ORLANDO – The incidence of Crohn’s disease and ulcerative colitis has stabilized in the Western world, but is rising rapidly in newly industrialized countries, according to a systematic review of population-based studies.

The findings could provide important new insights into the environmental, genetic, and microbiome-related factors and interactions that form the underpinnings of IBD, Gilaad Kaplan, MD, of the University of Calgary (Alta.) said at the World Congress of Gastroenterology at ACG 2017.

In turn, that information could lead to approaches to reduce IBD incidence, he said in a video interview.

It has been known that Crohn’s disease and ulcerative colitis are “modern diseases of modern times,” but few studies have addressed the epidemiology of IBD in newly industrialized countries in Asia, Africa, and South America, he said.

“We see a pattern that as newly industrialized countries transition toward a westernized society, IBD emerges and its incidence rises, and there are many different explanations for that,” he said, noting that in part, the increase is due to improved health care infrastructure and advances in adoption of medical technology that lead to better identification of new cases.

“But probably one of the most important factors is that there are environmental exposures linked to the westernization of society that are creating this pressure that’s driving incidence of IBD up in many of the countries of the world,” he said. “I think if we do a lot more research focused on how environment influences microbiome, we might start to see things we could do that could potentially stem the tide of IBD.”

Dr. Kaplan reported having no relevant disclosures.

[email protected]

ORLANDO – The incidence of Crohn’s disease and ulcerative colitis has stabilized in the Western world, but is rising rapidly in newly industrialized countries, according to a systematic review of population-based studies.

The findings could provide important new insights into the environmental, genetic, and microbiome-related factors and interactions that form the underpinnings of IBD, Gilaad Kaplan, MD, of the University of Calgary (Alta.) said at the World Congress of Gastroenterology at ACG 2017.

In turn, that information could lead to approaches to reduce IBD incidence, he said in a video interview.

It has been known that Crohn’s disease and ulcerative colitis are “modern diseases of modern times,” but few studies have addressed the epidemiology of IBD in newly industrialized countries in Asia, Africa, and South America, he said.

“We see a pattern that as newly industrialized countries transition toward a westernized society, IBD emerges and its incidence rises, and there are many different explanations for that,” he said, noting that in part, the increase is due to improved health care infrastructure and advances in adoption of medical technology that lead to better identification of new cases.

“But probably one of the most important factors is that there are environmental exposures linked to the westernization of society that are creating this pressure that’s driving incidence of IBD up in many of the countries of the world,” he said. “I think if we do a lot more research focused on how environment influences microbiome, we might start to see things we could do that could potentially stem the tide of IBD.”

Dr. Kaplan reported having no relevant disclosures.

[email protected]

ORLANDO – The incidence of Crohn’s disease and ulcerative colitis has stabilized in the Western world, but is rising rapidly in newly industrialized countries, according to a systematic review of population-based studies.

The findings could provide important new insights into the environmental, genetic, and microbiome-related factors and interactions that form the underpinnings of IBD, Gilaad Kaplan, MD, of the University of Calgary (Alta.) said at the World Congress of Gastroenterology at ACG 2017.

In turn, that information could lead to approaches to reduce IBD incidence, he said in a video interview.

It has been known that Crohn’s disease and ulcerative colitis are “modern diseases of modern times,” but few studies have addressed the epidemiology of IBD in newly industrialized countries in Asia, Africa, and South America, he said.

“We see a pattern that as newly industrialized countries transition toward a westernized society, IBD emerges and its incidence rises, and there are many different explanations for that,” he said, noting that in part, the increase is due to improved health care infrastructure and advances in adoption of medical technology that lead to better identification of new cases.

“But probably one of the most important factors is that there are environmental exposures linked to the westernization of society that are creating this pressure that’s driving incidence of IBD up in many of the countries of the world,” he said. “I think if we do a lot more research focused on how environment influences microbiome, we might start to see things we could do that could potentially stem the tide of IBD.”

Dr. Kaplan reported having no relevant disclosures.

[email protected]

ORLANDO – Mechanical enhancements to existing colonoscopes may be better than optical enhancements for improving adenoma detection, according to findings from a meta-analysis of data from 240 studies.

“Even though colonoscopy is felt to be our best test compared to others … we also recognize that we do not see every square inch of the colon,” Seth Gross, MD, of New York University Langone Medical Center said in a video interview at the World Congress of Gastroenterology at ACG 2017.

There has been a “tremendous drive” to improve the ability to inspect blind spots in the colon, and also to better recognize subtle precancerous lesions in visible areas of the colon, but it has been unclear whether optical or mechanical enhancements will better achieve that goal, Dr. Gross said.

Based on the findings of his meta-analysis, it appears that mechanical enhancements, including integrated balloons and single-use caps with finger-like projections or discs that clip on to the colonoscope to engage the colon wall and flatten areas to allow access to areas behind folds, are most effective.

The preliminary data should lead to more clinical questions about what can be done to improve exams, he said.

In fact, one four-arm study looking at standard colonoscopy vs. colonoscopy with various mechanical enhancements was just completed, and others looking at “deep learning” and computer assistance are underway.

The latter technology is intriguing, as “not every polyp that we’re missing is behind a fold,” Dr. Gross noted.

Preliminary findings from a study out of China demonstrated the feasibility of such computer assistance, and the researchers are now working on a prospective study of real-time cases to see if that type of integrated learning with computer assistance can improve polyp detection.

“Sometimes it’s just these subtle mucosal changes that we have to train our eye to identify,” he said. “So imagine having another set of eyes … where there’s a computer sort of highlighting an area that we should focus on.”

Dr. Gross reported having no relevant financial disclosures.

[email protected]

ORLANDO – Mechanical enhancements to existing colonoscopes may be better than optical enhancements for improving adenoma detection, according to findings from a meta-analysis of data from 240 studies.

