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MOC debate heats up
The American Board of Internal Medicine (ABIM) recently unveiled its first attempt to revitalize the maintenance of certification (MOC) program with pathway alternatives to the 10-year exam. While AGA has advocated for MOC reform and welcomed the efforts of the ABIM in responding to demands for change, we object to the pathways proposed by ABIM, which fall short of our principles of individualization, lifelong education, and low-stakes testing.
ABIM proposes to replace the 10-year exam with either a 2- (or 5-) year alternative MOC pathway. Every 2 (or 5) years, diplomates can take a single, 2- (or 5-) hour open-book exam, from their office or home. The exam would provide granular feedback on learning objectives in need of remediation. The exam is promoted as “low-stakes” since failure does not result in immediate loss of certification. Rather, the diplomate has the opportunity to take the next exam and, if they pass, continue on the pathway. Failure of two exams in a row means the diplomate must pass the traditional 10-year exam before continuing the MOC pathway.
AGA joined unanimously with other GI societies and the majority of other internal medicine societies in rejecting both proposed pathways as unacceptable in their present format.
AGA’s liaison to the ABIM Liaison Committee on Certification and Recertification (LCCR), Art DeCross, MD, outlined AGA’s issues with the proposal on the AGA Community in late September and kicked off a lively discussion about the future of MOC. Visit the AGA Community at community.gasto.org to read or join the conversation.
Additionally, here are two key things to know:
1. Regarding state legislation, AGA President Tim Wang, MD, notes that “We’re monitoring legislative actions in various states and note that there would need to be commitment to the same approach by all 50 states in order to have the necessary impact to completely unlink MOC certification from hospital and insurance credentialing for AGA members. So instead, AGA is focusing our work on national advocacy, which is where we can have the most impact.”
2. While there is a lot of activity related to reforming MOC, the time horizon for changes is long. Dr. DeCross notes that “members really should plan on continuing their current, standard MOC pathway process, including taking their recertification examinations, if they want to retain that credential at this time.”
This conversation is the latest in a long advocacy campaign lead by AGA to push ABIM to reform MOC. Learn more at www.gastro.org/career-center/maintenance-of-certification.
The American Board of Internal Medicine (ABIM) recently unveiled its first attempt to revitalize the maintenance of certification (MOC) program with pathway alternatives to the 10-year exam. While AGA has advocated for MOC reform and welcomed the efforts of the ABIM in responding to demands for change, we object to the pathways proposed by ABIM, which fall short of our principles of individualization, lifelong education, and low-stakes testing.
ABIM proposes to replace the 10-year exam with either a 2- (or 5-) year alternative MOC pathway. Every 2 (or 5) years, diplomates can take a single, 2- (or 5-) hour open-book exam, from their office or home. The exam would provide granular feedback on learning objectives in need of remediation. The exam is promoted as “low-stakes” since failure does not result in immediate loss of certification. Rather, the diplomate has the opportunity to take the next exam and, if they pass, continue on the pathway. Failure of two exams in a row means the diplomate must pass the traditional 10-year exam before continuing the MOC pathway.
AGA joined unanimously with other GI societies and the majority of other internal medicine societies in rejecting both proposed pathways as unacceptable in their present format.
AGA’s liaison to the ABIM Liaison Committee on Certification and Recertification (LCCR), Art DeCross, MD, outlined AGA’s issues with the proposal on the AGA Community in late September and kicked off a lively discussion about the future of MOC. Visit the AGA Community at community.gasto.org to read or join the conversation.
Additionally, here are two key things to know:
1. Regarding state legislation, AGA President Tim Wang, MD, notes that “We’re monitoring legislative actions in various states and note that there would need to be commitment to the same approach by all 50 states in order to have the necessary impact to completely unlink MOC certification from hospital and insurance credentialing for AGA members. So instead, AGA is focusing our work on national advocacy, which is where we can have the most impact.”
2. While there is a lot of activity related to reforming MOC, the time horizon for changes is long. Dr. DeCross notes that “members really should plan on continuing their current, standard MOC pathway process, including taking their recertification examinations, if they want to retain that credential at this time.”
This conversation is the latest in a long advocacy campaign lead by AGA to push ABIM to reform MOC. Learn more at www.gastro.org/career-center/maintenance-of-certification.
The American Board of Internal Medicine (ABIM) recently unveiled its first attempt to revitalize the maintenance of certification (MOC) program with pathway alternatives to the 10-year exam. While AGA has advocated for MOC reform and welcomed the efforts of the ABIM in responding to demands for change, we object to the pathways proposed by ABIM, which fall short of our principles of individualization, lifelong education, and low-stakes testing.
ABIM proposes to replace the 10-year exam with either a 2- (or 5-) year alternative MOC pathway. Every 2 (or 5) years, diplomates can take a single, 2- (or 5-) hour open-book exam, from their office or home. The exam would provide granular feedback on learning objectives in need of remediation. The exam is promoted as “low-stakes” since failure does not result in immediate loss of certification. Rather, the diplomate has the opportunity to take the next exam and, if they pass, continue on the pathway. Failure of two exams in a row means the diplomate must pass the traditional 10-year exam before continuing the MOC pathway.
AGA joined unanimously with other GI societies and the majority of other internal medicine societies in rejecting both proposed pathways as unacceptable in their present format.
AGA’s liaison to the ABIM Liaison Committee on Certification and Recertification (LCCR), Art DeCross, MD, outlined AGA’s issues with the proposal on the AGA Community in late September and kicked off a lively discussion about the future of MOC. Visit the AGA Community at community.gasto.org to read or join the conversation.
Additionally, here are two key things to know:
1. Regarding state legislation, AGA President Tim Wang, MD, notes that “We’re monitoring legislative actions in various states and note that there would need to be commitment to the same approach by all 50 states in order to have the necessary impact to completely unlink MOC certification from hospital and insurance credentialing for AGA members. So instead, AGA is focusing our work on national advocacy, which is where we can have the most impact.”
2. While there is a lot of activity related to reforming MOC, the time horizon for changes is long. Dr. DeCross notes that “members really should plan on continuing their current, standard MOC pathway process, including taking their recertification examinations, if they want to retain that credential at this time.”
