Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

EXPERT COMMENTARY

Although RRSO is routinely recommended to decrease the risk of ovarian as well as breast cancer in women who harbor BRCA mutations, whether or not surgery should include hysterectomy has not been clear. Shu and colleagues prospectively evaluated the risk of uterine cancer in BRCA1 and BRCA2 mutation carriers who underwent RRSO without hysterectomy at 1 of 9 centers in the United States or the United Kingdom, comparing it with rates expected from national surveillance data.

Details of the study

Among 1,083 women (median age, 45.6 years at the time of RRSO; median follow-up, 5.1 years), 8 incident uterine cancers were observed (4.3 were expected; observed to expected [O:E] ratio, 1.9; P = .09). In an analysis stratified by tumor subtype, no elevated risk for endometrioid endometrial cancer or sarcoma was noted. Five serous and/or serous-like endometrial cancers were observed after RRSO. Four were found in BRCA1 carriers and 1 in a BRCA2 carrier, with the O:E ratio of 22.2 (P<.001) for BRCA1 and 6.4 (P = .15) for BRCA2 carriers.

Details of the accompanying editorial

Commenting on the study, Leath and colleagues noted that while the number of cases was small, the study demonstrated a link between the presence of BRCA mutations (particularly BRCA1 mutations) and a "small but not null risk of endometrial cancer." Many of these uterine cancers have a serous histology, a concern due to the likelihood of worse outcomes compared with the more common endometrioid variant.
 
The authors suggest that clinicians make patients with BRCA mutations undergoing RRSO aware of the potential risks and benefits of concomitant hysterectomy and work to make an individualized decision based on the limitations of available data. They state, "Perhaps it is time to consider that the line for risk-reducing gynecologic surgery in patients with BRCA mutations not stop at the ovaries and fallopian tubes. Thus, concomitant hysterectomy with RRSO, when performed with a minimally invasive surgical approach, particularly for women with a BRCA1 mutation, should be able to be performed with minimum morbidity and allow for use of estrogen-only hormone therapy after surgery, if needed."

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

Although RRSO is routinely recommended to decrease the risk of ovarian as well as breast cancer in women who harbor BRCA mutations, whether or not surgery should include hysterectomy has not been clear. Shu and colleagues prospectively evaluated the risk of uterine cancer in BRCA1 and BRCA2 mutation carriers who underwent RRSO without hysterectomy at 1 of 9 centers in the United States or the United Kingdom, comparing it with rates expected from national surveillance data.

Details of the study

Among 1,083 women (median age, 45.6 years at the time of RRSO; median follow-up, 5.1 years), 8 incident uterine cancers were observed (4.3 were expected; observed to expected [O:E] ratio, 1.9; P = .09). In an analysis stratified by tumor subtype, no elevated risk for endometrioid endometrial cancer or sarcoma was noted. Five serous and/or serous-like endometrial cancers were observed after RRSO. Four were found in BRCA1 carriers and 1 in a BRCA2 carrier, with the O:E ratio of 22.2 (P<.001) for BRCA1 and 6.4 (P = .15) for BRCA2 carriers.

Details of the accompanying editorial

Commenting on the study, Leath and colleagues noted that while the number of cases was small, the study demonstrated a link between the presence of BRCA mutations (particularly BRCA1 mutations) and a "small but not null risk of endometrial cancer." Many of these uterine cancers have a serous histology, a concern due to the likelihood of worse outcomes compared with the more common endometrioid variant.
 
The authors suggest that clinicians make patients with BRCA mutations undergoing RRSO aware of the potential risks and benefits of concomitant hysterectomy and work to make an individualized decision based on the limitations of available data. They state, "Perhaps it is time to consider that the line for risk-reducing gynecologic surgery in patients with BRCA mutations not stop at the ovaries and fallopian tubes. Thus, concomitant hysterectomy with RRSO, when performed with a minimally invasive surgical approach, particularly for women with a BRCA1 mutation, should be able to be performed with minimum morbidity and allow for use of estrogen-only hormone therapy after surgery, if needed."