“Even though colonoscopy is felt to be our best test compared to others … we also recognize that we do not see every square inch of the colon,” Seth Gross, MD, of New York University Langone Medical Center said in a video interview at the World Congress of Gastroenterology at ACG 2017.

There has been a “tremendous drive” to improve the ability to inspect blind spots in the colon, and also to better recognize subtle precancerous lesions in visible areas of the colon, but it has been unclear whether optical or mechanical enhancements will better achieve that goal, Dr. Gross said.

Based on the findings of his meta-analysis, it appears that mechanical enhancements, including integrated balloons and single-use caps with finger-like projections or discs that clip on to the colonoscope to engage the colon wall and flatten areas to allow access to areas behind folds, are most effective.

The preliminary data should lead to more clinical questions about what can be done to improve exams, he said.

In fact, one four-arm study looking at standard colonoscopy vs. colonoscopy with various mechanical enhancements was just completed, and others looking at “deep learning” and computer assistance are underway.

The latter technology is intriguing, as “not every polyp that we’re missing is behind a fold,” Dr. Gross noted.

Preliminary findings from a study out of China demonstrated the feasibility of such computer assistance, and the researchers are now working on a prospective study of real-time cases to see if that type of integrated learning with computer assistance can improve polyp detection.

“Sometimes it’s just these subtle mucosal changes that we have to train our eye to identify,” he said. “So imagine having another set of eyes … where there’s a computer sort of highlighting an area that we should focus on.”

Dr. Gross reported having no relevant financial disclosures.

[email protected]

ORLANDO – Mechanical enhancements to existing colonoscopes may be better than optical enhancements for improving adenoma detection, according to findings from a meta-analysis of data from 240 studies.

“Even though colonoscopy is felt to be our best test compared to others … we also recognize that we do not see every square inch of the colon,” Seth Gross, MD, of New York University Langone Medical Center said in a video interview at the World Congress of Gastroenterology at ACG 2017.

There has been a “tremendous drive” to improve the ability to inspect blind spots in the colon, and also to better recognize subtle precancerous lesions in visible areas of the colon, but it has been unclear whether optical or mechanical enhancements will better achieve that goal, Dr. Gross said.

Based on the findings of his meta-analysis, it appears that mechanical enhancements, including integrated balloons and single-use caps with finger-like projections or discs that clip on to the colonoscope to engage the colon wall and flatten areas to allow access to areas behind folds, are most effective.

The preliminary data should lead to more clinical questions about what can be done to improve exams, he said.

In fact, one four-arm study looking at standard colonoscopy vs. colonoscopy with various mechanical enhancements was just completed, and others looking at “deep learning” and computer assistance are underway.

The latter technology is intriguing, as “not every polyp that we’re missing is behind a fold,” Dr. Gross noted.

Preliminary findings from a study out of China demonstrated the feasibility of such computer assistance, and the researchers are now working on a prospective study of real-time cases to see if that type of integrated learning with computer assistance can improve polyp detection.

“Sometimes it’s just these subtle mucosal changes that we have to train our eye to identify,” he said. “So imagine having another set of eyes … where there’s a computer sort of highlighting an area that we should focus on.”

Dr. Gross reported having no relevant financial disclosures.

[email protected]

Myth: Popping pimples resolves acne faster

Acne patients may be compelled to squeeze or pop their pimples at home thinking it will clear their acne faster, but they should be advised that doing so without using the proper technique can actually make the condition worse.

When over-the-counter or prescription acne medications take too long to work, some patients may use their fingernails or even a physical instrument (eg, tweezers) to clear the contents of the pimple; however, this process often produces lesions that are inflamed and far more visible, slower to heal, and more likely to scar than lesions progressing through the natural disease course. According to the American Academy of Dermatology (AAD), unwanted side effects of popping pimples can include permanent acne scars, more noticeable and/or painful acne lesions, and infection from bacteria on the hands.

The AAD promotes that dermatologists know how to remove bothersome acne lesions safely. Also, the AAD guidelines of care for the management of acne vulgaris reported that comedo removal may be helpful for lesions resistant to other therapies. Acne extraction may be offered when standard treatments fail and involves the use of sterile instruments to clear comedones and microcomedones. For single lesions that are particularly painful, dermatologists may opt to inject the lesion with a corticosteroid to reduce inflammation, speed healing, and decrease the risk of scarring; the strength of this recommendation is level C, according to the AAD acne guidelines work group. Finally, incision and drainage using a sterile needle or surgical blade can be used to open and clear the contents of large or painful pimples, nodules, and cysts.

These procedures are not first-line acne therapies. To minimize the appearance of acne lesions and promote clearance while waiting to see results from prescribed treatment regimens, patients should be advised to keep their hands away from their face and avoid picking at lesions, to apply ice to painful lesions to reduce inflammation and relieve pain, and to be patient with the acne treatment prescribed by a dermatologist. If patients are prone to picking their acne lesions, a more aggressive approach to treatment may be necessary, as a reduced number of inflammatory lesions leaves the patient with fewer spots to manipulate.

Myth: Popping pimples resolves acne faster

Acne patients may be compelled to squeeze or pop their pimples at home thinking it will clear their acne faster, but they should be advised that doing so without using the proper technique can actually make the condition worse.

When over-the-counter or prescription acne medications take too long to work, some patients may use their fingernails or even a physical instrument (eg, tweezers) to clear the contents of the pimple; however, this process often produces lesions that are inflamed and far more visible, slower to heal, and more likely to scar than lesions progressing through the natural disease course. According to the American Academy of Dermatology (AAD), unwanted side effects of popping pimples can include permanent acne scars, more noticeable and/or painful acne lesions, and infection from bacteria on the hands.