This conversation is the latest in a long advocacy campaign lead by AGA to push ABIM to reform MOC. Learn more at www.gastro.org/career-center/maintenance-of-certification.
Lung cancer screening found effective in a community hospital
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
AT CHEST 2016
Key clinical point:
Major finding: Of nine lung cancers detected, seven (78%) were stage I or II lung cancers and the remaining two (22%) were stage II or IV.
Data source: Results from 514 patients enrolled in a community hospital–based lung cancer screening program between July 2013 and December 2015.
Disclosures: Dr. Salzano reported having no relevant financial disclosures.
Smoking-attributable cancer mortality highest in Kentucky
Almost 29% of cancer deaths among U.S. adults aged 35 years and older were attributable to cigarette smoking in 2014, according to investigators from the American Cancer Society.
Of the 585,000 cancer deaths among those 35 years and older that year, more than 167,000 (28.6%) were estimated to be the result of cigarette smoking, reported Joannie Lortet-Tieulent, MSc, and her associates at the ACS in Atlanta (JAMA Intern Med. 2016 Oct 24. doi: 10.1001/jamainternmed.2016.6530).
Among men aged 35 years and older, 33.7% of U.S. cancer deaths were attributable to cigarette smoking, compared with 22.9% for women. Arkansas had the highest rate (39.5%) for men and Kentucky had the highest rate (29.0%) for women. Not surprisingly, Utah had the lowest rate for both men (21.8%) and women (11.1%), according to the analysis of data from the 2014 Behavioral Risk Factor Surveillance System. For men, Utah was the only state with a rate below 30%.
The investigators did not report any conflicts of interest. The study was supported by the intramural research department of the American Cancer Society.
Almost 29% of cancer deaths among U.S. adults aged 35 years and older were attributable to cigarette smoking in 2014, according to investigators from the American Cancer Society.
Of the 585,000 cancer deaths among those 35 years and older that year, more than 167,000 (28.6%) were estimated to be the result of cigarette smoking, reported Joannie Lortet-Tieulent, MSc, and her associates at the ACS in Atlanta (JAMA Intern Med. 2016 Oct 24. doi: 10.1001/jamainternmed.2016.6530).
Among men aged 35 years and older, 33.7% of U.S. cancer deaths were attributable to cigarette smoking, compared with 22.9% for women. Arkansas had the highest rate (39.5%) for men and Kentucky had the highest rate (29.0%) for women. Not surprisingly, Utah had the lowest rate for both men (21.8%) and women (11.1%), according to the analysis of data from the 2014 Behavioral Risk Factor Surveillance System. For men, Utah was the only state with a rate below 30%.
The investigators did not report any conflicts of interest. The study was supported by the intramural research department of the American Cancer Society.
Almost 29% of cancer deaths among U.S. adults aged 35 years and older were attributable to cigarette smoking in 2014, according to investigators from the American Cancer Society.
Of the 585,000 cancer deaths among those 35 years and older that year, more than 167,000 (28.6%) were estimated to be the result of cigarette smoking, reported Joannie Lortet-Tieulent, MSc, and her associates at the ACS in Atlanta (JAMA Intern Med. 2016 Oct 24. doi: 10.1001/jamainternmed.2016.6530).
Among men aged 35 years and older, 33.7% of U.S. cancer deaths were attributable to cigarette smoking, compared with 22.9% for women. Arkansas had the highest rate (39.5%) for men and Kentucky had the highest rate (29.0%) for women. Not surprisingly, Utah had the lowest rate for both men (21.8%) and women (11.1%), according to the analysis of data from the 2014 Behavioral Risk Factor Surveillance System. For men, Utah was the only state with a rate below 30%.
The investigators did not report any conflicts of interest. The study was supported by the intramural research department of the American Cancer Society.
Joint European atrial fibrillation guidelines break new ground
ROME – The 2016 joint European guidelines on management of atrial fibrillation break new ground by declaring as a strong Class IA recommendation that the novel oral anticoagulants are now the drugs of choice – preferred over warfarin – for stroke prevention.
The joint guidelines from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery recommend that warfarin’s use be reserved for the relatively small proportion of atrial fibrillation (AF) patients who are ineligible for the four commercially available novel oral anticoagulants (NOACs). That’s mainly patients with mechanical heart valves, moderate to severe mitral stenosis, or severe chronic kidney disease.
The ESC/EACTS guidelines, taken together with the American College of Chest Physicians guidelines on antithrombotic therapy for venous thromboembolic disease released earlier in the year, suggest that the old war horse warfarin is being eased out to pasture. The ACCP guidelines recommend any of the four NOACS – apixaban, dabigatran, edoxaban, or rivaroxaban – be used preferentially over warfarin in the treatment of venous thromboembolism (Chest 2016 Feb;149[2]:315-52). Both sets of guidelines cite compelling evidence that the NOACs are significantly safer than warfarin yet equally effective.
The ESC/EACTS guidelines are a full rewrite containing numerous departures from the previous 2012 AF management guidelines as well as from current ACC/AHA guidelines. The report includes more than 1,000 references. Eighty percent of the 154 recommendations provide Class I or IIa guidance. Two-thirds of the recommendations are Level of Evidence A or B, task force chairperson Paulus Kirchhof, MD, said at the annual congress of the European Society of Cardiology.
He and co-chairperson Stefano Benussi, MD, presented some of the highlights.
The guidelines issue a strong call for greater use of targeted ECG screening in populations at risk for silent AF, including stroke survivors and the elderly. And AF should always be documented before starting treatment, given that all of the treatments carry risk, said Dr. Kirchhof, professor of cardiovascular medicine at the University of Birmingham (England).
Once the diagnosis is established, it’s essential to address in a structured way five domains of management: acute rate and rhythm control; management of precipitating factors, including underlying cardiovascular conditions such as hypertension or valvular heart disease; assessment of stroke risk using the CHA2DS2-VASc scoring system; assessment of heart rate; and evaluation of the impact of AF symptoms on the patient’s life, including fatigue and breathlessness, using a structured instrument such as the modified European Heart Rhythm Association symptom scale.
Men with a CHA2DS2-VASc score of 1 and women with a score of 2 should be considered for anticoagulation. And the treatment should be recommended – not merely considered – for men with a score of 2 or more and women with a score of 3; that’s a Class Ia recommendation, Dr. Kirchhof continued.
