Kidney failure in Native Americans and Alaska Natives with diabetes has declined drastically over the last 20 years, according to new data released as part of this month’s Vital Signs report by the CDC.

“The 54 percent decline in kidney failure from diabetes followed implementation of public health and population approaches to diabetes as well as improvements in clinical care by the IHS [Indian Health Service],” said Mary L. Smith, principal deputy director of the Indian Health Service.

Of all U.S.-based populations, Native Americans are the most susceptible to diabetes and are about twice as likely as white Americans to develop diabetes. Furthermore, 69% of kidney failure deaths in Native Americans are the result of diabetes (MMWR. 2017 Jan 10. doi: 10.15585/mmwr.mm6601e1).

Since 1996, however, kidney failure has dropped more among Native Americans than any other ethnic group in the country. The 54% drop represents a decrease from 57.3 diabetes-related end-stage renal disease cases per 100,000 population in 1996 to 26.5 per 100,000 population in 2013 among U.S. adults.

“This decline is especially remarkable given the well-documented health and socioeconomic disparities in the [Native American and Alaska Natives] population, including poverty, limited health care resources, and disproportionate burden of many health problems,” wrote the authors of the Vital Signs report.

According to the report, blood sugar control among Native American populations has improved by 10%, kidney testing in diabetic Native Americans aged 65 years or older is 50% greater than Medicare diabetes patients of the same age, and the average blood pressure of Native Americans with both diabetes and hypertension was 133/76 in 2015.

“We believe these strategies can be effective in any population,” Ms. Smith stated, a sentiment that was also shared by Tom Frieden, MD, director of the CDC.

“Strong coordinated clinical care and education, community outreach and environmental changes can make a dramatic difference in reducing complications from diabetes for all Americans,” Dr. Frieden said in a statement.

Not only does diabetes persist as a significant burden on the U.S. health care system, but kidney failure in particular can be costly. Figures released by the CDC indicate that average medical costs associated with kidney failure in 2013 were as high as $82,000 per patient, with Medicare spending nearly $14 billion for kidney failure treatments in the same year.

“The findings in this report are consistent with other studies among [Native Americans and Alaska Natives] nationwide and among Pima Indians in the Southwest, which concluded that improvements in blood pressure, blood glucose, and the use of ACE inhibitors and [angiotensin II receptor blockers] played a significant role in the decline of [diabetes-related end-stage renal disease] in these populations,” the report concludes.

To ensure that kidney failure decreases continue in Native Americans, the U.S. government will continue funding diabetes screening and prevention efforts in applicable communities, assist community health care facilities to provide care for diabetes, and will establish a nationwide system for tracking chronic kidney disease. The CDC also advocates using population approaches and coordinated care to treat diabetes, advising health care professionals to “integrate kidney disease prevention and education into routine diabetes care.”

“The Indian Health Service has made tremendous progress by applying population health and team-based approaches to diabetes and kidney care,” Dr. Frieden stated.

[email protected]

Kidney failure in Native Americans and Alaska Natives with diabetes has declined drastically over the last 20 years, according to new data released as part of this month’s Vital Signs report by the CDC.

“The 54 percent decline in kidney failure from diabetes followed implementation of public health and population approaches to diabetes as well as improvements in clinical care by the IHS [Indian Health Service],” said Mary L. Smith, principal deputy director of the Indian Health Service.

Of all U.S.-based populations, Native Americans are the most susceptible to diabetes and are about twice as likely as white Americans to develop diabetes. Furthermore, 69% of kidney failure deaths in Native Americans are the result of diabetes (MMWR. 2017 Jan 10. doi: 10.15585/mmwr.mm6601e1).

Since 1996, however, kidney failure has dropped more among Native Americans than any other ethnic group in the country. The 54% drop represents a decrease from 57.3 diabetes-related end-stage renal disease cases per 100,000 population in 1996 to 26.5 per 100,000 population in 2013 among U.S. adults.

“This decline is especially remarkable given the well-documented health and socioeconomic disparities in the [Native American and Alaska Natives] population, including poverty, limited health care resources, and disproportionate burden of many health problems,” wrote the authors of the Vital Signs report.

According to the report, blood sugar control among Native American populations has improved by 10%, kidney testing in diabetic Native Americans aged 65 years or older is 50% greater than Medicare diabetes patients of the same age, and the average blood pressure of Native Americans with both diabetes and hypertension was 133/76 in 2015.

“We believe these strategies can be effective in any population,” Ms. Smith stated, a sentiment that was also shared by Tom Frieden, MD, director of the CDC.

“Strong coordinated clinical care and education, community outreach and environmental changes can make a dramatic difference in reducing complications from diabetes for all Americans,” Dr. Frieden said in a statement.

Not only does diabetes persist as a significant burden on the U.S. health care system, but kidney failure in particular can be costly. Figures released by the CDC indicate that average medical costs associated with kidney failure in 2013 were as high as $82,000 per patient, with Medicare spending nearly $14 billion for kidney failure treatments in the same year.

“The findings in this report are consistent with other studies among [Native Americans and Alaska Natives] nationwide and among Pima Indians in the Southwest, which concluded that improvements in blood pressure, blood glucose, and the use of ACE inhibitors and [angiotensin II receptor blockers] played a significant role in the decline of [diabetes-related end-stage renal disease] in these populations,” the report concludes.

To ensure that kidney failure decreases continue in Native Americans, the U.S. government will continue funding diabetes screening and prevention efforts in applicable communities, assist community health care facilities to provide care for diabetes, and will establish a nationwide system for tracking chronic kidney disease. The CDC also advocates using population approaches and coordinated care to treat diabetes, advising health care professionals to “integrate kidney disease prevention and education into routine diabetes care.”

“The Indian Health Service has made tremendous progress by applying population health and team-based approaches to diabetes and kidney care,” Dr. Frieden stated.

[email protected]

Kidney failure in Native Americans and Alaska Natives with diabetes has declined drastically over the last 20 years, according to new data released as part of this month’s Vital Signs report by the CDC.

“The 54 percent decline in kidney failure from diabetes followed implementation of public health and population approaches to diabetes as well as improvements in clinical care by the IHS [Indian Health Service],” said Mary L. Smith, principal deputy director of the Indian Health Service.

Of all U.S.-based populations, Native Americans are the most susceptible to diabetes and are about twice as likely as white Americans to develop diabetes. Furthermore, 69% of kidney failure deaths in Native Americans are the result of diabetes (MMWR. 2017 Jan 10. doi: 10.15585/mmwr.mm6601e1).

Since 1996, however, kidney failure has dropped more among Native Americans than any other ethnic group in the country. The 54% drop represents a decrease from 57.3 diabetes-related end-stage renal disease cases per 100,000 population in 1996 to 26.5 per 100,000 population in 2013 among U.S. adults.

“This decline is especially remarkable given the well-documented health and socioeconomic disparities in the [Native American and Alaska Natives] population, including poverty, limited health care resources, and disproportionate burden of many health problems,” wrote the authors of the Vital Signs report.

According to the report, blood sugar control among Native American populations has improved by 10%, kidney testing in diabetic Native Americans aged 65 years or older is 50% greater than Medicare diabetes patients of the same age, and the average blood pressure of Native Americans with both diabetes and hypertension was 133/76 in 2015.

“We believe these strategies can be effective in any population,” Ms. Smith stated, a sentiment that was also shared by Tom Frieden, MD, director of the CDC.

“Strong coordinated clinical care and education, community outreach and environmental changes can make a dramatic difference in reducing complications from diabetes for all Americans,” Dr. Frieden said in a statement.

Not only does diabetes persist as a significant burden on the U.S. health care system, but kidney failure in particular can be costly. Figures released by the CDC indicate that average medical costs associated with kidney failure in 2013 were as high as $82,000 per patient, with Medicare spending nearly $14 billion for kidney failure treatments in the same year.

“The findings in this report are consistent with other studies among [Native Americans and Alaska Natives] nationwide and among Pima Indians in the Southwest, which concluded that improvements in blood pressure, blood glucose, and the use of ACE inhibitors and [angiotensin II receptor blockers] played a significant role in the decline of [diabetes-related end-stage renal disease] in these populations,” the report concludes.

To ensure that kidney failure decreases continue in Native Americans, the U.S. government will continue funding diabetes screening and prevention efforts in applicable communities, assist community health care facilities to provide care for diabetes, and will establish a nationwide system for tracking chronic kidney disease. The CDC also advocates using population approaches and coordinated care to treat diabetes, advising health care professionals to “integrate kidney disease prevention and education into routine diabetes care.”

“The Indian Health Service has made tremendous progress by applying population health and team-based approaches to diabetes and kidney care,” Dr. Frieden stated.

[email protected]

NEW ORLEANS – Patients who see a cardiologist for their newly diagnosed atrial fibrillation are at significantly lower subsequent risk for ischemic stroke and death than those who receive their care exclusively from primary care physicians, according to a huge Veterans Affairs study.

These superior outcomes were mediated in part by a significantly higher rate of oral anticoagulation prescription within 90 days after diagnosis of atrial fibrillation (AF) among patients who saw a cardiologist, Alexander C. Perino, MD, reported at the American Heart Association scientific sessions.

Bruce Jancin/Frontline Medical News

[email protected]

NEW ORLEANS – Patients who see a cardiologist for their newly diagnosed atrial fibrillation are at significantly lower subsequent risk for ischemic stroke and death than those who receive their care exclusively from primary care physicians, according to a huge Veterans Affairs study.