The AAD promotes that dermatologists know how to remove bothersome acne lesions safely. Also, the AAD guidelines of care for the management of acne vulgaris reported that comedo removal may be helpful for lesions resistant to other therapies. Acne extraction may be offered when standard treatments fail and involves the use of sterile instruments to clear comedones and microcomedones. For single lesions that are particularly painful, dermatologists may opt to inject the lesion with a corticosteroid to reduce inflammation, speed healing, and decrease the risk of scarring; the strength of this recommendation is level C, according to the AAD acne guidelines work group. Finally, incision and drainage using a sterile needle or surgical blade can be used to open and clear the contents of large or painful pimples, nodules, and cysts.

These procedures are not first-line acne therapies. To minimize the appearance of acne lesions and promote clearance while waiting to see results from prescribed treatment regimens, patients should be advised to keep their hands away from their face and avoid picking at lesions, to apply ice to painful lesions to reduce inflammation and relieve pain, and to be patient with the acne treatment prescribed by a dermatologist. If patients are prone to picking their acne lesions, a more aggressive approach to treatment may be necessary, as a reduced number of inflammatory lesions leaves the patient with fewer spots to manipulate.

Myth: Popping pimples resolves acne faster

Acne patients may be compelled to squeeze or pop their pimples at home thinking it will clear their acne faster, but they should be advised that doing so without using the proper technique can actually make the condition worse.

When over-the-counter or prescription acne medications take too long to work, some patients may use their fingernails or even a physical instrument (eg, tweezers) to clear the contents of the pimple; however, this process often produces lesions that are inflamed and far more visible, slower to heal, and more likely to scar than lesions progressing through the natural disease course. According to the American Academy of Dermatology (AAD), unwanted side effects of popping pimples can include permanent acne scars, more noticeable and/or painful acne lesions, and infection from bacteria on the hands.

The AAD promotes that dermatologists know how to remove bothersome acne lesions safely. Also, the AAD guidelines of care for the management of acne vulgaris reported that comedo removal may be helpful for lesions resistant to other therapies. Acne extraction may be offered when standard treatments fail and involves the use of sterile instruments to clear comedones and microcomedones. For single lesions that are particularly painful, dermatologists may opt to inject the lesion with a corticosteroid to reduce inflammation, speed healing, and decrease the risk of scarring; the strength of this recommendation is level C, according to the AAD acne guidelines work group. Finally, incision and drainage using a sterile needle or surgical blade can be used to open and clear the contents of large or painful pimples, nodules, and cysts.

These procedures are not first-line acne therapies. To minimize the appearance of acne lesions and promote clearance while waiting to see results from prescribed treatment regimens, patients should be advised to keep their hands away from their face and avoid picking at lesions, to apply ice to painful lesions to reduce inflammation and relieve pain, and to be patient with the acne treatment prescribed by a dermatologist. If patients are prone to picking their acne lesions, a more aggressive approach to treatment may be necessary, as a reduced number of inflammatory lesions leaves the patient with fewer spots to manipulate.

In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.

Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).

The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.

Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.

Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.

The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.

Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).

While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.

Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.

The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.

In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.

Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).

The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.

Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.

Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.

The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.

Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).

While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.

Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.

The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.

In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.

Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).

The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.

Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.

Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.

The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.

Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).

While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.

Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.

The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.

The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.

Rodrigo Cuel/Thinkstock

Don’t miss these sessions

Acoustic gunshot sensor technology impacts trauma care.

Press Conference:   TUESDAY, OCTOBER 24  - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)

~~~~

Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.

Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.

Location: 2, Upper Level of the San Diego Convention Center. 

The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:

•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)

•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)

•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)

•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)

•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)

•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)

•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)

•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)

•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)

•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)

•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)


Social media

Follow Therese Borden on Twitter for live tweets during the meeting.
 

[email protected]

On Twitter @ThereseBorden

The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.

Rodrigo Cuel/Thinkstock

Don’t miss these sessions

Acoustic gunshot sensor technology impacts trauma care.

Press Conference:   TUESDAY, OCTOBER 24  - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)

~~~~

Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.

Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.

Location: 2, Upper Level of the San Diego Convention Center. 

The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:

•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)

•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)

•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)

•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)

•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)

•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)

•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)

•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)

•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)

•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)

•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)


Social media

Follow Therese Borden on Twitter for live tweets during the meeting.
 

[email protected]

On Twitter @ThereseBorden

The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.

Rodrigo Cuel/Thinkstock

Don’t miss these sessions

Acoustic gunshot sensor technology impacts trauma care.