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

Although RRSO is routinely recommended to decrease the risk of ovarian as well as breast cancer in women who harbor BRCA mutations, whether or not surgery should include hysterectomy has not been clear. Shu and colleagues prospectively evaluated the risk of uterine cancer in BRCA1 and BRCA2 mutation carriers who underwent RRSO without hysterectomy at 1 of 9 centers in the United States or the United Kingdom, comparing it with rates expected from national surveillance data.

Details of the study

Among 1,083 women (median age, 45.6 years at the time of RRSO; median follow-up, 5.1 years), 8 incident uterine cancers were observed (4.3 were expected; observed to expected [O:E] ratio, 1.9; P = .09). In an analysis stratified by tumor subtype, no elevated risk for endometrioid endometrial cancer or sarcoma was noted. Five serous and/or serous-like endometrial cancers were observed after RRSO. Four were found in BRCA1 carriers and 1 in a BRCA2 carrier, with the O:E ratio of 22.2 (P<.001) for BRCA1 and 6.4 (P = .15) for BRCA2 carriers.

Details of the accompanying editorial

Commenting on the study, Leath and colleagues noted that while the number of cases was small, the study demonstrated a link between the presence of BRCA mutations (particularly BRCA1 mutations) and a "small but not null risk of endometrial cancer." Many of these uterine cancers have a serous histology, a concern due to the likelihood of worse outcomes compared with the more common endometrioid variant.
 
The authors suggest that clinicians make patients with BRCA mutations undergoing RRSO aware of the potential risks and benefits of concomitant hysterectomy and work to make an individualized decision based on the limitations of available data. They state, "Perhaps it is time to consider that the line for risk-reducing gynecologic surgery in patients with BRCA mutations not stop at the ovaries and fallopian tubes. Thus, concomitant hysterectomy with RRSO, when performed with a minimally invasive surgical approach, particularly for women with a BRCA1 mutation, should be able to be performed with minimum morbidity and allow for use of estrogen-only hormone therapy after surgery, if needed."

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Doctors examine a patient

Photo courtesy of NCI

New research has revealed sociodemographic factors that appear to influence survival in younger patients with multiple myeloma (MM).

The study, which included more than 10,000 MM patients under the age of 65, suggested that marital status, insurance status, and county-level income all affect a patient’s chance of survival.

However, race/ethnicity and county-level educational achievement were not associated with overall survival (OS).

Luciano Costa, MD, PhD, of the University of Alabama at Birmingham, and his colleagues reported these findings in Cancer.

The researchers analyzed data on patients who were diagnosed with MM before the age of 65, between 2007 and 2012. There were 10,161 cases of MM, and the median follow-up was 27 months (range, 0-71 months).

The sociodemographic variables assessed were marital status, insurance status, median household income in the county of residence, and county-level educational achievement.

The researchers also looked at race/ethnicity, which was defined as a self-reported construct including Hispanic, non-Hispanic black, non-Hispanic white, and “other.”

The researchers found that patients had an increased risk of death if they were not married, did not have private insurance (were uninsured or on Medicaid), or lived in a low-income area (belonging to the lowest 2 income quartiles).

The 4-year estimated OS rate was 71.1% for patients who did not have any of these adverse sociodemographic factors, but it was 63.2% for patients with 1 factor, 53.4% for patients with 2 factors, and 46.5% for patients with all 3 factors (P<0.001).

The researchers did find that Hispanic and non-Hispanic black individuals had more adverse sociodemographic factors and worse OS than non-Hispanic whites and people belonging to the “other” category.

However, when the population was stratified by the cumulative number of sociodemographic factors and the researchers adjusted for confounders, there was no consistent association between race/ethnicity and OS.

The researchers said this suggests the apparent impact of race/ethnicity on OS may be due to the disparate distribution of sociodemographic factors observed among the different races/ethnicities rather than the race/ethnicity construct itself.