The use of a specific bleeding risk score is no longer recommended in AF patients on oral anticoagulation. The emphasis has shifted to reduction of modifiable bleeding risk factors, including limiting alcohol intake to fewer than 8 drinks per week, control of hypertension, and discontinuing antiplatelet and anti-inflammatory agents.
Consideration of left atrial appendage occlusion devices should be reserved for the small percentage of patients who have clear contraindications to all forms of oral anticoagulation.
The task force concluded that patients who have bleeding on oral anticoagulation can often be managed with local therapy and discontinuation of anticoagulation therapy for a day or two before resumption. However, decisions regarding resumption of a NOAC or warfarin after an intracranial bleed should be handled by an interdisciplinary panel composed of a stroke neurologist, a cardiologist, a neuroradiologist, and a neurosurgeon.
Evidence-based treatment options in patients with symptomatic AF after failed catheter ablation include minimally invasive surgery with epicardial pulmonary vein isolation, more extensive catheter ablation, and hybrid procedures, according to Dr. Benussi, who is codirector of clinical cardiovascular surgery at University Hospital in Zurich.
The guidelines state that the data supporting catheter ablation to achieve long-term rhythm control are now sufficiently strong that this intervention should be considered as a first-line option alongside antiarrhythmic drugs as a matter of patient preference in the setting of symptomatic paroxysmal AF regardless of whether the patient has CAD, heart failure, valvular heart disease, or no structural heart disease.
Catheter ablation using radiofrequency energy or cryoablation should target complete isolation of the pulmonary veins.
“Additional ablation lines do not provide demonstrable clinical benefit and increase the risk of postablation left atrial arrhythmias,” the surgeon said.
Maze surgery, preferably biatrial, received a favorable Class IIa, Level of Evidence A recommendation as worthy of consideration in patients with symptomatic AF who are already undergoing cardiac surgery. This recommendation was based upon an external review by the Cochrane group which was commissioned by the guidelines task force. The Cochrane review of eight published studies concluded that Maze surgery under such circumstances was associated with a twofold increased freedom from AF, atrial flutter, and atrial tachycardia (Cochrane Database of Systematic Reviews 2016;8: CD012088. doi: 10.1002/14651858.CD012088.pub2).
The AF management guidelines are supported by the ESC Pocket Guidelines app, which includes an overall AF treatment manager developed by the European Union–funded CATCH ME (Characterizing Atrial Fibrillation by Translating its Causes Into Health Modifiers in the Elderly) project.
The multidisciplinary 17-member AF management task force was drawn from cardiology, stroke neurology, cardiac surgery, and specialist nursing. Dr. Kirchhof stressed that only recommendations supported by at least 75% of task force members made it into the guidelines (Eur Heart J. 2016 Aug 27. pii: ehw210. [Epub ahead of print] doi: 10.1093/eurheartj/ehw210).
ROME – The 2016 joint European guidelines on management of atrial fibrillation break new ground by declaring as a strong Class IA recommendation that the novel oral anticoagulants are now the drugs of choice – preferred over warfarin – for stroke prevention.
The joint guidelines from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery recommend that warfarin’s use be reserved for the relatively small proportion of atrial fibrillation (AF) patients who are ineligible for the four commercially available novel oral anticoagulants (NOACs). That’s mainly patients with mechanical heart valves, moderate to severe mitral stenosis, or severe chronic kidney disease.
The ESC/EACTS guidelines, taken together with the American College of Chest Physicians guidelines on antithrombotic therapy for venous thromboembolic disease released earlier in the year, suggest that the old war horse warfarin is being eased out to pasture. The ACCP guidelines recommend any of the four NOACS – apixaban, dabigatran, edoxaban, or rivaroxaban – be used preferentially over warfarin in the treatment of venous thromboembolism (Chest 2016 Feb;149[2]:315-52). Both sets of guidelines cite compelling evidence that the NOACs are significantly safer than warfarin yet equally effective.
The ESC/EACTS guidelines are a full rewrite containing numerous departures from the previous 2012 AF management guidelines as well as from current ACC/AHA guidelines. The report includes more than 1,000 references. Eighty percent of the 154 recommendations provide Class I or IIa guidance. Two-thirds of the recommendations are Level of Evidence A or B, task force chairperson Paulus Kirchhof, MD, said at the annual congress of the European Society of Cardiology.
He and co-chairperson Stefano Benussi, MD, presented some of the highlights.
The guidelines issue a strong call for greater use of targeted ECG screening in populations at risk for silent AF, including stroke survivors and the elderly. And AF should always be documented before starting treatment, given that all of the treatments carry risk, said Dr. Kirchhof, professor of cardiovascular medicine at the University of Birmingham (England).
Once the diagnosis is established, it’s essential to address in a structured way five domains of management: acute rate and rhythm control; management of precipitating factors, including underlying cardiovascular conditions such as hypertension or valvular heart disease; assessment of stroke risk using the CHA2DS2-VASc scoring system; assessment of heart rate; and evaluation of the impact of AF symptoms on the patient’s life, including fatigue and breathlessness, using a structured instrument such as the modified European Heart Rhythm Association symptom scale.
Men with a CHA2DS2-VASc score of 1 and women with a score of 2 should be considered for anticoagulation. And the treatment should be recommended – not merely considered – for men with a score of 2 or more and women with a score of 3; that’s a Class Ia recommendation, Dr. Kirchhof continued.
The use of a specific bleeding risk score is no longer recommended in AF patients on oral anticoagulation. The emphasis has shifted to reduction of modifiable bleeding risk factors, including limiting alcohol intake to fewer than 8 drinks per week, control of hypertension, and discontinuing antiplatelet and anti-inflammatory agents.
Consideration of left atrial appendage occlusion devices should be reserved for the small percentage of patients who have clear contraindications to all forms of oral anticoagulation.
The task force concluded that patients who have bleeding on oral anticoagulation can often be managed with local therapy and discontinuation of anticoagulation therapy for a day or two before resumption. However, decisions regarding resumption of a NOAC or warfarin after an intracranial bleed should be handled by an interdisciplinary panel composed of a stroke neurologist, a cardiologist, a neuroradiologist, and a neurosurgeon.