Press Conference:   TUESDAY, OCTOBER 24  - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)

~~~~

Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.

Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.

Location: 2, Upper Level of the San Diego Convention Center. 

The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:

•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)

•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)

•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)

•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)

•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)

•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)

•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)

•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)

•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)

•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)

•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)


Social media

Follow Therese Borden on Twitter for live tweets during the meeting.
 

[email protected]

On Twitter @ThereseBorden

It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.

Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?

I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.

There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.¹

Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.

Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.

Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.

References

1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.

2 Telemed J E Health. 2015;21(12):1038-41.

3 Mil Med. 2014 Aug;179(8):865-78.

It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.

Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?

I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.

There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.¹

Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.

Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.

Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.

References

1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.

2 Telemed J E Health. 2015;21(12):1038-41.

3 Mil Med. 2014 Aug;179(8):865-78.

It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.

Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?

I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.

There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.¹

Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.

Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.

Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.

References

1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.

2 Telemed J E Health. 2015;21(12):1038-41.

3 Mil Med. 2014 Aug;179(8):865-78.

In patients with castration-resistant prostate cancer (CRPC), a variant of the HSD3B1 gene predicts sensitivity to the CYP17A1 inhibitor ketoconazole, according to results of a single-center, observational study including 90 men treated between June 1998 and December 2012.

Median progression-free survival (PFS) increased along with the number of variant HSD3B1(1245C) alleles, wrote Nima Almassi, MD, of the Cleveland Clinic, and coauthors (JAMA Oncol. 2017 Oct 12. doi: 10.1001/jamaoncol.2017.3159).

Specifically, median PFS was just 5.0 months for patients with no variant HSD3B1(1245C) alleles, 7.5 months for patients with one allele, and 12.3 months for those with two alleles (P = .03).

“These findings suggest that the variant allele … may be a predictive biomarker of tumor vulnerability to pharmacologic CYP17A1 inhibition with a nonsteroidal drug,” Dr. Almassi and colleagues wrote.

The HSD3B1(1245C) germline variant was already known in the prostate cancer research community as a marker of tumor resistance to androgen deprivation therapy (ADT) and more rapid disease onset. In a separate study published in the same issue (JAMA Oncol. 2017 Oct 12. doi: 10.1001/jamaoncol.2017.3164) investigators provided additional evidence, showing that the genotype was associated with more rapid metastasis development in men with localized prostate cancer who received ADT for biochemical recurrence after radiation treatment.

In that observational study of 218 men treated between 1996 and 2003, median time to metastasis (TTM) decreased according to the number of inherited variant alleles, wrote Jason W. D. Hearn, MD, University of Michigan, Ann Arbor, and coauthors. Those with no variant HSD3B1(1245C) alleles had a TTM of 7.4 months, while those with one allele had a TTM of 5.8 months, and for those with two, TTM was only 4.4 months (P = .03).

However, investigators could not detect any such relationship between variant HSD3B1(1245C) alleles and time to progression (TTP) or overall survival (OS): “It is possible that the high rates of prior ADT exposure and frequent use of androgen receptor (AR) antagonists during salvage ADT modified the impact of genotype with respect to composite TTP and OS,” Dr. Hearn and colleagues wrote. “Nonetheless, the large impact on TTM is statistically and clinically significant.”

While the findings of Dr. Hearn and colleagues bolster existing knowledge that variant HSD3B1(1245C) alleles are associated with poorer outcomes in prostate cancer, the findings from Dr. Almassi and colleagues add new insights regarding the potential role of CYP17A1 inhibitors in patients with this genotype.

“As only a proportion of patients treated with potent CYP17A1 inhibitors or AR antagonists respond clinically, a predictive biomarker for the identification of patients who benefit would undoubtedly have clinical value,” Dr. Almassi and colleagues said.

The findings are somewhat limited, however, because they were focused on ketoconazole, a nonsteroidal CYP17A1 inhibitor that is no longer routinely used in clinic for prostate cancer.

Similar studies of the steroidal CYP17A1 inhibitor abiraterone acetate would be possible, however, “steroidal metabolites of [steroidal CYP17A1 inhibitors] make evaluation more complex,” Dr. Almassi and colleagues wrote.

In patients with castration-resistant prostate cancer (CRPC), a variant of the HSD3B1 gene predicts sensitivity to the CYP17A1 inhibitor ketoconazole, according to results of a single-center, observational study including 90 men treated between June 1998 and December 2012.

Median progression-free survival (PFS) increased along with the number of variant HSD3B1(1245C) alleles, wrote Nima Almassi, MD, of the Cleveland Clinic, and coauthors (JAMA Oncol. 2017 Oct 12. doi: 10.1001/jamaoncol.2017.3159).

Specifically, median PFS was just 5.0 months for patients with no variant HSD3B1(1245C) alleles, 7.5 months for patients with one allele, and 12.3 months for those with two alleles (P = .03).

“These findings suggest that the variant allele … may be a predictive biomarker of tumor vulnerability to pharmacologic CYP17A1 inhibition with a nonsteroidal drug,” Dr. Almassi and colleagues wrote.

The HSD3B1(1245C) germline variant was already known in the prostate cancer research community as a marker of tumor resistance to androgen deprivation therapy (ADT) and more rapid disease onset. In a separate study published in the same issue (JAMA Oncol. 2017 Oct 12. doi: 10.1001/jamaoncol.2017.3164) investigators provided additional evidence, showing that the genotype was associated with more rapid metastasis development in men with localized prostate cancer who received ADT for biochemical recurrence after radiation treatment.

