure of shortages as part of the caregiving process.”
More public awareness might also pressure stakeholders to tackle systemic failings underlying these drug shortages, he said. “It’s important that everyone – clinicians, patients, and the public – have a seat at the table as these strategies are developed.”
No specific funding was disclosed. The investigators reported no disclosures.
SOURCE: Frosch ZAK et al. Cancer. 2018 Apr 8. doi: 10.1002/cncr.31246.
Most Americans are unaware of cancer drug shortages, according to the results of a nationally representative survey.
But most would want to know about drug substitutions with differences in efficacy or safety, reported Zachary A.K. Frosch, MD, of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, with his associates. Most also would transfer care to avoid receiving a substitution with substantially lower efficacy or safety, the researchers wrote in Cancer.
Drug shortages have plagued oncology for years. In a recent survey of U.S. oncologists who treated lung or colorectal cancer, 74% had experienced a shortage of at least one injectable therapy in the prior year, and 28% had used a less effective alternative as a result (J Oncol Pract. 2015;11:e152-62). However, little is known about public awareness and response to these shortages.
Therefore, the investigators used a 13-item instrument to survey 420 U.S. adults about their personal cancer history, as well as their knowledge and preferences regarding drug shortages and substitutions. Respondents were chosen randomly from a demographically representative online sample.
Only 16% of respondents said they were aware of drug shortages (including 31% of those with a personal cancer history and 14% of those without one), but more than 80% would want to be told about resultant substitutions with major or minor differences in safety or efficacy.
Furthermore, most respondents said they would transfer care to avoid a substitution: 72% for major efficacy differences and 61% for major safety differences. Respondents who were black, of low educational or socioeconomic level, uninsured, or unemployed were less likely to transfer care because of substitutions.
The findings show the need for more clinician-patient counseling about drug shortages, Dr. Frosch said in a media release.
“It can be stressful for patients with cancer to learn that their care may be impacted by drug shortages, but it’s important for oncologists to engage patients in these discussions,” he said. “Our data suggest that people expect disclosure of shortages as part of the caregiving process.”
More public awareness might also pressure stakeholders to tackle systemic failings underlying these drug shortages, he said. “It’s important that everyone – clinicians, patients, and the public – have a seat at the table as these strategies are developed.”
No specific funding was disclosed. The investigators reported no disclosures.
SOURCE: Frosch ZAK et al. Cancer. 2018 Apr 8. doi: 10.1002/cncr.31246.
Most Americans are unaware of cancer drug shortages, according to the results of a nationally representative survey.
But most would want to know about drug substitutions with differences in efficacy or safety, reported Zachary A.K. Frosch, MD, of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, with his associates. Most also would transfer care to avoid receiving a substitution with substantially lower efficacy or safety, the researchers wrote in Cancer.
Drug shortages have plagued oncology for years. In a recent survey of U.S. oncologists who treated lung or colorectal cancer, 74% had experienced a shortage of at least one injectable therapy in the prior year, and 28% had used a less effective alternative as a result (J Oncol Pract. 2015;11:e152-62). However, little is known about public awareness and response to these shortages.
Therefore, the investigators used a 13-item instrument to survey 420 U.S. adults about their personal cancer history, as well as their knowledge and preferences regarding drug shortages and substitutions. Respondents were chosen randomly from a demographically representative online sample.
Only 16% of respondents said they were aware of drug shortages (including 31% of those with a personal cancer history and 14% of those without one), but more than 80% would want to be told about resultant substitutions with major or minor differences in safety or efficacy.
Furthermore, most respondents said they would transfer care to avoid a substitution: 72% for major efficacy differences and 61% for major safety differences. Respondents who were black, of low educational or socioeconomic level, uninsured, or unemployed were less likely to transfer care because of substitutions.
The findings show the need for more clinician-patient counseling about drug shortages, Dr. Frosch said in a media release.
“It can be stressful for patients with cancer to learn that their care may be impacted by drug shortages, but it’s important for oncologists to engage patients in these discussions,” he said. “Our data suggest that people expect disclosure of shortages as part of the caregiving process.”
More public awareness might also pressure stakeholders to tackle systemic failings underlying these drug shortages, he said. “It’s important that everyone – clinicians, patients, and the public – have a seat at the table as these strategies are developed.”
No specific funding was disclosed. The investigators reported no disclosures.
SOURCE: Frosch ZAK et al. Cancer. 2018 Apr 8. doi: 10.1002/cncr.31246.