These superior outcomes were mediated in part by a significantly higher rate of oral anticoagulation prescription within 90 days after diagnosis of atrial fibrillation (AF) among patients who saw a cardiologist, Alexander C. Perino, MD, reported at the American Heart Association scientific sessions.

Bruce Jancin/Frontline Medical News

[email protected]

NEW ORLEANS – Patients who see a cardiologist for their newly diagnosed atrial fibrillation are at significantly lower subsequent risk for ischemic stroke and death than those who receive their care exclusively from primary care physicians, according to a huge Veterans Affairs study.

These superior outcomes were mediated in part by a significantly higher rate of oral anticoagulation prescription within 90 days after diagnosis of atrial fibrillation (AF) among patients who saw a cardiologist, Alexander C. Perino, MD, reported at the American Heart Association scientific sessions.

Bruce Jancin/Frontline Medical News

[email protected]

Case

A 41-year-old man presented to our ED with a 4-day history of epigastric pain radiating to the bilateral flanks and back. His medical history was significant for hypertension, for which he was prescribed isosorbide dinitrite 30 mg four times per day; however, he reported that he did not regularly take this medication.

The patient had visited our ED 3 days earlier with the same complaint. Since his blood pressure (BP) reading at the first ED presentation was 213/141 mm Hg, he had been admitted for hypertensive urgency. The patient’s BP was controlled with antihypertensive agents during his stay, but he continued to experience epigastric pain. A basic work-up for abdominal pain was ordered, the results of which were normal. Based on these findings, the patient’s pain was attributed to gastritis, and he was discharged home with instructions to return to the ED if his pain became worse or persisted.

At both ED presentations, the patient denied experiencing any nausea, vomiting, diarrhea, or chest pain. At the second presentation, his triage BP was 158/106 mm Hg. A chest X-ray, complete blood count (CBC), basic metabolic profile (BMP), hepatic panel, and lipase evaluation were all unremarkable, with the exception of a mild increase in creatinine to 1.38 mg/dL. A point-of-care (POC) ultrasound study of the aorta was normal.

Discussion

Isolated DCA is a rare cause of abdominal pain. The first documented case of isolated DCA is often incorrectly attributed to Bauersfeld’s¹ 1947 case series on dissections,but that report described superior mesenteric artery dissection rather than a celiac artery dissection. Watson’s² 1956 dissection series is also incorrectly cited as the first DCA, but that series described a dissection of the splenic artery, which is a branch of the celiac artery. In a 1959 series, Foord and Lewis³ described what is most likely the first report of DCA as an incidental finding at autopsy. More frequent descriptions in recent years are thought to be due to the routine use of abdominal CTA.⁴

Dissection of the celiac artery is a rare occurrence, with less than 100 cases reported, and little evidence exists to guide its management.⁵ These dissections represent 36.8% of all visceral artery dissections,⁶ which themselves are less common than renal, carotid, and vertebral artery dissections.⁷ Dissection of visceral arteries occurs predominantly in men and more often in middle-aged patients.⁸ Risk factors for DCA are thought to mirror risk factors for dissection of other arteries, including atherosclerotic disease, hypertension, connective tissue disorders, trauma, vasculitis, and pregnancy.^9-11

Signs and Symptoms

Patients with DCA typically present with sudden onset of epigastric, flank, and/or chest pain, though 50% of patients may be asymptomatic.¹² This pain is easily overlooked because the physical examination and laboratory studies are typically unremarkable.¹³ Fortunately, DCA is rarely accompanied by fatal organ dysfunction due to collateral flow from other vessels.¹⁴

Diagnosis and Management

While CTA with contrast is considered the mainstay of diagnosis of DCA,¹⁵ optimal treatment for DCA has not been well established. Management options include medical management, operative repair, and endovascular embolization. Medical management is reserved for stable patients without signs of end organ dysfunction. Typical management involves anticoagulation with warfarin for 3 to 6 months and strict BP control accompanied by close surveillance for progression.^10,13 Some clinicians have argued that anticoagulation therapy may be unnecessary and that risk factor modification and BP control alone may be sufficient.^5,6 Others have advocated that surgical management should be favored in cases of persistent pain, development of aneurysm, or threatened or compromised flow to end organs.⁷

Point-of-Care Ultrasound

The American College of Emergency Physicians considers ultrasound of the abdominal aorta a core application of emergency ultrasound.¹⁶ While sensitivity and specificity of emergency ultrasound for abdominal aortic aneurysm are well established, data supporting its use for screening for dissections are less definitive. With a sensitivity of 67% to 80% and a specificity of 99% to 100% with visualization of an intimal flap, aortic dissection screening using ultrasound is less reliable than most emergency physicians (EPs) would prefer.^17,18 There are no published data reporting the sensitivity or specificity of emergency ultrasound for DCA. However, the vascular surgery literature encourages color Doppler ultrasound as part of the initial diagnostic work-up for this rare entity.¹⁹ While this may seem like an area ripe for emergency ultrasound, it is important to note—as seen in our case—that the site of the dissection is not often seen. Instead, the use of Doppler allows a screening for an abnormal flow pattern suggestive of dissection.²⁰

Conclusion

In our case, both resident EPs and an expert fellowship-trained emergency ultrasound attending physician were unable to visualize a dissection—even after knowledge of the lesion was established by CTA. This points out a limitation of emergency ultrasound. While a POC ultrasound may be able to effectively rule in dissections of the aorta and its branches, we cannot reliably rule out these lesions. As EPs continue to expand the use of ultrasound, it is important to balance the desire for efficiency and cost-effectiveness with a high index of suspicion, experience, and clinical acumen.

Case

A 41-year-old man presented to our ED with a 4-day history of epigastric pain radiating to the bilateral flanks and back. His medical history was significant for hypertension, for which he was prescribed isosorbide dinitrite 30 mg four times per day; however, he reported that he did not regularly take this medication.

The patient had visited our ED 3 days earlier with the same complaint. Since his blood pressure (BP) reading at the first ED presentation was 213/141 mm Hg, he had been admitted for hypertensive urgency. The patient’s BP was controlled with antihypertensive agents during his stay, but he continued to experience epigastric pain. A basic work-up for abdominal pain was ordered, the results of which were normal. Based on these findings, the patient’s pain was attributed to gastritis, and he was discharged home with instructions to return to the ED if his pain became worse or persisted.

At both ED presentations, the patient denied experiencing any nausea, vomiting, diarrhea, or chest pain. At the second presentation, his triage BP was 158/106 mm Hg. A chest X-ray, complete blood count (CBC), basic metabolic profile (BMP), hepatic panel, and lipase evaluation were all unremarkable, with the exception of a mild increase in creatinine to 1.38 mg/dL. A point-of-care (POC) ultrasound study of the aorta was normal.

Discussion

Isolated DCA is a rare cause of abdominal pain. The first documented case of isolated DCA is often incorrectly attributed to Bauersfeld’s¹ 1947 case series on dissections,but that report described superior mesenteric artery dissection rather than a celiac artery dissection. Watson’s² 1956 dissection series is also incorrectly cited as the first DCA, but that series described a dissection of the splenic artery, which is a branch of the celiac artery. In a 1959 series, Foord and Lewis³ described what is most likely the first report of DCA as an incidental finding at autopsy. More frequent descriptions in recent years are thought to be due to the routine use of abdominal CTA.⁴

Dissection of the celiac artery is a rare occurrence, with less than 100 cases reported, and little evidence exists to guide its management.⁵ These dissections represent 36.8% of all visceral artery dissections,⁶ which themselves are less common than renal, carotid, and vertebral artery dissections.⁷ Dissection of visceral arteries occurs predominantly in men and more often in middle-aged patients.⁸ Risk factors for DCA are thought to mirror risk factors for dissection of other arteries, including atherosclerotic disease, hypertension, connective tissue disorders, trauma, vasculitis, and pregnancy.^9-11

Signs and Symptoms

Patients with DCA typically present with sudden onset of epigastric, flank, and/or chest pain, though 50% of patients may be asymptomatic.¹² This pain is easily overlooked because the physical examination and laboratory studies are typically unremarkable.¹³ Fortunately, DCA is rarely accompanied by fatal organ dysfunction due to collateral flow from other vessels.¹⁴

Diagnosis and Management

While CTA with contrast is considered the mainstay of diagnosis of DCA,¹⁵ optimal treatment for DCA has not been well established. Management options include medical management, operative repair, and endovascular embolization. Medical management is reserved for stable patients without signs of end organ dysfunction. Typical management involves anticoagulation with warfarin for 3 to 6 months and strict BP control accompanied by close surveillance for progression.^10,13 Some clinicians have argued that anticoagulation therapy may be unnecessary and that risk factor modification and BP control alone may be sufficient.^5,6 Others have advocated that surgical management should be favored in cases of persistent pain, development of aneurysm, or threatened or compromised flow to end organs.⁷

Point-of-Care Ultrasound

The American College of Emergency Physicians considers ultrasound of the abdominal aorta a core application of emergency ultrasound.¹⁶ While sensitivity and specificity of emergency ultrasound for abdominal aortic aneurysm are well established, data supporting its use for screening for dissections are less definitive. With a sensitivity of 67% to 80% and a specificity of 99% to 100% with visualization of an intimal flap, aortic dissection screening using ultrasound is less reliable than most emergency physicians (EPs) would prefer.^17,18 There are no published data reporting the sensitivity or specificity of emergency ultrasound for DCA. However, the vascular surgery literature encourages color Doppler ultrasound as part of the initial diagnostic work-up for this rare entity.¹⁹ While this may seem like an area ripe for emergency ultrasound, it is important to note—as seen in our case—that the site of the dissection is not often seen. Instead, the use of Doppler allows a screening for an abnormal flow pattern suggestive of dissection.²⁰

Conclusion

In our case, both resident EPs and an expert fellowship-trained emergency ultrasound attending physician were unable to visualize a dissection—even after knowledge of the lesion was established by CTA. This points out a limitation of emergency ultrasound. While a POC ultrasound may be able to effectively rule in dissections of the aorta and its branches, we cannot reliably rule out these lesions. As EPs continue to expand the use of ultrasound, it is important to balance the desire for efficiency and cost-effectiveness with a high index of suspicion, experience, and clinical acumen.