Evidence-based treatment options in patients with symptomatic AF after failed catheter ablation include minimally invasive surgery with epicardial pulmonary vein isolation, more extensive catheter ablation, and hybrid procedures, according to Dr. Benussi, who is codirector of clinical cardiovascular surgery at University Hospital in Zurich.
The guidelines state that the data supporting catheter ablation to achieve long-term rhythm control are now sufficiently strong that this intervention should be considered as a first-line option alongside antiarrhythmic drugs as a matter of patient preference in the setting of symptomatic paroxysmal AF regardless of whether the patient has CAD, heart failure, valvular heart disease, or no structural heart disease.
Catheter ablation using radiofrequency energy or cryoablation should target complete isolation of the pulmonary veins.
“Additional ablation lines do not provide demonstrable clinical benefit and increase the risk of postablation left atrial arrhythmias,” the surgeon said.
Maze surgery, preferably biatrial, received a favorable Class IIa, Level of Evidence A recommendation as worthy of consideration in patients with symptomatic AF who are already undergoing cardiac surgery. This recommendation was based upon an external review by the Cochrane group which was commissioned by the guidelines task force. The Cochrane review of eight published studies concluded that Maze surgery under such circumstances was associated with a twofold increased freedom from AF, atrial flutter, and atrial tachycardia (Cochrane Database of Systematic Reviews 2016;8: CD012088. doi: 10.1002/14651858.CD012088.pub2).
The AF management guidelines are supported by the ESC Pocket Guidelines app, which includes an overall AF treatment manager developed by the European Union–funded CATCH ME (Characterizing Atrial Fibrillation by Translating its Causes Into Health Modifiers in the Elderly) project.
The multidisciplinary 17-member AF management task force was drawn from cardiology, stroke neurology, cardiac surgery, and specialist nursing. Dr. Kirchhof stressed that only recommendations supported by at least 75% of task force members made it into the guidelines (Eur Heart J. 2016 Aug 27. pii: ehw210. [Epub ahead of print] doi: 10.1093/eurheartj/ehw210).
ROME – The 2016 joint European guidelines on management of atrial fibrillation break new ground by declaring as a strong Class IA recommendation that the novel oral anticoagulants are now the drugs of choice – preferred over warfarin – for stroke prevention.
The joint guidelines from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery recommend that warfarin’s use be reserved for the relatively small proportion of atrial fibrillation (AF) patients who are ineligible for the four commercially available novel oral anticoagulants (NOACs). That’s mainly patients with mechanical heart valves, moderate to severe mitral stenosis, or severe chronic kidney disease.
The ESC/EACTS guidelines, taken together with the American College of Chest Physicians guidelines on antithrombotic therapy for venous thromboembolic disease released earlier in the year, suggest that the old war horse warfarin is being eased out to pasture. The ACCP guidelines recommend any of the four NOACS – apixaban, dabigatran, edoxaban, or rivaroxaban – be used preferentially over warfarin in the treatment of venous thromboembolism (Chest 2016 Feb;149[2]:315-52). Both sets of guidelines cite compelling evidence that the NOACs are significantly safer than warfarin yet equally effective.
The ESC/EACTS guidelines are a full rewrite containing numerous departures from the previous 2012 AF management guidelines as well as from current ACC/AHA guidelines. The report includes more than 1,000 references. Eighty percent of the 154 recommendations provide Class I or IIa guidance. Two-thirds of the recommendations are Level of Evidence A or B, task force chairperson Paulus Kirchhof, MD, said at the annual congress of the European Society of Cardiology.
He and co-chairperson Stefano Benussi, MD, presented some of the highlights.
The guidelines issue a strong call for greater use of targeted ECG screening in populations at risk for silent AF, including stroke survivors and the elderly. And AF should always be documented before starting treatment, given that all of the treatments carry risk, said Dr. Kirchhof, professor of cardiovascular medicine at the University of Birmingham (England).
Once the diagnosis is established, it’s essential to address in a structured way five domains of management: acute rate and rhythm control; management of precipitating factors, including underlying cardiovascular conditions such as hypertension or valvular heart disease; assessment of stroke risk using the CHA2DS2-VASc scoring system; assessment of heart rate; and evaluation of the impact of AF symptoms on the patient’s life, including fatigue and breathlessness, using a structured instrument such as the modified European Heart Rhythm Association symptom scale.
Men with a CHA2DS2-VASc score of 1 and women with a score of 2 should be considered for anticoagulation. And the treatment should be recommended – not merely considered – for men with a score of 2 or more and women with a score of 3; that’s a Class Ia recommendation, Dr. Kirchhof continued.
The use of a specific bleeding risk score is no longer recommended in AF patients on oral anticoagulation. The emphasis has shifted to reduction of modifiable bleeding risk factors, including limiting alcohol intake to fewer than 8 drinks per week, control of hypertension, and discontinuing antiplatelet and anti-inflammatory agents.
Consideration of left atrial appendage occlusion devices should be reserved for the small percentage of patients who have clear contraindications to all forms of oral anticoagulation.
The task force concluded that patients who have bleeding on oral anticoagulation can often be managed with local therapy and discontinuation of anticoagulation therapy for a day or two before resumption. However, decisions regarding resumption of a NOAC or warfarin after an intracranial bleed should be handled by an interdisciplinary panel composed of a stroke neurologist, a cardiologist, a neuroradiologist, and a neurosurgeon.
Evidence-based treatment options in patients with symptomatic AF after failed catheter ablation include minimally invasive surgery with epicardial pulmonary vein isolation, more extensive catheter ablation, and hybrid procedures, according to Dr. Benussi, who is codirector of clinical cardiovascular surgery at University Hospital in Zurich.
The guidelines state that the data supporting catheter ablation to achieve long-term rhythm control are now sufficiently strong that this intervention should be considered as a first-line option alongside antiarrhythmic drugs as a matter of patient preference in the setting of symptomatic paroxysmal AF regardless of whether the patient has CAD, heart failure, valvular heart disease, or no structural heart disease.
Catheter ablation using radiofrequency energy or cryoablation should target complete isolation of the pulmonary veins.
“Additional ablation lines do not provide demonstrable clinical benefit and increase the risk of postablation left atrial arrhythmias,” the surgeon said.