FROM CANCER
Key clinical point: Most Americans do not know about cancer drug shortages and would want to be informed about them.
Major finding: Only 16% of respondents said they were aware of drug shortages. More than 80% would want to be told about drug substitutions with major or minor differences in safety or efficacy.
Study details: A 13-item survey of 420 randomly selected U.S. adults.
Disclosures: No specific funding was disclosed. The investigators reported no disclosures.
Source: Frosch ZAK et al. Cancer. 2018 Apr 8. doi: 10.1002/cncr.31246.
Peanut exposure in at-risk infants does not reduce eczema, other allergic diseases
and does not hasten the resolution of eczema, according to George du Toit, MB, and his associates.
In a study published in The Journal of Allergy and Clinical Immunology, they reported on the results of a 12-month extension of the Learning Early About Peanut Allergy (LEAP) study, which found that early introduction of peanuts into the diets of infants at high risk of peanut allergy markedly reduced their risk of developing peanut allergy at age 5, compared with those who did not consume peanuts. As infants, the majority had severe eczema, which, with egg allergy, was used to identify those at high risk.
In the extension study, the rates of eczema decreased across study time points to 72 months of age in both groups, to 39% in the peanut avoidance group and 37% in the peanut consumption group. Eczema severity decreased across study time points, and there were no significant differences in severity between the two groups at any time point.
There were also no differences between the two groups in the rates of asthma, seasonal rhinoconjunctivitis, and perennial rhinoconjunctivitis at 30, 60, and 72 months of age.
“The underlying immune mechanisms associated with tolerance to peanut do not alter the natural history of allergic disease,” the researchers concluded. “Different prevention strategies or strategies that include multiple dietary interventions need to be tested to assess whether the reduction in peanut allergy observed in the LEAP consumption group can be extended to other common food allergens and allergic diseases.”
SOURCE: Du Toit G et al. J Allergy Clin Immunol. 2018 Apr;141[4]1343-53.
and does not hasten the resolution of eczema, according to George du Toit, MB, and his associates.
In a study published in The Journal of Allergy and Clinical Immunology, they reported on the results of a 12-month extension of the Learning Early About Peanut Allergy (LEAP) study, which found that early introduction of peanuts into the diets of infants at high risk of peanut allergy markedly reduced their risk of developing peanut allergy at age 5, compared with those who did not consume peanuts. As infants, the majority had severe eczema, which, with egg allergy, was used to identify those at high risk.
In the extension study, the rates of eczema decreased across study time points to 72 months of age in both groups, to 39% in the peanut avoidance group and 37% in the peanut consumption group. Eczema severity decreased across study time points, and there were no significant differences in severity between the two groups at any time point.
There were also no differences between the two groups in the rates of asthma, seasonal rhinoconjunctivitis, and perennial rhinoconjunctivitis at 30, 60, and 72 months of age.
“The underlying immune mechanisms associated with tolerance to peanut do not alter the natural history of allergic disease,” the researchers concluded. “Different prevention strategies or strategies that include multiple dietary interventions need to be tested to assess whether the reduction in peanut allergy observed in the LEAP consumption group can be extended to other common food allergens and allergic diseases.”
SOURCE: Du Toit G et al. J Allergy Clin Immunol. 2018 Apr;141[4]1343-53.
and does not hasten the resolution of eczema, according to George du Toit, MB, and his associates.
In a study published in The Journal of Allergy and Clinical Immunology, they reported on the results of a 12-month extension of the Learning Early About Peanut Allergy (LEAP) study, which found that early introduction of peanuts into the diets of infants at high risk of peanut allergy markedly reduced their risk of developing peanut allergy at age 5, compared with those who did not consume peanuts. As infants, the majority had severe eczema, which, with egg allergy, was used to identify those at high risk.
In the extension study, the rates of eczema decreased across study time points to 72 months of age in both groups, to 39% in the peanut avoidance group and 37% in the peanut consumption group. Eczema severity decreased across study time points, and there were no significant differences in severity between the two groups at any time point.
There were also no differences between the two groups in the rates of asthma, seasonal rhinoconjunctivitis, and perennial rhinoconjunctivitis at 30, 60, and 72 months of age.
“The underlying immune mechanisms associated with tolerance to peanut do not alter the natural history of allergic disease,” the researchers concluded. “Different prevention strategies or strategies that include multiple dietary interventions need to be tested to assess whether the reduction in peanut allergy observed in the LEAP consumption group can be extended to other common food allergens and allergic diseases.”
SOURCE: Du Toit G et al. J Allergy Clin Immunol. 2018 Apr;141[4]1343-53.