Case

A 41-year-old man presented to our ED with a 4-day history of epigastric pain radiating to the bilateral flanks and back. His medical history was significant for hypertension, for which he was prescribed isosorbide dinitrite 30 mg four times per day; however, he reported that he did not regularly take this medication.

The patient had visited our ED 3 days earlier with the same complaint. Since his blood pressure (BP) reading at the first ED presentation was 213/141 mm Hg, he had been admitted for hypertensive urgency. The patient’s BP was controlled with antihypertensive agents during his stay, but he continued to experience epigastric pain. A basic work-up for abdominal pain was ordered, the results of which were normal. Based on these findings, the patient’s pain was attributed to gastritis, and he was discharged home with instructions to return to the ED if his pain became worse or persisted.

At both ED presentations, the patient denied experiencing any nausea, vomiting, diarrhea, or chest pain. At the second presentation, his triage BP was 158/106 mm Hg. A chest X-ray, complete blood count (CBC), basic metabolic profile (BMP), hepatic panel, and lipase evaluation were all unremarkable, with the exception of a mild increase in creatinine to 1.38 mg/dL. A point-of-care (POC) ultrasound study of the aorta was normal.

Discussion

Isolated DCA is a rare cause of abdominal pain. The first documented case of isolated DCA is often incorrectly attributed to Bauersfeld’s¹ 1947 case series on dissections,but that report described superior mesenteric artery dissection rather than a celiac artery dissection. Watson’s² 1956 dissection series is also incorrectly cited as the first DCA, but that series described a dissection of the splenic artery, which is a branch of the celiac artery. In a 1959 series, Foord and Lewis³ described what is most likely the first report of DCA as an incidental finding at autopsy. More frequent descriptions in recent years are thought to be due to the routine use of abdominal CTA.⁴

Dissection of the celiac artery is a rare occurrence, with less than 100 cases reported, and little evidence exists to guide its management.⁵ These dissections represent 36.8% of all visceral artery dissections,⁶ which themselves are less common than renal, carotid, and vertebral artery dissections.⁷ Dissection of visceral arteries occurs predominantly in men and more often in middle-aged patients.⁸ Risk factors for DCA are thought to mirror risk factors for dissection of other arteries, including atherosclerotic disease, hypertension, connective tissue disorders, trauma, vasculitis, and pregnancy.^9-11

Signs and Symptoms

Patients with DCA typically present with sudden onset of epigastric, flank, and/or chest pain, though 50% of patients may be asymptomatic.¹² This pain is easily overlooked because the physical examination and laboratory studies are typically unremarkable.¹³ Fortunately, DCA is rarely accompanied by fatal organ dysfunction due to collateral flow from other vessels.¹⁴

Diagnosis and Management

While CTA with contrast is considered the mainstay of diagnosis of DCA,¹⁵ optimal treatment for DCA has not been well established. Management options include medical management, operative repair, and endovascular embolization. Medical management is reserved for stable patients without signs of end organ dysfunction. Typical management involves anticoagulation with warfarin for 3 to 6 months and strict BP control accompanied by close surveillance for progression.^10,13 Some clinicians have argued that anticoagulation therapy may be unnecessary and that risk factor modification and BP control alone may be sufficient.^5,6 Others have advocated that surgical management should be favored in cases of persistent pain, development of aneurysm, or threatened or compromised flow to end organs.⁷

Point-of-Care Ultrasound

The American College of Emergency Physicians considers ultrasound of the abdominal aorta a core application of emergency ultrasound.¹⁶ While sensitivity and specificity of emergency ultrasound for abdominal aortic aneurysm are well established, data supporting its use for screening for dissections are less definitive. With a sensitivity of 67% to 80% and a specificity of 99% to 100% with visualization of an intimal flap, aortic dissection screening using ultrasound is less reliable than most emergency physicians (EPs) would prefer.^17,18 There are no published data reporting the sensitivity or specificity of emergency ultrasound for DCA. However, the vascular surgery literature encourages color Doppler ultrasound as part of the initial diagnostic work-up for this rare entity.¹⁹ While this may seem like an area ripe for emergency ultrasound, it is important to note—as seen in our case—that the site of the dissection is not often seen. Instead, the use of Doppler allows a screening for an abnormal flow pattern suggestive of dissection.²⁰

Conclusion

In our case, both resident EPs and an expert fellowship-trained emergency ultrasound attending physician were unable to visualize a dissection—even after knowledge of the lesion was established by CTA. This points out a limitation of emergency ultrasound. While a POC ultrasound may be able to effectively rule in dissections of the aorta and its branches, we cannot reliably rule out these lesions. As EPs continue to expand the use of ultrasound, it is important to balance the desire for efficiency and cost-effectiveness with a high index of suspicion, experience, and clinical acumen.

A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician. 

Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any Times readers ever learned of the “clarifications.”

We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.

Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected. 

The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?

In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.

But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect. 

A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician. 

Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any Times readers ever learned of the “clarifications.”

We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.

Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected. 

The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?

In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.

But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect. 

A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician. 

Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any Times readers ever learned of the “clarifications.”

We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.

Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected. 

The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?

In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.

But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect. 