Maze surgery, preferably biatrial, received a favorable Class IIa, Level of Evidence A recommendation as worthy of consideration in patients with symptomatic AF who are already undergoing cardiac surgery. This recommendation was based upon an external review by the Cochrane group which was commissioned by the guidelines task force. The Cochrane review of eight published studies concluded that Maze surgery under such circumstances was associated with a twofold increased freedom from AF, atrial flutter, and atrial tachycardia (Cochrane Database of Systematic Reviews 2016;8: CD012088. doi: 10.1002/14651858.CD012088.pub2).
The AF management guidelines are supported by the ESC Pocket Guidelines app, which includes an overall AF treatment manager developed by the European Union–funded CATCH ME (Characterizing Atrial Fibrillation by Translating its Causes Into Health Modifiers in the Elderly) project.
The multidisciplinary 17-member AF management task force was drawn from cardiology, stroke neurology, cardiac surgery, and specialist nursing. Dr. Kirchhof stressed that only recommendations supported by at least 75% of task force members made it into the guidelines (Eur Heart J. 2016 Aug 27. pii: ehw210. [Epub ahead of print] doi: 10.1093/eurheartj/ehw210).
Advisor’s Viewpoint: State legislative update
In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.
The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.
Another topic discussed was the push to create a Maternal Mortality Committee in each state. Some states have had this committee for many years and shared pearls for how to get the legislation passed. Collaboration with advocates in the medical community and with the state departments of health was considered to be critical in the passage of legislation to support the creation of these committees.
There was prolonged discussion in the general session, as well as in breakout sessions, about the different types of midwives and the goal to establish a collaborative working relationship with them. Questions discussed included the educational goals for each group, as well as their level of responsibility. The licensing of midwives varies between states, ranging from the State Board of Midwifery to the State Board of Nursing to the State Board of Medicine. Maine was recognized as a state that has successfully created a collaborative relationship with the midwives who practice there. ACOG continues to work with the American College of Nurse-Midwives to create collaborative practice relationships.
Another breakout session focused on reproductive health. This group discussed legislation that interferes with the patient-physician relationship, including mandating an outdated protocol for administering medication abortion and even threatening physicians who provide abortion services with jail time. State legislation to allow pharmacists to prescribe hormonal contraception was also reviewed.
There was consensus among the meeting participants that communication with legislators about evidence-based medicine and sound science, along with ob.gyns.’ advocacy in state legislatures, is critical to counterbalancing inappropriate political interference in the patient-physician relationship. The discussion also touched on the importance of continued collaboration with partners across the medical community, since attempts to legislate the practice of medicine can negatively impact a wide range of clinical practices.
Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.
In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.
The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.
Another topic discussed was the push to create a Maternal Mortality Committee in each state. Some states have had this committee for many years and shared pearls for how to get the legislation passed. Collaboration with advocates in the medical community and with the state departments of health was considered to be critical in the passage of legislation to support the creation of these committees.
There was prolonged discussion in the general session, as well as in breakout sessions, about the different types of midwives and the goal to establish a collaborative working relationship with them. Questions discussed included the educational goals for each group, as well as their level of responsibility. The licensing of midwives varies between states, ranging from the State Board of Midwifery to the State Board of Nursing to the State Board of Medicine. Maine was recognized as a state that has successfully created a collaborative relationship with the midwives who practice there. ACOG continues to work with the American College of Nurse-Midwives to create collaborative practice relationships.
Another breakout session focused on reproductive health. This group discussed legislation that interferes with the patient-physician relationship, including mandating an outdated protocol for administering medication abortion and even threatening physicians who provide abortion services with jail time. State legislation to allow pharmacists to prescribe hormonal contraception was also reviewed.
There was consensus among the meeting participants that communication with legislators about evidence-based medicine and sound science, along with ob.gyns.’ advocacy in state legislatures, is critical to counterbalancing inappropriate political interference in the patient-physician relationship. The discussion also touched on the importance of continued collaboration with partners across the medical community, since attempts to legislate the practice of medicine can negatively impact a wide range of clinical practices.
Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.
In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.
The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.
Another topic discussed was the push to create a Maternal Mortality Committee in each state. Some states have had this committee for many years and shared pearls for how to get the legislation passed. Collaboration with advocates in the medical community and with the state departments of health was considered to be critical in the passage of legislation to support the creation of these committees.
There was prolonged discussion in the general session, as well as in breakout sessions, about the different types of midwives and the goal to establish a collaborative working relationship with them. Questions discussed included the educational goals for each group, as well as their level of responsibility. The licensing of midwives varies between states, ranging from the State Board of Midwifery to the State Board of Nursing to the State Board of Medicine. Maine was recognized as a state that has successfully created a collaborative relationship with the midwives who practice there. ACOG continues to work with the American College of Nurse-Midwives to create collaborative practice relationships.
Another breakout session focused on reproductive health. This group discussed legislation that interferes with the patient-physician relationship, including mandating an outdated protocol for administering medication abortion and even threatening physicians who provide abortion services with jail time. State legislation to allow pharmacists to prescribe hormonal contraception was also reviewed.
There was consensus among the meeting participants that communication with legislators about evidence-based medicine and sound science, along with ob.gyns.’ advocacy in state legislatures, is critical to counterbalancing inappropriate political interference in the patient-physician relationship. The discussion also touched on the importance of continued collaboration with partners across the medical community, since attempts to legislate the practice of medicine can negatively impact a wide range of clinical practices.
Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.
Automated colonoscopy risk classification for veterans
LAS VEGAS – A new scoring system for military veterans estimates risk of advanced colorectal neoplasia based on a list of lifestyle and clinical factors, and could help prioritize patients for screening colonoscopy. The study used natural-language processing to analyze patient medical records from the VA health care system.
“Those who were at very low risk had no colon cancer, and their risk of advanced polyps was pretty low, while those in the high-risk group should probably give thought to having a colonoscopy,” Thomas F. Imperiale, MD, a gastroenterologist and professor of medicine at the Indiana University School of Medicine, Indianapolis, said in an interview. Dr. Imperiale presented the results at the annual meeting of the American College of Gastroenterology.
When asked during the Q&A session if he could identify a subset of patients who could skip colonoscopies altogether, Dr. Imperiale said that he could not. “Prediction is possible, and if those predictions stand up in validation, they may be used to at least provide veterans with a choice, and perhaps provide the health care system a choice about how they screen their patients,” he said.