In that observational study of 218 men treated between 1996 and 2003, median time to metastasis (TTM) decreased according to the number of inherited variant alleles, wrote Jason W. D. Hearn, MD, University of Michigan, Ann Arbor, and coauthors. Those with no variant HSD3B1(1245C) alleles had a TTM of 7.4 months, while those with one allele had a TTM of 5.8 months, and for those with two, TTM was only 4.4 months (P = .03).

However, investigators could not detect any such relationship between variant HSD3B1(1245C) alleles and time to progression (TTP) or overall survival (OS): “It is possible that the high rates of prior ADT exposure and frequent use of androgen receptor (AR) antagonists during salvage ADT modified the impact of genotype with respect to composite TTP and OS,” Dr. Hearn and colleagues wrote. “Nonetheless, the large impact on TTM is statistically and clinically significant.”

While the findings of Dr. Hearn and colleagues bolster existing knowledge that variant HSD3B1(1245C) alleles are associated with poorer outcomes in prostate cancer, the findings from Dr. Almassi and colleagues add new insights regarding the potential role of CYP17A1 inhibitors in patients with this genotype.

“As only a proportion of patients treated with potent CYP17A1 inhibitors or AR antagonists respond clinically, a predictive biomarker for the identification of patients who benefit would undoubtedly have clinical value,” Dr. Almassi and colleagues said.

The findings are somewhat limited, however, because they were focused on ketoconazole, a nonsteroidal CYP17A1 inhibitor that is no longer routinely used in clinic for prostate cancer.

Similar studies of the steroidal CYP17A1 inhibitor abiraterone acetate would be possible, however, “steroidal metabolites of [steroidal CYP17A1 inhibitors] make evaluation more complex,” Dr. Almassi and colleagues wrote.

In patients with castration-resistant prostate cancer (CRPC), a variant of the HSD3B1 gene predicts sensitivity to the CYP17A1 inhibitor ketoconazole, according to results of a single-center, observational study including 90 men treated between June 1998 and December 2012.

Median progression-free survival (PFS) increased along with the number of variant HSD3B1(1245C) alleles, wrote Nima Almassi, MD, of the Cleveland Clinic, and coauthors (JAMA Oncol. 2017 Oct 12. doi: 10.1001/jamaoncol.2017.3159).

Specifically, median PFS was just 5.0 months for patients with no variant HSD3B1(1245C) alleles, 7.5 months for patients with one allele, and 12.3 months for those with two alleles (P = .03).

“These findings suggest that the variant allele … may be a predictive biomarker of tumor vulnerability to pharmacologic CYP17A1 inhibition with a nonsteroidal drug,” Dr. Almassi and colleagues wrote.

The HSD3B1(1245C) germline variant was already known in the prostate cancer research community as a marker of tumor resistance to androgen deprivation therapy (ADT) and more rapid disease onset. In a separate study published in the same issue (JAMA Oncol. 2017 Oct 12. doi: 10.1001/jamaoncol.2017.3164) investigators provided additional evidence, showing that the genotype was associated with more rapid metastasis development in men with localized prostate cancer who received ADT for biochemical recurrence after radiation treatment.

In that observational study of 218 men treated between 1996 and 2003, median time to metastasis (TTM) decreased according to the number of inherited variant alleles, wrote Jason W. D. Hearn, MD, University of Michigan, Ann Arbor, and coauthors. Those with no variant HSD3B1(1245C) alleles had a TTM of 7.4 months, while those with one allele had a TTM of 5.8 months, and for those with two, TTM was only 4.4 months (P = .03).

However, investigators could not detect any such relationship between variant HSD3B1(1245C) alleles and time to progression (TTP) or overall survival (OS): “It is possible that the high rates of prior ADT exposure and frequent use of androgen receptor (AR) antagonists during salvage ADT modified the impact of genotype with respect to composite TTP and OS,” Dr. Hearn and colleagues wrote. “Nonetheless, the large impact on TTM is statistically and clinically significant.”

While the findings of Dr. Hearn and colleagues bolster existing knowledge that variant HSD3B1(1245C) alleles are associated with poorer outcomes in prostate cancer, the findings from Dr. Almassi and colleagues add new insights regarding the potential role of CYP17A1 inhibitors in patients with this genotype.

“As only a proportion of patients treated with potent CYP17A1 inhibitors or AR antagonists respond clinically, a predictive biomarker for the identification of patients who benefit would undoubtedly have clinical value,” Dr. Almassi and colleagues said.

The findings are somewhat limited, however, because they were focused on ketoconazole, a nonsteroidal CYP17A1 inhibitor that is no longer routinely used in clinic for prostate cancer.

Similar studies of the steroidal CYP17A1 inhibitor abiraterone acetate would be possible, however, “steroidal metabolites of [steroidal CYP17A1 inhibitors] make evaluation more complex,” Dr. Almassi and colleagues wrote.

The VA has boiled down its experience in dealing with the opioid epidemic to 8 best practices, which it is now sharing with others in government and the health care industry who work to balance pain management and opioid prescribing. 

The best practices are summed up by the acronym STOP PAIN, which stands for:

• S—Stepped Care Model, which encourages a continuum of care from onset through treatment. It also incorporates self-management through participation in groups such as Narcotics or Alcoholics Anonymous, counseling, treatment programs, primary care, and other medical specialists;
• T—Treatment alternatives/complementary care, expanding provider options beyond standard care in treating chronic pain. “Complementary health” includes evidence-based treatments, such as acupuncture, yoga, and progressive relaxation;

Related:  Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic

• O—Ongoing monitoring of usage;
• P—Practice guidelines, which provide evidence-based recommendations for minimizing harm and increasing patient safety. (https://www.healthquality.va.gov/guidelines/MH/sud/ and https://www.healthquality.va.gov/guidelines/Pain/cot/);
• P—Prescription monitoring. The VA has a number of data sources to allow it to monitor opioid use to target specific education in real time. The practice patterns of providers differ, along with the case mixes: a provider with relatively high opioid prescribing may have an appropriate practice, or be someone who could benefit from education. These tools allow the VA to drill down to the patient level to evaluate use. Other tools can evaluate the treatment of patient panels and the veterans’ risk of potential abuse. Together, these allow identification of potential problems, educational targeting, and tracking of progress;

Related: Prescribing Patterns Shift After Detailing-Policy Change

• A—Academic detailing. The Academic Detailing program, a one-on-one peer education program for frontline providers, gives specific information on practice alternatives and resources, opioid safety, and can compare the practice of the provider to that of peers; (https://www.pbm.va.gov/PBM/academicdetailingservicehome.asp and