Justin Kimsey, Alabama

Mohammed N.Y. Shah, MD, Alaska

Katharina Beeler, MD, Arizona

Khoi Nguyen, MD, Arizona

Vinay Saini, MD, Arizona

Maria Aceves, PA-C, California

Sarvenaz Alibeigi, California

Peter Cadman, MD, California

Katrina Chapman, DO, MPH, California

Cheryll Gallardo-Villena, MD, California

Sripriya Ganesan, California

Alice Gong, MD, California

Henry Kwang, MD, California

Kevin Li, California

Anthony Murphy, MD, California

Dan Nguyen, California

Daniel Oh, California

Joon Parle, California

Katie Raffel, California

Darshana Sarathchandra, MD, California

Lifang Zhang, California

Jaime Baker, MD, Colorado

Eric Johnson, PA-C, Colorado

Juan Lessing, MD, Colorado

Benjamin Ruckman, DO, Colorado

Rehaan Shaffie, MD, Colorado

Deborah Casey, MD, Connecticut

Daniel Heacock, PA-C, Connecticut

Shabana Ansari, DO, Delaware

Madhu Prattipati, MD, Delaware

Pallavi Aneja, MD, Florida

Satcha Borgella, MD, Florida

Thendrex H. Estrella, MD, Florida

Abid Hussain, MD, Florida

Daphnee Hutchinson, DO, Florida

Muhammad Jaffer, Florida

Sue Lee, ANP, Florida

Melissa Odermann, DO, Florida

Jose Guillermo Revelo Paiz, MD, Florida

Rafael J. Rolon Rivera, MD, Florida

Eleonor Rongo, Florida

Esther Roth, Florida

Shitaye Argaw, MD, Georgia

Taryn DeGrazia, Georgia

Becca Feistritzer, Georgia

Jamal Fitts, Georgia

Kristen Flint, Georgia

Zachary Hermes, Georgia

Mukesh Kumar, Georgia

Kajal Patel, Georgia

Madeline Smith, Georgia

Wade Flowers, PharmD, Idaho

Ajay Bhandare, Illinois

Kimberly Brighton, Illinois

Hristo D. Hristov, MD, Illinois

Sidney Iriana, Illinois

Aurelian Ivan, Illinois

Ming Lee, MD, Illinois

Michelle Lundholm, Illinois

Idrees Mohiuddin, MD, Illinois

Murr Murray, Illinois

Tad Nair, MD, Illinois

Shalini Reddy, MD, Illinois

Richard Rethorst, MD, Illinois

Kelly Robertshaw, Illinois

Gracelene Wegrzyn, Illinois

Evan Yates, Illinois

Lora J. Jones McClure, MD, Indiana

Carleigh Wilson, DO, Indiana

Erin Brown, ARNP, Iowa

Adam Gray, Iowa

Paul Greco, MD, Iowa

Shelly McGurk, ACNP, ARNP, Iowa

Julie Stanik-Hutt, ACNP, CNS, PhD, Iowa

Elizabeth Cozad, DO, Kansas

Roshan Pais, Kentucky

Mark Youssef, MD, Kentucky

Heather Kahn, MD, Louisiana

Danielle Parrott, PA-C, Maine

Erica Lafferty, ACNP, Maryland

Andrea Limpuangthip, Maryland

Steven Schwartz, CCM, MD, Maryland

Eisha Azhar, MBBS, Massachusetts

Badal Kalamkar, MD, MPH, Massachusetts

Bhavya Rajanna, MD, Massachusetts

Sahib Baljinder Singh, MD, Massachusetts

Kathryn Adams, Michigan

Haseeb Aslam, MD, MBBS, Michigan

Hilda Crispin, MD, Michigan

Sharmistha Dev, MD, Michigan

Tristan Feierabend, MD, Michigan

Sonal Kamalia, MD, MBBS, Michigan

Matthew Luzum, MD, Michigan

Daniel Mitzel, MD, Michigan

Richard Raad, Michigan

Mythri Ramegowda, MD, Michigan

Katie Scally, MD, Michigan

Linden Spital, MSN, NP, Michigan

Porama Koy Thanaporn, MD, Michigan

Chanteil Ulatowski, Michigan

Tingting Xiong, MD, Michigan

Adam Zahr, Michigan

Mike Beste, MD, Minnesota

Elise Haupt, PA-C, Minnesota

Lobsang Trasar, MD, Minnesota

Kari Goan, DO, Mississippi

David C. Pierre, Mississippi

Sudheer Tangella, MD, Mississippi

Tahani Atieh, Missouri

Nicholas Arnold, Missouri

Amanda Calhoun, Missouri

Jyotirmoy Das, Missouri

Umber Dube, Missouri

Daniel Gaughan, Missouri

Woojin Joo, Missouri

Khaled Jumean, MBBS, Missouri

Salma Kazmi, MBBS, MD, Missouri

Yoon Kook (Danny) Kim, Missouri

Ryan Kronen, Missouri

Alyssa Kroner, Missouri

Randy Laine, Missouri

Edward Lee, Missouri

Cerena Leung, Missouri

Patricia Lithrow, Missouri

Brandt Lydon, Missouri

Mary Morgan Scott, Missouri

Jay Patel, Missouri

Justin Porter, Missouri

Danelle Reagin, FNP-C, Missouri

Amanda Reis, Missouri

Awik Som, Missouri

Abby Sung, Missouri

Mary Sutherland, Missouri

Maggie Wang, Missouri

Noah Wasserman, Missouri

Alexis Webber, Missouri

Ryan White, Missouri

Amy Xu, Missouri

Ran Xu, Missouri

Michael Yang, Missouri

Christopher Dietrich, MD, Montana

Jason Kunz, DO, Montana

Jodi Cantrell, MD, Nebraska

Steven Hart, MD, Nebraska

Kurt Kapels, MD, Nebraska

Brian Keegan, MD, Nebraska

Shaun Jang, MD, Nevada

Gurpinder Singh, MD, New Hampshire

Pragati Banda, MD, New Jersey

Sahai Donaldson, MBBS, New Jersey

Ashesha Mechineni, MD, New Jersey

Alisa Clark, New Mexico

Prajit Arora, MBBS, New Mexico

Crystal Cardwell, New Mexico

Landon Casaus, New Mexico

Tapuwa Mupfumira, MD, New Mexico

Eric Rightley, New Mexico

David S. Anderson, New York

Joan Bosco, MD, New York

Jessica Caro, New York

Anna Dewan, New York

Amrita Dhillon, MBBS, New York

Julia Frydman, New York

Radhika Gali, MBBS, MDS, New York

Allison Guttmann, MD, New York

Aryles Hedjar, MD, New York

Peter Janes, New York

Nadine Kalavazoff, New York

Jeffrey Lach, DO, New York

Keron Lezama, MD, New York

Yingheng Liu, New York

Taimur Mirza, New York

Cyrus Nensey, MD, New York

Nekee Pandya, MD, New York

Thushara Paul, MD, New York

Yu Sung, New York

Joel Boggan, MD, North Carolina

Angela Fletcher, North Carolina

Rebecca Gimpert, PA-C, North Carolina

Samantha Levering, PA-C, North Carolina

Nancy Martin, North Carolina

Richard Sherwood, North Carolina

Kranthi K. Sitammagari, MD, North Carolina

Aaron Swedberg, MPAS, PA-C, North Carolina

Yih-Cherng Tsai, North Carolina

Richard Bakker, MD, PhD, Ohio

Matthew Broderick, MD, Ohio

Subbaraju Budharaju, MD, MS, Ohio

Steven Bumb, MD, Ohio

Ahmed Eltelbany, MD, Ohio

Tracey Hardin, MS, Ohio

Patricia Hardman, APRN, Ohio

Michael Lewis, MD, Ohio

Volodymyr Manko, Ohio

Rebecca Stone, Ohio

Chaitanya Valluri, Ohio

Holly Wierzbicki, CNP, Ohio

Jamie Yockey, APRN, CNP, Ohio

Mahdi Mussa, MD, Oklahoma

Monica Saemz, DO, Oklahoma

Peter Ganter, MD, Oregon

Bethany Roy, MD, Oregon

Mary Clare Bohnett, Oregon

Molly Rabinowitz, Oregon

Abdullateef Abdulkareem, MD, MPH, Pennsylvania

David Ahamba, MD, MPH, Pennsylvania

David Chin, MD, Pennsylvania

Thomas Conlon, Pennsylvania

Dan Giesler, MD, Pennsylvania

Umair Randhawa, MD, Pennsylvania

Syed Yusuf, MBBS, Pennsylvania

Michael Rigatti, Pennsylvania

Thaylon Barreto, Rhode Island

Jessica Cook, MD, South Carolina

Robin Malik, MD, South Carolina

John Busigin, Tennessee

Shefali Paranjape, MD, Tennessee

Thai Dang, MD, Texas

Matthew Glover, MD, Texas

Snigdha Jain, MD, Texas

David Kellenberger, Texas

Sumeet Kumar, Texas

Kyle McClendon, PA-C, Texas

Sowjanya Mohan, Texas

Akhil D. Vats, MD, Texas

Samatha Vellanki, Texas

Lee-Anna Burgess, MD, Vermont

Rick Hildebrant, MD, Vermont

Matthew Backens, MD, Virginia

Megan Coe, Virginia

Kevin Dehaan, Virginia

Stephen Fox, Virginia

Amber Inofuentes, MD, Virginia

Jessica Keiser, MD, Virginia

Joseph Perez, MD, FAAFP, MBA, Virginia

Kanwapreet S. Saini, MD, Virginia

Erin Vipler, MD, Virginia

Naveen Voore, MBBS, Virginia

Abhishek Agarwal, MD, MBBS, Washington

Robert Cooney, MD, Washington

Cynthia Horton, MD, Washington

Rich A. Kukreja, MD, Washington

Ji Young Nam, MD, Washington

Kai Wilhelm, MD, Washington

In Kyu Yoo, Washington

Temu Brown, Wisconsin

Pablo Colon Nieves, Wisconsin

Christina Evans, PAC, Wisconsin

Swetha Karturi, MBBS, Wisconsin

Mark Babcock, DO, Wyoming

Ahmad Von Schlegell, Canada

Anand Kartha, Japan

Mohamed Sadek, Qatar

Amine Rakab, MD, Qatar

Abazar Saeed, Qatar

Joao Guerra, MD

Justin Kimsey, Alabama

Mohammed N.Y. Shah, MD, Alaska

Katharina Beeler, MD, Arizona

Khoi Nguyen, MD, Arizona

Vinay Saini, MD, Arizona

Maria Aceves, PA-C, California

Sarvenaz Alibeigi, California

Peter Cadman, MD, California

Katrina Chapman, DO, MPH, California

Cheryll Gallardo-Villena, MD, California

Sripriya Ganesan, California

Alice Gong, MD, California