FROM THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY
Anxiety, depression prevalent in children with comorbid autism and ADHD
Children with comorbid autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are at an increased risk of anxiety and mood disorders, a cross-sectional analysis has shown.
“Our study supports that anxiety and mood disorders, although highly prevalent in those with ASD alone, are even more prevalent in individuals who have ADHD,” wrote Eliza Gordon-Lipkin, MD, of the Kennedy Krieger Institute, Baltimore, and her associates. ”The identification of psychiatric conditions in children with ASD is important because these disorders are treatable and affect quality of life.”
The study was published in Pediatrics.
Most of the children were male (83%), white (87%), and non-Hispanic (92%); the mean age of the children was 10 years. Almost half of the children in the study had parent-reported ADHD (45%). Almost one-third of patients were diagnosed with an anxiety disorder (31%), and many also were reported to have been diagnosed with a mood disorder (16%). An increased risk of reported anxiety disorder was found in patients with both ADHD and ASD (adjusted relative risk, 2.20; 95% confidence interval, 1.97-2.46).
The researchers also found an increased risk of mood disorders (aRR, 2.72; 95% CI, 2.28-3.24) among children with comorbid conditions. Those risks increased with age (both P less than .001). An increased prevalence of anxiety and mood disorders was found in adolescents, compared with school-aged children with both ASD and ADHD or ASD alone. But higher relative risk ratios were found for the younger children, compared with the adolescents for those in the ADHD/ASD group and the ASD alone group.
“This suggests that or more likely to exhibit detectable symptoms at an earlier age,” reported Dr. Gordon-Lipkin, also with the department of pediatrics at Johns Hopkins University, in Baltimore.
The research team cited several limitations. For example, patient-reported data might be subject to recall or reporting biases. Also, computer and Internet access was required to complete the IAN questionnaires, which means that the findings could be biased toward people of higher socioeconomic status.
Nevertheless, the researchers wrote, their study is the largest to compare comorbidities in patients with ASD and ADHD, or ASD alone.
Further research is needed to better understand the relationship between ASD and ADHD. “ADHD affects nearly half of the children with ASD. This subgroup of individuals with ASD may represent a distinct clinical phenotype, with different diagnostic and therapeutic implications,” Dr. Gordon-Lipkin and her associates wrote. “Better understanding the differences between children with ASD with and without ADHD is crucial to designing effective interventions.”
None of the study authors had relevant financial disclosures to report. The Interactive Autism Network is funded by the Simons Foundation and the Patient-Centered Outcomes Research Institute.
SOURCE: Gordon-Lipkin E et al. Pediatrics. 2018 Mar 30. doi: 10.1542/ peds.2017-1377.
The work of Gordon-Lipkin et al. is one of the largest studies analyzing the relationships between autism, ADHD, and anxiety and mood disorders. But because of the inherent behavioral and biological complexity of autism, changes in the diagnostic criteria, and the use of parent-reported data, the current study might not reflect what is truly occurring in patients with autism, Christopher J. McDougle, MD, said in an interview.
“There are a number of things to say about [the study]. [One] of the strengths of the paper [is] the sample size,” Dr. McDougle said.“It’s always good to have a big sample size. The downside to having informant-databased information is that it is exactly what it is. This is fine, but the information may be inaccurate.”
In addition to parent-reported data, physicians are dealing with the relatively new diagnostic criteria. The May 2013 update of the Diagnostic and Statistical Manual of Mental Disorders to the DSM-5 brought with it the ability to diagnose ADHD with autism, when just the day before the DSM-5 was released, this differential diagnosis was not listed in the manual, Dr. McDougle said. “If something that important can change with the strike of the clock, it makes me concerned.” He also said listing the differential diagnosis in the diagnostic manual underscored the uncertainty of medicine’s understanding of comorbid autism and ADHD.
“That’s reflective of the field’s lack of knowledge. Sometimes I think we like to portray things as though we understand what’s going on, when I think it’s better to be honest and say we really don’t; we are just doing our best.”
Dr. McDougle is the director of the Lurie Center for Autism at Massachusetts General Hospital and is the Nancy Lurie Marks Professor of Psychiatry at Harvard Medical Center, both in Boston. He treats children, adolescents, and adults with autism spectrum disorder and other neurodevelopmental disorders. He was asked to comment on this study.