The researchers identified 66,725 veterans who underwent a diagnostic or screening colonoscopy between 2002 and 2009 at one of 14 VA medical centers. They used natural language processing to identify the most advanced finding and the location within the colorectum.
The rate of advanced neoplasia was 8.8%, and the rate of colorectal cancer (CRC) was 1.2%. Independent risk factors included age, sex, tobacco use, and exposure to COX-1 and COX-2 nonsteroidal anti-inflammatory drugs. The researchers defined four risk categories, low to high, with advanced neoplasia risks of 2.9% (CRC risk, 0%), 5.3% (CRC risk, 0.5%), 8.5% (CRC risk, 0.9%), and 11.4% (CRC risk, 2.1%). For advanced neoplasia, the goodness-of-fit P value was 1.00 and the c statistic was 0.58. For CRC, these values were 1.00 and 0.64, respectively.
Dr. Imperiale noted that the results remain relatively crude, and that the field of natural-language processing continues to evolve. In fact, software available today outperforms that used in the study. “It’s a field that’s moving quickly,” said Dr. Imperiale.
The results could help prioritize patients for colonoscopies, according to Victor Levy, MD, a senior attending physician at Mary Imogene Bassett Healthcare, Cooperstown, N.Y., who attended the presentation. And the study represents good news for the field overall. “Big data analytics has been accepted in other industries, and it’s now finally beginning to exert its effects in health care,” Dr. Levy said in an interview.
The results don’t generalize to other groups, because veterans have unique covariables and confounding factors. A new model would have to be developed for other populations.
Dr. Imperiale and Dr. Levy have no disclosures.
*Updated on 10/27/16
LAS VEGAS – A new scoring system for military veterans estimates risk of advanced colorectal neoplasia based on a list of lifestyle and clinical factors, and could help prioritize patients for screening colonoscopy. The study used natural-language processing to analyze patient medical records from the VA health care system.
“Those who were at very low risk had no colon cancer, and their risk of advanced polyps was pretty low, while those in the high-risk group should probably give thought to having a colonoscopy,” Thomas F. Imperiale, MD, a gastroenterologist and professor of medicine at the Indiana University School of Medicine, Indianapolis, said in an interview. Dr. Imperiale presented the results at the annual meeting of the American College of Gastroenterology.
When asked during the Q&A session if he could identify a subset of patients who could skip colonoscopies altogether, Dr. Imperiale said that he could not. “Prediction is possible, and if those predictions stand up in validation, they may be used to at least provide veterans with a choice, and perhaps provide the health care system a choice about how they screen their patients,” he said.
The researchers identified 66,725 veterans who underwent a diagnostic or screening colonoscopy between 2002 and 2009 at one of 14 VA medical centers. They used natural language processing to identify the most advanced finding and the location within the colorectum.
The rate of advanced neoplasia was 8.8%, and the rate of colorectal cancer (CRC) was 1.2%. Independent risk factors included age, sex, tobacco use, and exposure to COX-1 and COX-2 nonsteroidal anti-inflammatory drugs. The researchers defined four risk categories, low to high, with advanced neoplasia risks of 2.9% (CRC risk, 0%), 5.3% (CRC risk, 0.5%), 8.5% (CRC risk, 0.9%), and 11.4% (CRC risk, 2.1%). For advanced neoplasia, the goodness-of-fit P value was 1.00 and the c statistic was 0.58. For CRC, these values were 1.00 and 0.64, respectively.
Dr. Imperiale noted that the results remain relatively crude, and that the field of natural-language processing continues to evolve. In fact, software available today outperforms that used in the study. “It’s a field that’s moving quickly,” said Dr. Imperiale.
The results could help prioritize patients for colonoscopies, according to Victor Levy, MD, a senior attending physician at Mary Imogene Bassett Healthcare, Cooperstown, N.Y., who attended the presentation. And the study represents good news for the field overall. “Big data analytics has been accepted in other industries, and it’s now finally beginning to exert its effects in health care,” Dr. Levy said in an interview.
The results don’t generalize to other groups, because veterans have unique covariables and confounding factors. A new model would have to be developed for other populations.
Dr. Imperiale and Dr. Levy have no disclosures.
*Updated on 10/27/16
LAS VEGAS – A new scoring system for military veterans estimates risk of advanced colorectal neoplasia based on a list of lifestyle and clinical factors, and could help prioritize patients for screening colonoscopy. The study used natural-language processing to analyze patient medical records from the VA health care system.
“Those who were at very low risk had no colon cancer, and their risk of advanced polyps was pretty low, while those in the high-risk group should probably give thought to having a colonoscopy,” Thomas F. Imperiale, MD, a gastroenterologist and professor of medicine at the Indiana University School of Medicine, Indianapolis, said in an interview. Dr. Imperiale presented the results at the annual meeting of the American College of Gastroenterology.
When asked during the Q&A session if he could identify a subset of patients who could skip colonoscopies altogether, Dr. Imperiale said that he could not. “Prediction is possible, and if those predictions stand up in validation, they may be used to at least provide veterans with a choice, and perhaps provide the health care system a choice about how they screen their patients,” he said.
The researchers identified 66,725 veterans who underwent a diagnostic or screening colonoscopy between 2002 and 2009 at one of 14 VA medical centers. They used natural language processing to identify the most advanced finding and the location within the colorectum.
The rate of advanced neoplasia was 8.8%, and the rate of colorectal cancer (CRC) was 1.2%. Independent risk factors included age, sex, tobacco use, and exposure to COX-1 and COX-2 nonsteroidal anti-inflammatory drugs. The researchers defined four risk categories, low to high, with advanced neoplasia risks of 2.9% (CRC risk, 0%), 5.3% (CRC risk, 0.5%), 8.5% (CRC risk, 0.9%), and 11.4% (CRC risk, 2.1%). For advanced neoplasia, the goodness-of-fit P value was 1.00 and the c statistic was 0.58. For CRC, these values were 1.00 and 0.64, respectively.
Dr. Imperiale noted that the results remain relatively crude, and that the field of natural-language processing continues to evolve. In fact, software available today outperforms that used in the study. “It’s a field that’s moving quickly,” said Dr. Imperiale.