Henry Kwang, MD, California

Kevin Li, California

Anthony Murphy, MD, California

Dan Nguyen, California

Daniel Oh, California

Joon Parle, California

Katie Raffel, California

Darshana Sarathchandra, MD, California

Lifang Zhang, California

Jaime Baker, MD, Colorado

Eric Johnson, PA-C, Colorado

Juan Lessing, MD, Colorado

Benjamin Ruckman, DO, Colorado

Rehaan Shaffie, MD, Colorado

Deborah Casey, MD, Connecticut

Daniel Heacock, PA-C, Connecticut

Shabana Ansari, DO, Delaware

Madhu Prattipati, MD, Delaware

Pallavi Aneja, MD, Florida

Satcha Borgella, MD, Florida

Thendrex H. Estrella, MD, Florida

Abid Hussain, MD, Florida

Daphnee Hutchinson, DO, Florida

Muhammad Jaffer, Florida

Sue Lee, ANP, Florida

Melissa Odermann, DO, Florida

Jose Guillermo Revelo Paiz, MD, Florida

Rafael J. Rolon Rivera, MD, Florida

Eleonor Rongo, Florida

Esther Roth, Florida

Shitaye Argaw, MD, Georgia

Taryn DeGrazia, Georgia

Becca Feistritzer, Georgia

Jamal Fitts, Georgia

Kristen Flint, Georgia

Zachary Hermes, Georgia

Mukesh Kumar, Georgia

Kajal Patel, Georgia

Madeline Smith, Georgia

Wade Flowers, PharmD, Idaho

Ajay Bhandare, Illinois

Kimberly Brighton, Illinois

Hristo D. Hristov, MD, Illinois

Sidney Iriana, Illinois

Aurelian Ivan, Illinois

Ming Lee, MD, Illinois

Michelle Lundholm, Illinois

Idrees Mohiuddin, MD, Illinois

Murr Murray, Illinois

Tad Nair, MD, Illinois

Shalini Reddy, MD, Illinois

Richard Rethorst, MD, Illinois

Kelly Robertshaw, Illinois

Gracelene Wegrzyn, Illinois

Evan Yates, Illinois

Lora J. Jones McClure, MD, Indiana

Carleigh Wilson, DO, Indiana

Erin Brown, ARNP, Iowa

Adam Gray, Iowa

Paul Greco, MD, Iowa

Shelly McGurk, ACNP, ARNP, Iowa

Julie Stanik-Hutt, ACNP, CNS, PhD, Iowa

Elizabeth Cozad, DO, Kansas

Roshan Pais, Kentucky

Mark Youssef, MD, Kentucky

Heather Kahn, MD, Louisiana

Danielle Parrott, PA-C, Maine

Erica Lafferty, ACNP, Maryland

Andrea Limpuangthip, Maryland

Steven Schwartz, CCM, MD, Maryland

Eisha Azhar, MBBS, Massachusetts

Badal Kalamkar, MD, MPH, Massachusetts

Bhavya Rajanna, MD, Massachusetts

Sahib Baljinder Singh, MD, Massachusetts

Kathryn Adams, Michigan

Haseeb Aslam, MD, MBBS, Michigan

Hilda Crispin, MD, Michigan

Sharmistha Dev, MD, Michigan

Tristan Feierabend, MD, Michigan

Sonal Kamalia, MD, MBBS, Michigan

Matthew Luzum, MD, Michigan

Daniel Mitzel, MD, Michigan

Richard Raad, Michigan

Mythri Ramegowda, MD, Michigan

Katie Scally, MD, Michigan

Linden Spital, MSN, NP, Michigan

Porama Koy Thanaporn, MD, Michigan

Chanteil Ulatowski, Michigan

Tingting Xiong, MD, Michigan

Adam Zahr, Michigan

Mike Beste, MD, Minnesota

Elise Haupt, PA-C, Minnesota

Lobsang Trasar, MD, Minnesota

Kari Goan, DO, Mississippi

David C. Pierre, Mississippi

Sudheer Tangella, MD, Mississippi

Tahani Atieh, Missouri

Nicholas Arnold, Missouri

Amanda Calhoun, Missouri

Jyotirmoy Das, Missouri

Umber Dube, Missouri

Daniel Gaughan, Missouri

Woojin Joo, Missouri

Khaled Jumean, MBBS, Missouri

Salma Kazmi, MBBS, MD, Missouri

Yoon Kook (Danny) Kim, Missouri

Ryan Kronen, Missouri

Alyssa Kroner, Missouri

Randy Laine, Missouri

Edward Lee, Missouri

Cerena Leung, Missouri

Patricia Lithrow, Missouri

Brandt Lydon, Missouri

Mary Morgan Scott, Missouri

Jay Patel, Missouri

Justin Porter, Missouri

Danelle Reagin, FNP-C, Missouri

Amanda Reis, Missouri

Awik Som, Missouri

Abby Sung, Missouri

Mary Sutherland, Missouri

Maggie Wang, Missouri

Noah Wasserman, Missouri

Alexis Webber, Missouri

Ryan White, Missouri

Amy Xu, Missouri

Ran Xu, Missouri

Michael Yang, Missouri

Christopher Dietrich, MD, Montana

Jason Kunz, DO, Montana

Jodi Cantrell, MD, Nebraska

Steven Hart, MD, Nebraska

Kurt Kapels, MD, Nebraska

Brian Keegan, MD, Nebraska

Shaun Jang, MD, Nevada

Gurpinder Singh, MD, New Hampshire

Pragati Banda, MD, New Jersey

Sahai Donaldson, MBBS, New Jersey

Ashesha Mechineni, MD, New Jersey

Alisa Clark, New Mexico

Prajit Arora, MBBS, New Mexico

Crystal Cardwell, New Mexico

Landon Casaus, New Mexico

Tapuwa Mupfumira, MD, New Mexico

Eric Rightley, New Mexico

David S. Anderson, New York

Joan Bosco, MD, New York

Jessica Caro, New York

Anna Dewan, New York

Amrita Dhillon, MBBS, New York

Julia Frydman, New York

Radhika Gali, MBBS, MDS, New York

Allison Guttmann, MD, New York

Aryles Hedjar, MD, New York

Peter Janes, New York

Nadine Kalavazoff, New York

Jeffrey Lach, DO, New York

Keron Lezama, MD, New York

Yingheng Liu, New York

Taimur Mirza, New York

Cyrus Nensey, MD, New York

Nekee Pandya, MD, New York

Thushara Paul, MD, New York

Yu Sung, New York

Joel Boggan, MD, North Carolina

Angela Fletcher, North Carolina

Rebecca Gimpert, PA-C, North Carolina

Samantha Levering, PA-C, North Carolina

Nancy Martin, North Carolina

Richard Sherwood, North Carolina

Kranthi K. Sitammagari, MD, North Carolina

Aaron Swedberg, MPAS, PA-C, North Carolina

Yih-Cherng Tsai, North Carolina

Richard Bakker, MD, PhD, Ohio

Matthew Broderick, MD, Ohio

Subbaraju Budharaju, MD, MS, Ohio

Steven Bumb, MD, Ohio

Ahmed Eltelbany, MD, Ohio

Tracey Hardin, MS, Ohio

Patricia Hardman, APRN, Ohio

Michael Lewis, MD, Ohio

Volodymyr Manko, Ohio

Rebecca Stone, Ohio

Chaitanya Valluri, Ohio

Holly Wierzbicki, CNP, Ohio

Jamie Yockey, APRN, CNP, Ohio

Mahdi Mussa, MD, Oklahoma

Monica Saemz, DO, Oklahoma

Peter Ganter, MD, Oregon

Bethany Roy, MD, Oregon

Mary Clare Bohnett, Oregon

Molly Rabinowitz, Oregon

Abdullateef Abdulkareem, MD, MPH, Pennsylvania

David Ahamba, MD, MPH, Pennsylvania

David Chin, MD, Pennsylvania

Thomas Conlon, Pennsylvania

Dan Giesler, MD, Pennsylvania

Umair Randhawa, MD, Pennsylvania

Syed Yusuf, MBBS, Pennsylvania

Michael Rigatti, Pennsylvania

Thaylon Barreto, Rhode Island

Jessica Cook, MD, South Carolina

Robin Malik, MD, South Carolina

John Busigin, Tennessee

Shefali Paranjape, MD, Tennessee

Thai Dang, MD, Texas

Matthew Glover, MD, Texas

Snigdha Jain, MD, Texas

David Kellenberger, Texas

Sumeet Kumar, Texas

Kyle McClendon, PA-C, Texas

Sowjanya Mohan, Texas

Akhil D. Vats, MD, Texas

Samatha Vellanki, Texas

Lee-Anna Burgess, MD, Vermont

Rick Hildebrant, MD, Vermont

Matthew Backens, MD, Virginia

Megan Coe, Virginia

Kevin Dehaan, Virginia

Stephen Fox, Virginia

Amber Inofuentes, MD, Virginia

Jessica Keiser, MD, Virginia

Joseph Perez, MD, FAAFP, MBA, Virginia

Kanwapreet S. Saini, MD, Virginia

Erin Vipler, MD, Virginia

Naveen Voore, MBBS, Virginia

Abhishek Agarwal, MD, MBBS, Washington

Robert Cooney, MD, Washington

Cynthia Horton, MD, Washington

Rich A. Kukreja, MD, Washington

Ji Young Nam, MD, Washington

Kai Wilhelm, MD, Washington

In Kyu Yoo, Washington

Temu Brown, Wisconsin

Pablo Colon Nieves, Wisconsin

Christina Evans, PAC, Wisconsin

Swetha Karturi, MBBS, Wisconsin

Mark Babcock, DO, Wyoming

Ahmad Von Schlegell, Canada

Anand Kartha, Japan

Mohamed Sadek, Qatar

Amine Rakab, MD, Qatar

Abazar Saeed, Qatar

Joao Guerra, MD

Justin Kimsey, Alabama

Mohammed N.Y. Shah, MD, Alaska

Katharina Beeler, MD, Arizona

Khoi Nguyen, MD, Arizona

Vinay Saini, MD, Arizona

Maria Aceves, PA-C, California

Sarvenaz Alibeigi, California

Peter Cadman, MD, California

Katrina Chapman, DO, MPH, California

Cheryll Gallardo-Villena, MD, California

Sripriya Ganesan, California

Alice Gong, MD, California

Henry Kwang, MD, California

Kevin Li, California

Anthony Murphy, MD, California

Dan Nguyen, California

Daniel Oh, California

Joon Parle, California

Katie Raffel, California

Darshana Sarathchandra, MD, California

Lifang Zhang, California

Jaime Baker, MD, Colorado

Eric Johnson, PA-C, Colorado

Juan Lessing, MD, Colorado

Benjamin Ruckman, DO, Colorado

Rehaan Shaffie, MD, Colorado