https://www.pbm.va.gov/PBM/academicdetailingservice/Pain_and_Opioid_Safety.asp)

• I—Informed consent for patients prior to long-term opioid therapy. This process includes education on the risks of opioid therapy, opioid interactions, and safe prescribing practices such as urine drug screens; and
• N—Naloxone distribution. The Opioid Overdose Education & Naloxone Distribution program focuses on educating providers (https://www.pbm.va.gov/PBM/academicdetailingservice/Opioid_Overdose_Education_and_Naloxone_Distribution.asp).

For more information, visit https://www.va.gov/painmanagement.

The VA has boiled down its experience in dealing with the opioid epidemic to 8 best practices, which it is now sharing with others in government and the health care industry who work to balance pain management and opioid prescribing. 

The best practices are summed up by the acronym STOP PAIN, which stands for:

• S—Stepped Care Model, which encourages a continuum of care from onset through treatment. It also incorporates self-management through participation in groups such as Narcotics or Alcoholics Anonymous, counseling, treatment programs, primary care, and other medical specialists;
• T—Treatment alternatives/complementary care, expanding provider options beyond standard care in treating chronic pain. “Complementary health” includes evidence-based treatments, such as acupuncture, yoga, and progressive relaxation;

Related:  Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic

• O—Ongoing monitoring of usage;
• P—Practice guidelines, which provide evidence-based recommendations for minimizing harm and increasing patient safety. (https://www.healthquality.va.gov/guidelines/MH/sud/ and https://www.healthquality.va.gov/guidelines/Pain/cot/);
• P—Prescription monitoring. The VA has a number of data sources to allow it to monitor opioid use to target specific education in real time. The practice patterns of providers differ, along with the case mixes: a provider with relatively high opioid prescribing may have an appropriate practice, or be someone who could benefit from education. These tools allow the VA to drill down to the patient level to evaluate use. Other tools can evaluate the treatment of patient panels and the veterans’ risk of potential abuse. Together, these allow identification of potential problems, educational targeting, and tracking of progress;

Related: Prescribing Patterns Shift After Detailing-Policy Change

• A—Academic detailing. The Academic Detailing program, a one-on-one peer education program for frontline providers, gives specific information on practice alternatives and resources, opioid safety, and can compare the practice of the provider to that of peers; (https://www.pbm.va.gov/PBM/academicdetailingservicehome.asp and

https://www.pbm.va.gov/PBM/academicdetailingservice/Pain_and_Opioid_Safety.asp)

• I—Informed consent for patients prior to long-term opioid therapy. This process includes education on the risks of opioid therapy, opioid interactions, and safe prescribing practices such as urine drug screens; and
• N—Naloxone distribution. The Opioid Overdose Education & Naloxone Distribution program focuses on educating providers (https://www.pbm.va.gov/PBM/academicdetailingservice/Opioid_Overdose_Education_and_Naloxone_Distribution.asp).

For more information, visit https://www.va.gov/painmanagement.

The VA has boiled down its experience in dealing with the opioid epidemic to 8 best practices, which it is now sharing with others in government and the health care industry who work to balance pain management and opioid prescribing. 

The best practices are summed up by the acronym STOP PAIN, which stands for:

• S—Stepped Care Model, which encourages a continuum of care from onset through treatment. It also incorporates self-management through participation in groups such as Narcotics or Alcoholics Anonymous, counseling, treatment programs, primary care, and other medical specialists;
• T—Treatment alternatives/complementary care, expanding provider options beyond standard care in treating chronic pain. “Complementary health” includes evidence-based treatments, such as acupuncture, yoga, and progressive relaxation;

Related:  Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic

• O—Ongoing monitoring of usage;
• P—Practice guidelines, which provide evidence-based recommendations for minimizing harm and increasing patient safety. (https://www.healthquality.va.gov/guidelines/MH/sud/ and https://www.healthquality.va.gov/guidelines/Pain/cot/);
• P—Prescription monitoring. The VA has a number of data sources to allow it to monitor opioid use to target specific education in real time. The practice patterns of providers differ, along with the case mixes: a provider with relatively high opioid prescribing may have an appropriate practice, or be someone who could benefit from education. These tools allow the VA to drill down to the patient level to evaluate use. Other tools can evaluate the treatment of patient panels and the veterans’ risk of potential abuse. Together, these allow identification of potential problems, educational targeting, and tracking of progress;

Related: Prescribing Patterns Shift After Detailing-Policy Change

• A—Academic detailing. The Academic Detailing program, a one-on-one peer education program for frontline providers, gives specific information on practice alternatives and resources, opioid safety, and can compare the practice of the provider to that of peers; (https://www.pbm.va.gov/PBM/academicdetailingservicehome.asp and

https://www.pbm.va.gov/PBM/academicdetailingservice/Pain_and_Opioid_Safety.asp)

• I—Informed consent for patients prior to long-term opioid therapy. This process includes education on the risks of opioid therapy, opioid interactions, and safe prescribing practices such as urine drug screens; and
• N—Naloxone distribution. The Opioid Overdose Education & Naloxone Distribution program focuses on educating providers (https://www.pbm.va.gov/PBM/academicdetailingservice/Opioid_Overdose_Education_and_Naloxone_Distribution.asp).

For more information, visit https://www.va.gov/painmanagement.

A 40-year-old man suddenly began to lose vision in his left eye. The retinal exam was normal for the right eye. But the left showed isolated subinternal limited membrane hemorrhage at the fovea along with a white-centered hemorrhage above the fovea.

The patient had no history of trauma or Valsalva retinopathy. His blood pressure was normal as was his blood glucose. However, when bloodwork showed a high total count, increased platelet count, and the peripheral smear indicated myeloid hyperplasia, clinicians at LV Prasad Eye Institute in Hyderabad, India, diagnosed the patient with underlying chronic myeloid leukemia (CML).  

A physical examination revealed a palpable spleenomegaly—underscoring the fact, the clinicians note, that when an ophthalmologic finding suggests a systemic disease, a general physical examination will reveal more clinical clues. The patient was referred to an oncologist and started on imatinib for CML.