The results could help prioritize patients for colonoscopies, according to Victor Levy, MD, a senior attending physician at Mary Imogene Bassett Healthcare, Cooperstown, N.Y., who attended the presentation. And the study represents good news for the field overall. “Big data analytics has been accepted in other industries, and it’s now finally beginning to exert its effects in health care,” Dr. Levy said in an interview.
The results don’t generalize to other groups, because veterans have unique covariables and confounding factors. A new model would have to be developed for other populations.
Dr. Imperiale and Dr. Levy have no disclosures.
*Updated on 10/27/16
AT ACG 2016
Key clinical point:
Major finding: Patients in the lowest-risk group were predicted to have no colorectal cancers and to be at low risk for other advanced neoplasia. The high-risk patient group had higher predicted rates of advanced neoplasia and may be candidates for more aggressive screening.
Data source: Retrospective analysis of electronic medical records.
Disclosures: Dr. Imperiale and Dr. Levy have no disclosures.
Modafinil improves cognitive impairment in remitted depression
VIENNA – Modafinil shows potential for the treatment of episodic and working memory dysfunction in patients with remitted depression, Muzaffer Kaser, MD, reported at the annual congress of the European College of Neuropsychopharmacology.
He presented a randomized, double-blind, placebo-controlled proof-of-concept study in which 60 patients with remitted depression undertook a battery of cognitive tests before and 2 hours after either a single 200-mg dose of modafinil or placebo.
“For episodic memory we saw a medium-to-large effect size for modafinil’s effects over placebo, and a medium effect size for working memory. So for administration of a single dose we think these results are quite promising,” said Dr. Kaser, a psychiatrist and PhD candidate at the University of Cambridge, England. 
Longer-term studies of modafinil are planned in light of the major unmet need for treatments to address cognitive dysfunction in depression, he added in an interview. Currently, there are none. Yet it is now recognized that cognitive dysfunction in the domains of memory, attention, and planning are a core feature of depression, and they tend to persist after mood symptoms have recovered.
“Because of the cognitive dysfunction, people have difficulty getting back to work at the same pre-illness level, which creates more stress and increases the potential for future relapse. So cognitive dysfunction in depression should be a target for treatment,” the psychiatrist said.
Modafinil’s well-established safety profile makes it an attractive candidate, he continued. In placebo-controlled studies of the drug as augmentation therapy for depression, modafinil’s side effects were at the placebo level.
In this proof-of-concept study, the payoff with a single dose of modafinil was confined to the domain of memory, where the effects were most evident at the most difficult stages of the tests. Most impressively, the modafinil group made half as many errors on the episodic memory test. However, the drug did not improve performance on tests of planning accuracy or sustained attention.
Study participants had a mean of 3.2 prior depressive episodes and were in their current remission for 8.2 months.
The tests were drawn from the Cambridge Neuropsychological Test Automated Battery. They included the Paired Associates Learning measure of episodic memory, Spatial Working Memory, the Stockings of Cambridge measure of planning and executive function, and the Rapid Visual Information Processing measure of sustained attention.
The study was funded by the U.K. Medical Research Council and the Wellcome Trust. Dr. Kaser reported having no financial conflicts of interest.
Correction, 12/15/16: An earlier version of this article misstated Dr. Kaser's name in the photo caption.
VIENNA – Modafinil shows potential for the treatment of episodic and working memory dysfunction in patients with remitted depression, Muzaffer Kaser, MD, reported at the annual congress of the European College of Neuropsychopharmacology.
He presented a randomized, double-blind, placebo-controlled proof-of-concept study in which 60 patients with remitted depression undertook a battery of cognitive tests before and 2 hours after either a single 200-mg dose of modafinil or placebo.
“For episodic memory we saw a medium-to-large effect size for modafinil’s effects over placebo, and a medium effect size for working memory. So for administration of a single dose we think these results are quite promising,” said Dr. Kaser, a psychiatrist and PhD candidate at the University of Cambridge, England.
Longer-term studies of modafinil are planned in light of the major unmet need for treatments to address cognitive dysfunction in depression, he added in an interview. Currently, there are none. Yet it is now recognized that cognitive dysfunction in the domains of memory, attention, and planning are a core feature of depression, and they tend to persist after mood symptoms have recovered.
“Because of the cognitive dysfunction, people have difficulty getting back to work at the same pre-illness level, which creates more stress and increases the potential for future relapse. So cognitive dysfunction in depression should be a target for treatment,” the psychiatrist said.
Modafinil’s well-established safety profile makes it an attractive candidate, he continued. In placebo-controlled studies of the drug as augmentation therapy for depression, modafinil’s side effects were at the placebo level.
In this proof-of-concept study, the payoff with a single dose of modafinil was confined to the domain of memory, where the effects were most evident at the most difficult stages of the tests. Most impressively, the modafinil group made half as many errors on the episodic memory test. However, the drug did not improve performance on tests of planning accuracy or sustained attention.
Study participants had a mean of 3.2 prior depressive episodes and were in their current remission for 8.2 months.
The tests were drawn from the Cambridge Neuropsychological Test Automated Battery. They included the Paired Associates Learning measure of episodic memory, Spatial Working Memory, the Stockings of Cambridge measure of planning and executive function, and the Rapid Visual Information Processing measure of sustained attention.
The study was funded by the U.K. Medical Research Council and the Wellcome Trust. Dr. Kaser reported having no financial conflicts of interest.
Correction, 12/15/16: An earlier version of this article misstated Dr. Kaser's name in the photo caption.
VIENNA – Modafinil shows potential for the treatment of episodic and working memory dysfunction in patients with remitted depression, Muzaffer Kaser, MD, reported at the annual congress of the European College of Neuropsychopharmacology.
He presented a randomized, double-blind, placebo-controlled proof-of-concept study in which 60 patients with remitted depression undertook a battery of cognitive tests before and 2 hours after either a single 200-mg dose of modafinil or placebo.
“For episodic memory we saw a medium-to-large effect size for modafinil’s effects over placebo, and a medium effect size for working memory. So for administration of a single dose we think these results are quite promising,” said Dr. Kaser, a psychiatrist and PhD candidate at the University of Cambridge, England.