Deborah Casey, MD, Connecticut

Daniel Heacock, PA-C, Connecticut

Shabana Ansari, DO, Delaware

Madhu Prattipati, MD, Delaware

Pallavi Aneja, MD, Florida

Satcha Borgella, MD, Florida

Thendrex H. Estrella, MD, Florida

Abid Hussain, MD, Florida

Daphnee Hutchinson, DO, Florida

Muhammad Jaffer, Florida

Sue Lee, ANP, Florida

Melissa Odermann, DO, Florida

Jose Guillermo Revelo Paiz, MD, Florida

Rafael J. Rolon Rivera, MD, Florida

Eleonor Rongo, Florida

Esther Roth, Florida

Shitaye Argaw, MD, Georgia

Taryn DeGrazia, Georgia

Becca Feistritzer, Georgia

Jamal Fitts, Georgia

Kristen Flint, Georgia

Zachary Hermes, Georgia

Mukesh Kumar, Georgia

Kajal Patel, Georgia

Madeline Smith, Georgia

Wade Flowers, PharmD, Idaho

Ajay Bhandare, Illinois

Kimberly Brighton, Illinois

Hristo D. Hristov, MD, Illinois

Sidney Iriana, Illinois

Aurelian Ivan, Illinois

Ming Lee, MD, Illinois

Michelle Lundholm, Illinois

Idrees Mohiuddin, MD, Illinois

Murr Murray, Illinois

Tad Nair, MD, Illinois

Shalini Reddy, MD, Illinois

Richard Rethorst, MD, Illinois

Kelly Robertshaw, Illinois

Gracelene Wegrzyn, Illinois

Evan Yates, Illinois

Lora J. Jones McClure, MD, Indiana

Carleigh Wilson, DO, Indiana

Erin Brown, ARNP, Iowa

Adam Gray, Iowa

Paul Greco, MD, Iowa

Shelly McGurk, ACNP, ARNP, Iowa

Julie Stanik-Hutt, ACNP, CNS, PhD, Iowa

Elizabeth Cozad, DO, Kansas

Roshan Pais, Kentucky

Mark Youssef, MD, Kentucky

Heather Kahn, MD, Louisiana

Danielle Parrott, PA-C, Maine

Erica Lafferty, ACNP, Maryland

Andrea Limpuangthip, Maryland

Steven Schwartz, CCM, MD, Maryland

Eisha Azhar, MBBS, Massachusetts

Badal Kalamkar, MD, MPH, Massachusetts

Bhavya Rajanna, MD, Massachusetts

Sahib Baljinder Singh, MD, Massachusetts

Kathryn Adams, Michigan

Haseeb Aslam, MD, MBBS, Michigan

Hilda Crispin, MD, Michigan

Sharmistha Dev, MD, Michigan

Tristan Feierabend, MD, Michigan

Sonal Kamalia, MD, MBBS, Michigan

Matthew Luzum, MD, Michigan

Daniel Mitzel, MD, Michigan

Richard Raad, Michigan

Mythri Ramegowda, MD, Michigan

Katie Scally, MD, Michigan

Linden Spital, MSN, NP, Michigan

Porama Koy Thanaporn, MD, Michigan

Chanteil Ulatowski, Michigan

Tingting Xiong, MD, Michigan

Adam Zahr, Michigan

Mike Beste, MD, Minnesota

Elise Haupt, PA-C, Minnesota

Lobsang Trasar, MD, Minnesota

Kari Goan, DO, Mississippi

David C. Pierre, Mississippi

Sudheer Tangella, MD, Mississippi

Tahani Atieh, Missouri

Nicholas Arnold, Missouri

Amanda Calhoun, Missouri

Jyotirmoy Das, Missouri

Umber Dube, Missouri

Daniel Gaughan, Missouri

Woojin Joo, Missouri

Khaled Jumean, MBBS, Missouri

Salma Kazmi, MBBS, MD, Missouri

Yoon Kook (Danny) Kim, Missouri

Ryan Kronen, Missouri

Alyssa Kroner, Missouri

Randy Laine, Missouri

Edward Lee, Missouri

Cerena Leung, Missouri

Patricia Lithrow, Missouri

Brandt Lydon, Missouri

Mary Morgan Scott, Missouri

Jay Patel, Missouri

Justin Porter, Missouri

Danelle Reagin, FNP-C, Missouri

Amanda Reis, Missouri

Awik Som, Missouri

Abby Sung, Missouri

Mary Sutherland, Missouri

Maggie Wang, Missouri

Noah Wasserman, Missouri

Alexis Webber, Missouri

Ryan White, Missouri

Amy Xu, Missouri

Ran Xu, Missouri

Michael Yang, Missouri

Christopher Dietrich, MD, Montana

Jason Kunz, DO, Montana

Jodi Cantrell, MD, Nebraska

Steven Hart, MD, Nebraska

Kurt Kapels, MD, Nebraska

Brian Keegan, MD, Nebraska

Shaun Jang, MD, Nevada

Gurpinder Singh, MD, New Hampshire

Pragati Banda, MD, New Jersey

Sahai Donaldson, MBBS, New Jersey

Ashesha Mechineni, MD, New Jersey

Alisa Clark, New Mexico

Prajit Arora, MBBS, New Mexico

Crystal Cardwell, New Mexico

Landon Casaus, New Mexico

Tapuwa Mupfumira, MD, New Mexico

Eric Rightley, New Mexico

David S. Anderson, New York

Joan Bosco, MD, New York

Jessica Caro, New York

Anna Dewan, New York

Amrita Dhillon, MBBS, New York

Julia Frydman, New York

Radhika Gali, MBBS, MDS, New York

Allison Guttmann, MD, New York

Aryles Hedjar, MD, New York

Peter Janes, New York

Nadine Kalavazoff, New York

Jeffrey Lach, DO, New York

Keron Lezama, MD, New York

Yingheng Liu, New York

Taimur Mirza, New York

Cyrus Nensey, MD, New York

Nekee Pandya, MD, New York

Thushara Paul, MD, New York

Yu Sung, New York

Joel Boggan, MD, North Carolina

Angela Fletcher, North Carolina

Rebecca Gimpert, PA-C, North Carolina

Samantha Levering, PA-C, North Carolina

Nancy Martin, North Carolina

Richard Sherwood, North Carolina

Kranthi K. Sitammagari, MD, North Carolina

Aaron Swedberg, MPAS, PA-C, North Carolina

Yih-Cherng Tsai, North Carolina

Richard Bakker, MD, PhD, Ohio

Matthew Broderick, MD, Ohio

Subbaraju Budharaju, MD, MS, Ohio

Steven Bumb, MD, Ohio

Ahmed Eltelbany, MD, Ohio

Tracey Hardin, MS, Ohio

Patricia Hardman, APRN, Ohio

Michael Lewis, MD, Ohio

Volodymyr Manko, Ohio

Rebecca Stone, Ohio

Chaitanya Valluri, Ohio

Holly Wierzbicki, CNP, Ohio

Jamie Yockey, APRN, CNP, Ohio

Mahdi Mussa, MD, Oklahoma

Monica Saemz, DO, Oklahoma

Peter Ganter, MD, Oregon

Bethany Roy, MD, Oregon

Mary Clare Bohnett, Oregon

Molly Rabinowitz, Oregon

Abdullateef Abdulkareem, MD, MPH, Pennsylvania

David Ahamba, MD, MPH, Pennsylvania

David Chin, MD, Pennsylvania

Thomas Conlon, Pennsylvania

Dan Giesler, MD, Pennsylvania

Umair Randhawa, MD, Pennsylvania

Syed Yusuf, MBBS, Pennsylvania

Michael Rigatti, Pennsylvania

Thaylon Barreto, Rhode Island

Jessica Cook, MD, South Carolina

Robin Malik, MD, South Carolina

John Busigin, Tennessee

Shefali Paranjape, MD, Tennessee

Thai Dang, MD, Texas

Matthew Glover, MD, Texas

Snigdha Jain, MD, Texas

David Kellenberger, Texas

Sumeet Kumar, Texas

Kyle McClendon, PA-C, Texas

Sowjanya Mohan, Texas

Akhil D. Vats, MD, Texas

Samatha Vellanki, Texas

Lee-Anna Burgess, MD, Vermont

Rick Hildebrant, MD, Vermont

Matthew Backens, MD, Virginia

Megan Coe, Virginia

Kevin Dehaan, Virginia

Stephen Fox, Virginia

Amber Inofuentes, MD, Virginia

Jessica Keiser, MD, Virginia

Joseph Perez, MD, FAAFP, MBA, Virginia

Kanwapreet S. Saini, MD, Virginia

Erin Vipler, MD, Virginia

Naveen Voore, MBBS, Virginia

Abhishek Agarwal, MD, MBBS, Washington

Robert Cooney, MD, Washington

Cynthia Horton, MD, Washington

Rich A. Kukreja, MD, Washington

Ji Young Nam, MD, Washington

Kai Wilhelm, MD, Washington

In Kyu Yoo, Washington

Temu Brown, Wisconsin

Pablo Colon Nieves, Wisconsin

Christina Evans, PAC, Wisconsin

Swetha Karturi, MBBS, Wisconsin

Mark Babcock, DO, Wyoming

Ahmad Von Schlegell, Canada

Anand Kartha, Japan

Mohamed Sadek, Qatar

Amine Rakab, MD, Qatar

Abazar Saeed, Qatar

Joao Guerra, MD

NEW ORLEANS – The adoption and use of HIV preexposure prophylaxis (PrEP) continues to lag behind studies showing its effectiveness in the high-risk population of men who have sex with men, says a clinician who works with these patients.

John Krotchko, MD, a family practitioner at Denver Health and Hospital Authority, has studied the impact of a community outreach program – targeting HIV-negative men who have sex with men – that educates about HIV PrEP and offers HIV testing. He and his colleagues have examined the effectiveness of this approach, how comfortable participants are discussing their behaviors, and have tried to determine whether availability of HIV PrEP increases high-risk behaviors.

Dr. Krotchko and his colleagues also studied overall trends in awareness about PrEP over time, as well as the acceptability of participants to take a once-daily emtricitabine/tenofovir pill. He explained in a video interview why he believes it’s important to manage these patients in a primary care setting. The interview took place at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Dr. Krotchko had no relevant financial disclosures.