White-centered or pale-centered hemorrhages are believed to represent an accumulation of leukemic cells or platelet fibrin aggregates, the clinicians say. Blood dyscrasias, such as anemias, leukemia, multiple myeloma, and other platelet disorders may present with similar features. Such hemorrhages are known to resolve spontaneously when the patient is treated for the underlying condition, and the hematologic status improves, the clinicians say. This patient’s hemorrhage gradually resolved over the next month, and his visual acuity improved to 20/20.

Ocular manifestations as a presenting sign of leukemia, especially chronic, are rare, the clinicians say. They note that retinal hemorrhages are one of the “most striking findings” in leukemia, and because they can be directly observed, they provide a “subtle but important clue toward an otherwise asymptomatic disease.” If diagnosed early and treated promptly, patients with CML have a good survival rate.

Source:

Tyagi M, Agarwal K, Paulose RM, Rani PK. BMJ Case Rep. 2017;2017: pii: bcr-2017-21974.

doi: 10.1136/bcr-2017-219741.

A 40-year-old man suddenly began to lose vision in his left eye. The retinal exam was normal for the right eye. But the left showed isolated subinternal limited membrane hemorrhage at the fovea along with a white-centered hemorrhage above the fovea.

The patient had no history of trauma or Valsalva retinopathy. His blood pressure was normal as was his blood glucose. However, when bloodwork showed a high total count, increased platelet count, and the peripheral smear indicated myeloid hyperplasia, clinicians at LV Prasad Eye Institute in Hyderabad, India, diagnosed the patient with underlying chronic myeloid leukemia (CML).  

A physical examination revealed a palpable spleenomegaly—underscoring the fact, the clinicians note, that when an ophthalmologic finding suggests a systemic disease, a general physical examination will reveal more clinical clues. The patient was referred to an oncologist and started on imatinib for CML.

White-centered or pale-centered hemorrhages are believed to represent an accumulation of leukemic cells or platelet fibrin aggregates, the clinicians say. Blood dyscrasias, such as anemias, leukemia, multiple myeloma, and other platelet disorders may present with similar features. Such hemorrhages are known to resolve spontaneously when the patient is treated for the underlying condition, and the hematologic status improves, the clinicians say. This patient’s hemorrhage gradually resolved over the next month, and his visual acuity improved to 20/20.

Ocular manifestations as a presenting sign of leukemia, especially chronic, are rare, the clinicians say. They note that retinal hemorrhages are one of the “most striking findings” in leukemia, and because they can be directly observed, they provide a “subtle but important clue toward an otherwise asymptomatic disease.” If diagnosed early and treated promptly, patients with CML have a good survival rate.

Source:

Tyagi M, Agarwal K, Paulose RM, Rani PK. BMJ Case Rep. 2017;2017: pii: bcr-2017-21974.

doi: 10.1136/bcr-2017-219741.

A 40-year-old man suddenly began to lose vision in his left eye. The retinal exam was normal for the right eye. But the left showed isolated subinternal limited membrane hemorrhage at the fovea along with a white-centered hemorrhage above the fovea.

The patient had no history of trauma or Valsalva retinopathy. His blood pressure was normal as was his blood glucose. However, when bloodwork showed a high total count, increased platelet count, and the peripheral smear indicated myeloid hyperplasia, clinicians at LV Prasad Eye Institute in Hyderabad, India, diagnosed the patient with underlying chronic myeloid leukemia (CML).  

A physical examination revealed a palpable spleenomegaly—underscoring the fact, the clinicians note, that when an ophthalmologic finding suggests a systemic disease, a general physical examination will reveal more clinical clues. The patient was referred to an oncologist and started on imatinib for CML.

White-centered or pale-centered hemorrhages are believed to represent an accumulation of leukemic cells or platelet fibrin aggregates, the clinicians say. Blood dyscrasias, such as anemias, leukemia, multiple myeloma, and other platelet disorders may present with similar features. Such hemorrhages are known to resolve spontaneously when the patient is treated for the underlying condition, and the hematologic status improves, the clinicians say. This patient’s hemorrhage gradually resolved over the next month, and his visual acuity improved to 20/20.

Ocular manifestations as a presenting sign of leukemia, especially chronic, are rare, the clinicians say. They note that retinal hemorrhages are one of the “most striking findings” in leukemia, and because they can be directly observed, they provide a “subtle but important clue toward an otherwise asymptomatic disease.” If diagnosed early and treated promptly, patients with CML have a good survival rate.

Source:

Tyagi M, Agarwal K, Paulose RM, Rani PK. BMJ Case Rep. 2017;2017: pii: bcr-2017-21974.

doi: 10.1136/bcr-2017-219741.

Photo by Bill Branson

Vaccination may fail to protect young leukemia patients from developing influenza during cancer treatment, according to research published in the Journal of Pediatrics.

Researchers found that young patients with acute leukemia who received flu shots were just as likely as their unvaccinated peers to develop the flu.

The team said these results are preliminary, but they suggest a need for more research and additional efforts to prevent flu in young patients with leukemia.

“The annual flu shot, whose side effects are generally mild and short-lived, is still recommended for patients with acute leukemia who are being treated for their disease,” said study author Elisabeth Adderson, MD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“However, the results do highlight the need for additional research in this area and for us to redouble our efforts to protect our patients through other means.”

In this retrospective study, Dr Adderson and her colleagues looked at rates of flu infection during 3 successive flu seasons (2010-2013) in 498 patients treated for acute leukemia at St. Jude.

The patients’ median age was 6 years (range, 1-21). Most patients had acute lymphoblastic leukemia (ALL, 94%), though some had acute myeloid leukemia (4.8%) or mixed-lineage leukemia (1.2%).

Most patients (n=354) received flu shots, including 98 patients who received booster doses. The remaining 144 patients were not vaccinated.

The vaccinated patients received the trivalent vaccine, which is designed to protect against 3 flu strains predicted to be in wide circulation during a particular flu season. The vaccine was a fairly good match for circulating flu viruses during the flu seasons included in this analysis.

Demographic characteristic were largely similar between vaccinated and unvaccinated patients. The exceptions were that more vaccinated patients had ALL (95.5% vs 90.3%; P=0.034) and vaccinated patients were more likely to be in a low-intensity phase of cancer therapy (90.7% vs 73.6%, P<0.0001).

Results

There were no significant differences between vaccinated and unvaccinated patients when it came to flu rates or rates of flu-like illnesses.

There were 37 episodes of flu in vaccinated patients and 16 episodes in unvaccinated patients. The rates (per 1000 patient days) were 0.73 and 0.70, respectively (P=0.874).