The work of Gordon-Lipkin et al. is one of the largest studies analyzing the relationships between autism, ADHD, and anxiety and mood disorders. But because of the inherent behavioral and biological complexity of autism, changes in the diagnostic criteria, and the use of parent-reported data, the current study might not reflect what is truly occurring in patients with autism, Christopher J. McDougle, MD, said in an interview.
“There are a number of things to say about [the study]. [One] of the strengths of the paper [is] the sample size,” Dr. McDougle said.“It’s always good to have a big sample size. The downside to having informant-databased information is that it is exactly what it is. This is fine, but the information may be inaccurate.”
In addition to parent-reported data, physicians are dealing with the relatively new diagnostic criteria. The May 2013 update of the Diagnostic and Statistical Manual of Mental Disorders to the DSM-5 brought with it the ability to diagnose ADHD with autism, when just the day before the DSM-5 was released, this differential diagnosis was not listed in the manual, Dr. McDougle said. “If something that important can change with the strike of the clock, it makes me concerned.” He also said listing the differential diagnosis in the diagnostic manual underscored the uncertainty of medicine’s understanding of comorbid autism and ADHD.
“That’s reflective of the field’s lack of knowledge. Sometimes I think we like to portray things as though we understand what’s going on, when I think it’s better to be honest and say we really don’t; we are just doing our best.”
Dr. McDougle is the director of the Lurie Center for Autism at Massachusetts General Hospital and is the Nancy Lurie Marks Professor of Psychiatry at Harvard Medical Center, both in Boston. He treats children, adolescents, and adults with autism spectrum disorder and other neurodevelopmental disorders. He was asked to comment on this study.
The work of Gordon-Lipkin et al. is one of the largest studies analyzing the relationships between autism, ADHD, and anxiety and mood disorders. But because of the inherent behavioral and biological complexity of autism, changes in the diagnostic criteria, and the use of parent-reported data, the current study might not reflect what is truly occurring in patients with autism, Christopher J. McDougle, MD, said in an interview.
“There are a number of things to say about [the study]. [One] of the strengths of the paper [is] the sample size,” Dr. McDougle said.“It’s always good to have a big sample size. The downside to having informant-databased information is that it is exactly what it is. This is fine, but the information may be inaccurate.”
In addition to parent-reported data, physicians are dealing with the relatively new diagnostic criteria. The May 2013 update of the Diagnostic and Statistical Manual of Mental Disorders to the DSM-5 brought with it the ability to diagnose ADHD with autism, when just the day before the DSM-5 was released, this differential diagnosis was not listed in the manual, Dr. McDougle said. “If something that important can change with the strike of the clock, it makes me concerned.” He also said listing the differential diagnosis in the diagnostic manual underscored the uncertainty of medicine’s understanding of comorbid autism and ADHD.
“That’s reflective of the field’s lack of knowledge. Sometimes I think we like to portray things as though we understand what’s going on, when I think it’s better to be honest and say we really don’t; we are just doing our best.”
Dr. McDougle is the director of the Lurie Center for Autism at Massachusetts General Hospital and is the Nancy Lurie Marks Professor of Psychiatry at Harvard Medical Center, both in Boston. He treats children, adolescents, and adults with autism spectrum disorder and other neurodevelopmental disorders. He was asked to comment on this study.
Children with comorbid autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are at an increased risk of anxiety and mood disorders, a cross-sectional analysis has shown.
“Our study supports that anxiety and mood disorders, although highly prevalent in those with ASD alone, are even more prevalent in individuals who have ADHD,” wrote Eliza Gordon-Lipkin, MD, of the Kennedy Krieger Institute, Baltimore, and her associates. ”The identification of psychiatric conditions in children with ASD is important because these disorders are treatable and affect quality of life.”
The study was published in Pediatrics.
Most of the children were male (83%), white (87%), and non-Hispanic (92%); the mean age of the children was 10 years. Almost half of the children in the study had parent-reported ADHD (45%). Almost one-third of patients were diagnosed with an anxiety disorder (31%), and many also were reported to have been diagnosed with a mood disorder (16%). An increased risk of reported anxiety disorder was found in patients with both ADHD and ASD (adjusted relative risk, 2.20; 95% confidence interval, 1.97-2.46).
The researchers also found an increased risk of mood disorders (aRR, 2.72; 95% CI, 2.28-3.24) among children with comorbid conditions. Those risks increased with age (both P less than .001). An increased prevalence of anxiety and mood disorders was found in adolescents, compared with school-aged children with both ASD and ADHD or ASD alone. But higher relative risk ratios were found for the younger children, compared with the adolescents for those in the ADHD/ASD group and the ASD alone group.