NEW ORLEANS – The adoption and use of HIV preexposure prophylaxis (PrEP) continues to lag behind studies showing its effectiveness in the high-risk population of men who have sex with men, says a clinician who works with these patients.

John Krotchko, MD, a family practitioner at Denver Health and Hospital Authority, has studied the impact of a community outreach program – targeting HIV-negative men who have sex with men – that educates about HIV PrEP and offers HIV testing. He and his colleagues have examined the effectiveness of this approach, how comfortable participants are discussing their behaviors, and have tried to determine whether availability of HIV PrEP increases high-risk behaviors.

Dr. Krotchko and his colleagues also studied overall trends in awareness about PrEP over time, as well as the acceptability of participants to take a once-daily emtricitabine/tenofovir pill. He explained in a video interview why he believes it’s important to manage these patients in a primary care setting. The interview took place at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Dr. Krotchko had no relevant financial disclosures.

NEW ORLEANS – The adoption and use of HIV preexposure prophylaxis (PrEP) continues to lag behind studies showing its effectiveness in the high-risk population of men who have sex with men, says a clinician who works with these patients.

John Krotchko, MD, a family practitioner at Denver Health and Hospital Authority, has studied the impact of a community outreach program – targeting HIV-negative men who have sex with men – that educates about HIV PrEP and offers HIV testing. He and his colleagues have examined the effectiveness of this approach, how comfortable participants are discussing their behaviors, and have tried to determine whether availability of HIV PrEP increases high-risk behaviors.

Dr. Krotchko and his colleagues also studied overall trends in awareness about PrEP over time, as well as the acceptability of participants to take a once-daily emtricitabine/tenofovir pill. He explained in a video interview why he believes it’s important to manage these patients in a primary care setting. The interview took place at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Dr. Krotchko had no relevant financial disclosures.

WASHINGTON – Big changes could be in store for the Medicaid program under the potential leadership of Seema Verma as administrator of the Centers for Medicare & Medicaid Services.

In nominating Ms. Verma, President Trump called her a leading expert on Medicaid and Medicare who will help “transform our health care system for the benefit of all Americans.”

A relative unknown, Ms. Verma is a health policy consultant who has spent 20 years quietly designing policy projects involving Medicaid, including the crafting of Indiana’s Medicaid expansion under the Affordable Care Act in which she worked closely with Vice President Pence.

How the savvy consultant could alter the Medicaid program during her potential CMS tenure has been the source of much speculation. President Trump and Rep. Tom Price (R-Ga.), Health & Human Services secretary–designee, have called for the restructuring of Medicaid, including the possibility of block grants that would set limits on total annual spending regardless of enrollment or caps that would limit average spending per enrollee.

Ms. Verma’s role in the revamp will largely depend on what Congress allows, said Mark Polston, a Washington, D.C.–based health law attorney and former associate general counsel for litigation in the HHS Office of General Counsel, CMS division, under President George W. Bush.

“We don’t know what cards she has in her hands – let alone what’s in the deck for her to deal from,” Mr. Polston said at a meeting sponsored by the American Bar Association. “That’s really going to be set by Congress.”

Alicia Gallegos/Frontline Medical News

Alicia Gallegos/Frontline Medical News

Alicia Gallegos/Frontline Medical News

WASHINGTON – Big changes could be in store for the Medicaid program under the potential leadership of Seema Verma as administrator of the Centers for Medicare & Medicaid Services.

In nominating Ms. Verma, President Trump called her a leading expert on Medicaid and Medicare who will help “transform our health care system for the benefit of all Americans.”

A relative unknown, Ms. Verma is a health policy consultant who has spent 20 years quietly designing policy projects involving Medicaid, including the crafting of Indiana’s Medicaid expansion under the Affordable Care Act in which she worked closely with Vice President Pence.

How the savvy consultant could alter the Medicaid program during her potential CMS tenure has been the source of much speculation. President Trump and Rep. Tom Price (R-Ga.), Health & Human Services secretary–designee, have called for the restructuring of Medicaid, including the possibility of block grants that would set limits on total annual spending regardless of enrollment or caps that would limit average spending per enrollee.

Ms. Verma’s role in the revamp will largely depend on what Congress allows, said Mark Polston, a Washington, D.C.–based health law attorney and former associate general counsel for litigation in the HHS Office of General Counsel, CMS division, under President George W. Bush.

“We don’t know what cards she has in her hands – let alone what’s in the deck for her to deal from,” Mr. Polston said at a meeting sponsored by the American Bar Association. “That’s really going to be set by Congress.”

Alicia Gallegos/Frontline Medical News

Alicia Gallegos/Frontline Medical News

Alicia Gallegos/Frontline Medical News

WASHINGTON – Big changes could be in store for the Medicaid program under the potential leadership of Seema Verma as administrator of the Centers for Medicare & Medicaid Services.

In nominating Ms. Verma, President Trump called her a leading expert on Medicaid and Medicare who will help “transform our health care system for the benefit of all Americans.”

A relative unknown, Ms. Verma is a health policy consultant who has spent 20 years quietly designing policy projects involving Medicaid, including the crafting of Indiana’s Medicaid expansion under the Affordable Care Act in which she worked closely with Vice President Pence.

How the savvy consultant could alter the Medicaid program during her potential CMS tenure has been the source of much speculation. President Trump and Rep. Tom Price (R-Ga.), Health & Human Services secretary–designee, have called for the restructuring of Medicaid, including the possibility of block grants that would set limits on total annual spending regardless of enrollment or caps that would limit average spending per enrollee.

Ms. Verma’s role in the revamp will largely depend on what Congress allows, said Mark Polston, a Washington, D.C.–based health law attorney and former associate general counsel for litigation in the HHS Office of General Counsel, CMS division, under President George W. Bush.

“We don’t know what cards she has in her hands – let alone what’s in the deck for her to deal from,” Mr. Polston said at a meeting sponsored by the American Bar Association. “That’s really going to be set by Congress.”

Alicia Gallegos/Frontline Medical News

Alicia Gallegos/Frontline Medical News

Alicia Gallegos/Frontline Medical News

Nearly half of newly detected antimitochondrial antibodies (AMAs) in clinical practice do not lead to a diagnosis of primary biliary cholangitis (PBC), according to a prospective study.
 

Geraldine Dahlqvist, MD, and her associates examined 720 patients whose AMA tests were registered during a 1-year census period. They were divided into groups according to whether they were newly diagnosed (275), were previously diagnosed (216), or had a nonestablished diagnosis (229) of PBC. Results showed the prevalence of AMA-positive patients without evidence of PBC was 16.1 per 100,000 inhabitants. It was four (all AMA-positive patients) to six (PBC patients) times higher in women than in men. The median age was 58 years, with the median AMA titer at 1:16. Normal serum alkaline phosphatases (ALP) were 74%, and were 1.5 times above the upper limit of normal in 13% of patients, while cirrhosis was found in 6%. Among the patients with normal ALP and no evidence of cirrhosis, the 5-year incidence rate of PBC was 16%.

It was noted that no patients died officially from PBC in this study. The 1-, 3-, and 5-year rates of survival were 95%, 90%, and 75% (95% CI, 63-87), respectively, compared with 90% in the control group.

“The younger age and lower autoantibody titer of these patients, together with the frequent mild abnormalities of their biochemical liver tests, supports a very early, presymptomatic precholestatic stage of the disease,” Dr. Dahlqvist, of Catholic University of Louvain (Belgium), and her colleagues noted. “The incidence of clinical manifestations of PBC seems, however, much lower than previously reported.”

Find the full story in Hepatology (doi: 10.1002/hep.28559).

[email protected]

Nearly half of newly detected antimitochondrial antibodies (AMAs) in clinical practice do not lead to a diagnosis of primary biliary cholangitis (PBC), according to a prospective study.
 

Geraldine Dahlqvist, MD, and her associates examined 720 patients whose AMA tests were registered during a 1-year census period. They were divided into groups according to whether they were newly diagnosed (275), were previously diagnosed (216), or had a nonestablished diagnosis (229) of PBC. Results showed the prevalence of AMA-positive patients without evidence of PBC was 16.1 per 100,000 inhabitants. It was four (all AMA-positive patients) to six (PBC patients) times higher in women than in men. The median age was 58 years, with the median AMA titer at 1:16. Normal serum alkaline phosphatases (ALP) were 74%, and were 1.5 times above the upper limit of normal in 13% of patients, while cirrhosis was found in 6%. Among the patients with normal ALP and no evidence of cirrhosis, the 5-year incidence rate of PBC was 16%.

It was noted that no patients died officially from PBC in this study. The 1-, 3-, and 5-year rates of survival were 95%, 90%, and 75% (95% CI, 63-87), respectively, compared with 90% in the control group.

“The younger age and lower autoantibody titer of these patients, together with the frequent mild abnormalities of their biochemical liver tests, supports a very early, presymptomatic precholestatic stage of the disease,” Dr. Dahlqvist, of Catholic University of Louvain (Belgium), and her colleagues noted. “The incidence of clinical manifestations of PBC seems, however, much lower than previously reported.”

Find the full story in Hepatology (doi: 10.1002/hep.28559).

[email protected]

Nearly half of newly detected antimitochondrial antibodies (AMAs) in clinical practice do not lead to a diagnosis of primary biliary cholangitis (PBC), according to a prospective study.
 