Longer-term studies of modafinil are planned in light of the major unmet need for treatments to address cognitive dysfunction in depression, he added in an interview. Currently, there are none. Yet it is now recognized that cognitive dysfunction in the domains of memory, attention, and planning are a core feature of depression, and they tend to persist after mood symptoms have recovered.
“Because of the cognitive dysfunction, people have difficulty getting back to work at the same pre-illness level, which creates more stress and increases the potential for future relapse. So cognitive dysfunction in depression should be a target for treatment,” the psychiatrist said.
Modafinil’s well-established safety profile makes it an attractive candidate, he continued. In placebo-controlled studies of the drug as augmentation therapy for depression, modafinil’s side effects were at the placebo level.
In this proof-of-concept study, the payoff with a single dose of modafinil was confined to the domain of memory, where the effects were most evident at the most difficult stages of the tests. Most impressively, the modafinil group made half as many errors on the episodic memory test. However, the drug did not improve performance on tests of planning accuracy or sustained attention.
Study participants had a mean of 3.2 prior depressive episodes and were in their current remission for 8.2 months.
The tests were drawn from the Cambridge Neuropsychological Test Automated Battery. They included the Paired Associates Learning measure of episodic memory, Spatial Working Memory, the Stockings of Cambridge measure of planning and executive function, and the Rapid Visual Information Processing measure of sustained attention.
The study was funded by the U.K. Medical Research Council and the Wellcome Trust. Dr. Kaser reported having no financial conflicts of interest.
Correction, 12/15/16: An earlier version of this article misstated Dr. Kaser's name in the photo caption.
Key clinical point:
Major finding: Patients with remitted depression made half as many errors on a well-established measure of episodic memory 2 hours after taking a single dose of modafinil, compared with placebo.
Data source: This double-blind, randomized, placebo-controlled study included 60 adults with remitted depression who underwent cognitive testing before and 2 hours after taking a single 200-mg dose of modafinil or placebo.
Disclosures: The study was funded by the UK Medical Research Council and the Wellcome Trust. The presenter reported having no financial conflicts of interest.
Talking to military service members and veterans
The following opinions are my own and not those of the Veterans Health Administration.
A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”
There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.
Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”
So start with neutral subjects and their strengths.
I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).
Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.
The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.
What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.
This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.
Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.
Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”
Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.
So again, focus on strengths. “What did you do in the military that you are most proud of?”
A very practical approach about other issues, such as housing and employment, will go a long way.
Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)
I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.
Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.
So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)
The following opinions are my own and not those of the Veterans Health Administration.
A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”
There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.
Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”
So start with neutral subjects and their strengths.
I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).
Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.
The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.
What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.
This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.
Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.
Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”
Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.
So again, focus on strengths. “What did you do in the military that you are most proud of?”
A very practical approach about other issues, such as housing and employment, will go a long way.
Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)
I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.
Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.
So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)
The following opinions are my own and not those of the Veterans Health Administration.
A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”
There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.
Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”
So start with neutral subjects and their strengths.
I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).
Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.
The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.
What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.
This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.
Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.
Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”
Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.
So again, focus on strengths. “What did you do in the military that you are most proud of?”
A very practical approach about other issues, such as housing and employment, will go a long way.
Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)
I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.
Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.
So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)
SVS Recommends Coverage for Supervised Exercise Therapy for PAD
SVS and colleagues from ACC, ACR, AHA, SCAI, SIR, SVM and VIVA recently submitted a letter to the Centers for Medicare & Medicaid Services (CMS) supporting a proposal to grant coverage for Supervised Exercise Therapy (SET) for symptomatic peripheral artery disease (PAD). Additionally, on behalf of its 5,600 members, SVS submitted a separate letter to CMS strongly supporting this coverage, which could potentially help the 8-12 million Americans affected by PAD.
CMS is considering the AHA’s recommendation to expand coverage and asked the public for comment on this proposal. A proposed decision memo is expected in March 2017.
SVS and colleagues from ACC, ACR, AHA, SCAI, SIR, SVM and VIVA recently submitted a letter to the Centers for Medicare & Medicaid Services (CMS) supporting a proposal to grant coverage for Supervised Exercise Therapy (SET) for symptomatic peripheral artery disease (PAD). Additionally, on behalf of its 5,600 members, SVS submitted a separate letter to CMS strongly supporting this coverage, which could potentially help the 8-12 million Americans affected by PAD.
CMS is considering the AHA’s recommendation to expand coverage and asked the public for comment on this proposal. A proposed decision memo is expected in March 2017.
SVS and colleagues from ACC, ACR, AHA, SCAI, SIR, SVM and VIVA recently submitted a letter to the Centers for Medicare & Medicaid Services (CMS) supporting a proposal to grant coverage for Supervised Exercise Therapy (SET) for symptomatic peripheral artery disease (PAD). Additionally, on behalf of its 5,600 members, SVS submitted a separate letter to CMS strongly supporting this coverage, which could potentially help the 8-12 million Americans affected by PAD.
CMS is considering the AHA’s recommendation to expand coverage and asked the public for comment on this proposal. A proposed decision memo is expected in March 2017.
SVS Offers Digital Pocket Guidelines
The SVS now offers its most recent practice guidelines as digital pocket cards through Guideline Central. These quick reference guideline tools contain everything you need to know from the full text guidelines, only in a more condensed and user-friendly format.
Members are eligible for free access to the SVS digital pocket guidelines by following the link below. Printed pocket cards are also available for purchase (discounted for SVS members). Non-members must purchase the guidelines individually, starting at $8.99.
Click here for info.
The SVS now offers its most recent practice guidelines as digital pocket cards through Guideline Central. These quick reference guideline tools contain everything you need to know from the full text guidelines, only in a more condensed and user-friendly format.
Members are eligible for free access to the SVS digital pocket guidelines by following the link below. Printed pocket cards are also available for purchase (discounted for SVS members). Non-members must purchase the guidelines individually, starting at $8.99.
Click here for info.
The SVS now offers its most recent practice guidelines as digital pocket cards through Guideline Central. These quick reference guideline tools contain everything you need to know from the full text guidelines, only in a more condensed and user-friendly format.
Members are eligible for free access to the SVS digital pocket guidelines by following the link below. Printed pocket cards are also available for purchase (discounted for SVS members). Non-members must purchase the guidelines individually, starting at $8.99.
Click here for info.