“This suggests that or more likely to exhibit detectable symptoms at an earlier age,” reported Dr. Gordon-Lipkin, also with the department of pediatrics at Johns Hopkins University, in Baltimore.
The research team cited several limitations. For example, patient-reported data might be subject to recall or reporting biases. Also, computer and Internet access was required to complete the IAN questionnaires, which means that the findings could be biased toward people of higher socioeconomic status.
Nevertheless, the researchers wrote, their study is the largest to compare comorbidities in patients with ASD and ADHD, or ASD alone.
Further research is needed to better understand the relationship between ASD and ADHD. “ADHD affects nearly half of the children with ASD. This subgroup of individuals with ASD may represent a distinct clinical phenotype, with different diagnostic and therapeutic implications,” Dr. Gordon-Lipkin and her associates wrote. “Better understanding the differences between children with ASD with and without ADHD is crucial to designing effective interventions.”
None of the study authors had relevant financial disclosures to report. The Interactive Autism Network is funded by the Simons Foundation and the Patient-Centered Outcomes Research Institute.
SOURCE: Gordon-Lipkin E et al. Pediatrics. 2018 Mar 30. doi: 10.1542/ peds.2017-1377.
Children with comorbid autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are at an increased risk of anxiety and mood disorders, a cross-sectional analysis has shown.
“Our study supports that anxiety and mood disorders, although highly prevalent in those with ASD alone, are even more prevalent in individuals who have ADHD,” wrote Eliza Gordon-Lipkin, MD, of the Kennedy Krieger Institute, Baltimore, and her associates. ”The identification of psychiatric conditions in children with ASD is important because these disorders are treatable and affect quality of life.”
The study was published in Pediatrics.
Most of the children were male (83%), white (87%), and non-Hispanic (92%); the mean age of the children was 10 years. Almost half of the children in the study had parent-reported ADHD (45%). Almost one-third of patients were diagnosed with an anxiety disorder (31%), and many also were reported to have been diagnosed with a mood disorder (16%). An increased risk of reported anxiety disorder was found in patients with both ADHD and ASD (adjusted relative risk, 2.20; 95% confidence interval, 1.97-2.46).
The researchers also found an increased risk of mood disorders (aRR, 2.72; 95% CI, 2.28-3.24) among children with comorbid conditions. Those risks increased with age (both P less than .001). An increased prevalence of anxiety and mood disorders was found in adolescents, compared with school-aged children with both ASD and ADHD or ASD alone. But higher relative risk ratios were found for the younger children, compared with the adolescents for those in the ADHD/ASD group and the ASD alone group.
“This suggests that or more likely to exhibit detectable symptoms at an earlier age,” reported Dr. Gordon-Lipkin, also with the department of pediatrics at Johns Hopkins University, in Baltimore.
The research team cited several limitations. For example, patient-reported data might be subject to recall or reporting biases. Also, computer and Internet access was required to complete the IAN questionnaires, which means that the findings could be biased toward people of higher socioeconomic status.
Nevertheless, the researchers wrote, their study is the largest to compare comorbidities in patients with ASD and ADHD, or ASD alone.
Further research is needed to better understand the relationship between ASD and ADHD. “ADHD affects nearly half of the children with ASD. This subgroup of individuals with ASD may represent a distinct clinical phenotype, with different diagnostic and therapeutic implications,” Dr. Gordon-Lipkin and her associates wrote. “Better understanding the differences between children with ASD with and without ADHD is crucial to designing effective interventions.”
None of the study authors had relevant financial disclosures to report. The Interactive Autism Network is funded by the Simons Foundation and the Patient-Centered Outcomes Research Institute.
SOURCE: Gordon-Lipkin E et al. Pediatrics. 2018 Mar 30. doi: 10.1542/ peds.2017-1377.
FROM PEDIATRICS
Key clinical point: “Better understanding the differences between children with ASD with and without ADHD is crucial to designing effective interventions.”
Major finding: Sixteen percent of the children with autistic spectrum disorder had a mood disorder, and 31% had an anxiety disorder.
Study details: A cross-sectional analysis of information on 3,319 patients, obtained between 2006 and 2013 in the Interactive Autism Network (IAN), an online autism research registry that uses parent report information.
Disclosures: None of the study authors reported relevant financial disclosures. The Interactive Autism Network is funded by the Simons Foundation and the Patient-Centered Outcomes Research Institute.
Source: Gordon-Lipkin E et al. Pediatrics. 2018 Mar 30. doi: 10.1542/ peds.2017-1377.