Geraldine Dahlqvist, MD, and her associates examined 720 patients whose AMA tests were registered during a 1-year census period. They were divided into groups according to whether they were newly diagnosed (275), were previously diagnosed (216), or had a nonestablished diagnosis (229) of PBC. Results showed the prevalence of AMA-positive patients without evidence of PBC was 16.1 per 100,000 inhabitants. It was four (all AMA-positive patients) to six (PBC patients) times higher in women than in men. The median age was 58 years, with the median AMA titer at 1:16. Normal serum alkaline phosphatases (ALP) were 74%, and were 1.5 times above the upper limit of normal in 13% of patients, while cirrhosis was found in 6%. Among the patients with normal ALP and no evidence of cirrhosis, the 5-year incidence rate of PBC was 16%.

It was noted that no patients died officially from PBC in this study. The 1-, 3-, and 5-year rates of survival were 95%, 90%, and 75% (95% CI, 63-87), respectively, compared with 90% in the control group.

“The younger age and lower autoantibody titer of these patients, together with the frequent mild abnormalities of their biochemical liver tests, supports a very early, presymptomatic precholestatic stage of the disease,” Dr. Dahlqvist, of Catholic University of Louvain (Belgium), and her colleagues noted. “The incidence of clinical manifestations of PBC seems, however, much lower than previously reported.”

Find the full story in Hepatology (doi: 10.1002/hep.28559).

[email protected]

Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.

A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.¹ Patients also report less satisfaction and increased isolation.¹

My colleagues and I recently published a study² in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.

Medical University of South Carolina

Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.

References

1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.

2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.

Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.

A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.¹ Patients also report less satisfaction and increased isolation.¹

My colleagues and I recently published a study² in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.

Medical University of South Carolina

Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.

References

1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.

2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.

Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.

A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.¹ Patients also report less satisfaction and increased isolation.¹

My colleagues and I recently published a study² in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.

Medical University of South Carolina

Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.

References

1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.

2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.

The AKT inhibitor MK-2206 was not superior to everolimus (Afinitor) for patients with metastatic renal cell carcinoma refractory to vascular endothelial growth factor inhibitors, according to a phase II trial from the University of Texas MD Anderson Cancer Center, Houston.

Median progression-free survival was 3.68 months in the 29 patients randomized to MK-2206, versus 5.98 months in the 14 randomized to everolimus, leading to closure of the study, reported Eric Jonasch, MD, of the department of genitourinary medical oncology at MD Anderson, and his associates.

However, dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm.

“Whereas patients treated with everolimus for the large part had minimal changes in tumor size, MK-2206 induced a fairly dichotomous response dynamic, with [a few] patients demonstrating profound response, [but] a number of patients exhibiting rapid growth,” Dr. Jonasch and associates said (Ann Oncol. 2017 Jan 3. pii: mdw676. doi: 10.1093/annonc/mdw676).

Several studies have shown that upregulation of the PI3K/AKT pathway is associated with poor prognosis in renal cell carcinoma (RCC), making the pathway an attractive target for therapeutic intervention. The trial “results indicate that potential exists for effective blockade of the PI3K pathway in patients with RCC, but considerable work is required to better understand the nuances of this pathway before we can consistently modulate it to benefit patients with RCC,” the investigators said.

Molecular analysis failed to find a biomarker for response, but did demonstrate that deleterious tumor protein 53 or ataxia telangiectasia mutations or deletions were associated with poor prognosis. Among patients who progressed, 57.1% had TP53 or ATM aberrations; TP53 and ATM defects were absent in patients who did not progress.

Malfunction of DNA repair driven by TP53 and ATM gene modifications, the group said, “are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC ... This subcategory of patients clearly needs new approaches based on our emerging understanding of the significance of TP53 mutations in RCC biology.”

MK-2206 induced significantly more rash and pruritus than did everolimus, with dose reduction in 37.9% of MK-2206 versus 21.4% of everolimus patients.

Subjects were a median of 63.5 years old in the everolimus group and 59 years in the MK-2206 group. The majority of patients were white men. More than 65% of the patients had performance status 1 and around 60% were in the Memorial Sloan Kettering Cancer Center intermediate risk group. The majority of patients in both treatment arms had clear cell histology; 57.1% (8) in the everolimus group and 82.8% (24) in the MK-2206 group had lung metastasis; half of the everolimus and 59% (17) of MK-2206 subjects were previously treated with sunitinib (Sutent).

The National Institutes of Health funded the work. The authors reported no conflicts of interest.

[email protected]

The AKT inhibitor MK-2206 was not superior to everolimus (Afinitor) for patients with metastatic renal cell carcinoma refractory to vascular endothelial growth factor inhibitors, according to a phase II trial from the University of Texas MD Anderson Cancer Center, Houston.

Median progression-free survival was 3.68 months in the 29 patients randomized to MK-2206, versus 5.98 months in the 14 randomized to everolimus, leading to closure of the study, reported Eric Jonasch, MD, of the department of genitourinary medical oncology at MD Anderson, and his associates.

However, dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm.

“Whereas patients treated with everolimus for the large part had minimal changes in tumor size, MK-2206 induced a fairly dichotomous response dynamic, with [a few] patients demonstrating profound response, [but] a number of patients exhibiting rapid growth,” Dr. Jonasch and associates said (Ann Oncol. 2017 Jan 3. pii: mdw676. doi: 10.1093/annonc/mdw676).

Several studies have shown that upregulation of the PI3K/AKT pathway is associated with poor prognosis in renal cell carcinoma (RCC), making the pathway an attractive target for therapeutic intervention. The trial “results indicate that potential exists for effective blockade of the PI3K pathway in patients with RCC, but considerable work is required to better understand the nuances of this pathway before we can consistently modulate it to benefit patients with RCC,” the investigators said.

Molecular analysis failed to find a biomarker for response, but did demonstrate that deleterious tumor protein 53 or ataxia telangiectasia mutations or deletions were associated with poor prognosis. Among patients who progressed, 57.1% had TP53 or ATM aberrations; TP53 and ATM defects were absent in patients who did not progress.

Malfunction of DNA repair driven by TP53 and ATM gene modifications, the group said, “are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC ... This subcategory of patients clearly needs new approaches based on our emerging understanding of the significance of TP53 mutations in RCC biology.”

MK-2206 induced significantly more rash and pruritus than did everolimus, with dose reduction in 37.9% of MK-2206 versus 21.4% of everolimus patients.

Subjects were a median of 63.5 years old in the everolimus group and 59 years in the MK-2206 group. The majority of patients were white men. More than 65% of the patients had performance status 1 and around 60% were in the Memorial Sloan Kettering Cancer Center intermediate risk group. The majority of patients in both treatment arms had clear cell histology; 57.1% (8) in the everolimus group and 82.8% (24) in the MK-2206 group had lung metastasis; half of the everolimus and 59% (17) of MK-2206 subjects were previously treated with sunitinib (Sutent).

The National Institutes of Health funded the work. The authors reported no conflicts of interest.

[email protected]

The AKT inhibitor MK-2206 was not superior to everolimus (Afinitor) for patients with metastatic renal cell carcinoma refractory to vascular endothelial growth factor inhibitors, according to a phase II trial from the University of Texas MD Anderson Cancer Center, Houston.

Median progression-free survival was 3.68 months in the 29 patients randomized to MK-2206, versus 5.98 months in the 14 randomized to everolimus, leading to closure of the study, reported Eric Jonasch, MD, of the department of genitourinary medical oncology at MD Anderson, and his associates.

However, dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm.

“Whereas patients treated with everolimus for the large part had minimal changes in tumor size, MK-2206 induced a fairly dichotomous response dynamic, with [a few] patients demonstrating profound response, [but] a number of patients exhibiting rapid growth,” Dr. Jonasch and associates said (Ann Oncol. 2017 Jan 3. pii: mdw676. doi: 10.1093/annonc/mdw676).

Several studies have shown that upregulation of the PI3K/AKT pathway is associated with poor prognosis in renal cell carcinoma (RCC), making the pathway an attractive target for therapeutic intervention. The trial “results indicate that potential exists for effective blockade of the PI3K pathway in patients with RCC, but considerable work is required to better understand the nuances of this pathway before we can consistently modulate it to benefit patients with RCC,” the investigators said.

Molecular analysis failed to find a biomarker for response, but did demonstrate that deleterious tumor protein 53 or ataxia telangiectasia mutations or deletions were associated with poor prognosis. Among patients who progressed, 57.1% had TP53 or ATM aberrations; TP53 and ATM defects were absent in patients who did not progress.

Malfunction of DNA repair driven by TP53 and ATM gene modifications, the group said, “are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC ... This subcategory of patients clearly needs new approaches based on our emerging understanding of the significance of TP53 mutations in RCC biology.”

MK-2206 induced significantly more rash and pruritus than did everolimus, with dose reduction in 37.9% of MK-2206 versus 21.4% of everolimus patients.

Subjects were a median of 63.5 years old in the everolimus group and 59 years in the MK-2206 group. The majority of patients were white men. More than 65% of the patients had performance status 1 and around 60% were in the Memorial Sloan Kettering Cancer Center intermediate risk group. The majority of patients in both treatment arms had clear cell histology; 57.1% (8) in the everolimus group and 82.8% (24) in the MK-2206 group had lung metastasis; half of the everolimus and 59% (17) of MK-2206 subjects were previously treated with sunitinib (Sutent).

The National Institutes of Health funded the work. The authors reported no conflicts of interest.

[email protected]