There were 123 cases of flu-like illnesses in vaccinated patients and 55 cases in unvaccinated patients. The rates were 2.44 and 2.41, respectively (P=0.932).

Likewise, there was no significant difference in the rates of flu or flu-like illnesses between patients who received 1 dose of flu vaccine and those who received 2 doses.

The flu rates were 0.60 and 1.02, respectively (P=0.107). And the rates of flu-like illnesses were 2.42 and 2.73, respectively (P=0.529).

Dr Adderson said additional research is needed to determine if a subset of young leukemia patients may benefit from vaccination.

She added that patients at risk of flu should practice good hand hygiene and avoid crowds during the flu season. Patients may also benefit from “cocooning,” a process that focuses on getting family members, healthcare providers, and others in close contact with at-risk patients vaccinated.

Photo by Bill Branson

Vaccination may fail to protect young leukemia patients from developing influenza during cancer treatment, according to research published in the Journal of Pediatrics.

Researchers found that young patients with acute leukemia who received flu shots were just as likely as their unvaccinated peers to develop the flu.

The team said these results are preliminary, but they suggest a need for more research and additional efforts to prevent flu in young patients with leukemia.

“The annual flu shot, whose side effects are generally mild and short-lived, is still recommended for patients with acute leukemia who are being treated for their disease,” said study author Elisabeth Adderson, MD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“However, the results do highlight the need for additional research in this area and for us to redouble our efforts to protect our patients through other means.”

In this retrospective study, Dr Adderson and her colleagues looked at rates of flu infection during 3 successive flu seasons (2010-2013) in 498 patients treated for acute leukemia at St. Jude.

The patients’ median age was 6 years (range, 1-21). Most patients had acute lymphoblastic leukemia (ALL, 94%), though some had acute myeloid leukemia (4.8%) or mixed-lineage leukemia (1.2%).

Most patients (n=354) received flu shots, including 98 patients who received booster doses. The remaining 144 patients were not vaccinated.

The vaccinated patients received the trivalent vaccine, which is designed to protect against 3 flu strains predicted to be in wide circulation during a particular flu season. The vaccine was a fairly good match for circulating flu viruses during the flu seasons included in this analysis.

Demographic characteristic were largely similar between vaccinated and unvaccinated patients. The exceptions were that more vaccinated patients had ALL (95.5% vs 90.3%; P=0.034) and vaccinated patients were more likely to be in a low-intensity phase of cancer therapy (90.7% vs 73.6%, P<0.0001).

Results

There were no significant differences between vaccinated and unvaccinated patients when it came to flu rates or rates of flu-like illnesses.

There were 37 episodes of flu in vaccinated patients and 16 episodes in unvaccinated patients. The rates (per 1000 patient days) were 0.73 and 0.70, respectively (P=0.874).

There were 123 cases of flu-like illnesses in vaccinated patients and 55 cases in unvaccinated patients. The rates were 2.44 and 2.41, respectively (P=0.932).

Likewise, there was no significant difference in the rates of flu or flu-like illnesses between patients who received 1 dose of flu vaccine and those who received 2 doses.

The flu rates were 0.60 and 1.02, respectively (P=0.107). And the rates of flu-like illnesses were 2.42 and 2.73, respectively (P=0.529).

Dr Adderson said additional research is needed to determine if a subset of young leukemia patients may benefit from vaccination.

She added that patients at risk of flu should practice good hand hygiene and avoid crowds during the flu season. Patients may also benefit from “cocooning,” a process that focuses on getting family members, healthcare providers, and others in close contact with at-risk patients vaccinated.

Photo by Bill Branson

Vaccination may fail to protect young leukemia patients from developing influenza during cancer treatment, according to research published in the Journal of Pediatrics.

Researchers found that young patients with acute leukemia who received flu shots were just as likely as their unvaccinated peers to develop the flu.

The team said these results are preliminary, but they suggest a need for more research and additional efforts to prevent flu in young patients with leukemia.

“The annual flu shot, whose side effects are generally mild and short-lived, is still recommended for patients with acute leukemia who are being treated for their disease,” said study author Elisabeth Adderson, MD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“However, the results do highlight the need for additional research in this area and for us to redouble our efforts to protect our patients through other means.”

In this retrospective study, Dr Adderson and her colleagues looked at rates of flu infection during 3 successive flu seasons (2010-2013) in 498 patients treated for acute leukemia at St. Jude.

The patients’ median age was 6 years (range, 1-21). Most patients had acute lymphoblastic leukemia (ALL, 94%), though some had acute myeloid leukemia (4.8%) or mixed-lineage leukemia (1.2%).

Most patients (n=354) received flu shots, including 98 patients who received booster doses. The remaining 144 patients were not vaccinated.

The vaccinated patients received the trivalent vaccine, which is designed to protect against 3 flu strains predicted to be in wide circulation during a particular flu season. The vaccine was a fairly good match for circulating flu viruses during the flu seasons included in this analysis.

Demographic characteristic were largely similar between vaccinated and unvaccinated patients. The exceptions were that more vaccinated patients had ALL (95.5% vs 90.3%; P=0.034) and vaccinated patients were more likely to be in a low-intensity phase of cancer therapy (90.7% vs 73.6%, P<0.0001).

Results

There were no significant differences between vaccinated and unvaccinated patients when it came to flu rates or rates of flu-like illnesses.

There were 37 episodes of flu in vaccinated patients and 16 episodes in unvaccinated patients. The rates (per 1000 patient days) were 0.73 and 0.70, respectively (P=0.874).

There were 123 cases of flu-like illnesses in vaccinated patients and 55 cases in unvaccinated patients. The rates were 2.44 and 2.41, respectively (P=0.932).

Likewise, there was no significant difference in the rates of flu or flu-like illnesses between patients who received 1 dose of flu vaccine and those who received 2 doses.

The flu rates were 0.60 and 1.02, respectively (P=0.107). And the rates of flu-like illnesses were 2.42 and 2.73, respectively (P=0.529).

Dr Adderson said additional research is needed to determine if a subset of young leukemia patients may benefit from vaccination.

She added that patients at risk of flu should practice good hand hygiene and avoid crowds during the flu season. Patients may also benefit from “cocooning,” a process that focuses on getting family members, healthcare providers, and others in close contact with at-risk patients vaccinated.