“This [study] strongly suggests that there is a huge disparity in outcomes that could potentially be overcome by improving access and affordability of treatments,” Dr Costa said.

“With the recent emphasis on comparative effectiveness in oncology, it also becomes crucial that all variables affecting outcomes—including sociodemographic factors—are accounted for when comparisons between different therapeutic approaches and healthcare systems are made.”

Doctors examine a patient

Photo courtesy of NCI

New research has revealed sociodemographic factors that appear to influence survival in younger patients with multiple myeloma (MM).

The study, which included more than 10,000 MM patients under the age of 65, suggested that marital status, insurance status, and county-level income all affect a patient’s chance of survival.

However, race/ethnicity and county-level educational achievement were not associated with overall survival (OS).

Luciano Costa, MD, PhD, of the University of Alabama at Birmingham, and his colleagues reported these findings in Cancer.

The researchers analyzed data on patients who were diagnosed with MM before the age of 65, between 2007 and 2012. There were 10,161 cases of MM, and the median follow-up was 27 months (range, 0-71 months).

The sociodemographic variables assessed were marital status, insurance status, median household income in the county of residence, and county-level educational achievement.

The researchers also looked at race/ethnicity, which was defined as a self-reported construct including Hispanic, non-Hispanic black, non-Hispanic white, and “other.”

The researchers found that patients had an increased risk of death if they were not married, did not have private insurance (were uninsured or on Medicaid), or lived in a low-income area (belonging to the lowest 2 income quartiles).

The 4-year estimated OS rate was 71.1% for patients who did not have any of these adverse sociodemographic factors, but it was 63.2% for patients with 1 factor, 53.4% for patients with 2 factors, and 46.5% for patients with all 3 factors (P<0.001).

The researchers did find that Hispanic and non-Hispanic black individuals had more adverse sociodemographic factors and worse OS than non-Hispanic whites and people belonging to the “other” category.

However, when the population was stratified by the cumulative number of sociodemographic factors and the researchers adjusted for confounders, there was no consistent association between race/ethnicity and OS.

The researchers said this suggests the apparent impact of race/ethnicity on OS may be due to the disparate distribution of sociodemographic factors observed among the different races/ethnicities rather than the race/ethnicity construct itself.

“This [study] strongly suggests that there is a huge disparity in outcomes that could potentially be overcome by improving access and affordability of treatments,” Dr Costa said.

“With the recent emphasis on comparative effectiveness in oncology, it also becomes crucial that all variables affecting outcomes—including sociodemographic factors—are accounted for when comparisons between different therapeutic approaches and healthcare systems are made.”

Doctors examine a patient

Photo courtesy of NCI

New research has revealed sociodemographic factors that appear to influence survival in younger patients with multiple myeloma (MM).

The study, which included more than 10,000 MM patients under the age of 65, suggested that marital status, insurance status, and county-level income all affect a patient’s chance of survival.

However, race/ethnicity and county-level educational achievement were not associated with overall survival (OS).

Luciano Costa, MD, PhD, of the University of Alabama at Birmingham, and his colleagues reported these findings in Cancer.

The researchers analyzed data on patients who were diagnosed with MM before the age of 65, between 2007 and 2012. There were 10,161 cases of MM, and the median follow-up was 27 months (range, 0-71 months).

The sociodemographic variables assessed were marital status, insurance status, median household income in the county of residence, and county-level educational achievement.

The researchers also looked at race/ethnicity, which was defined as a self-reported construct including Hispanic, non-Hispanic black, non-Hispanic white, and “other.”

The researchers found that patients had an increased risk of death if they were not married, did not have private insurance (were uninsured or on Medicaid), or lived in a low-income area (belonging to the lowest 2 income quartiles).

The 4-year estimated OS rate was 71.1% for patients who did not have any of these adverse sociodemographic factors, but it was 63.2% for patients with 1 factor, 53.4% for patients with 2 factors, and 46.5% for patients with all 3 factors (P<0.001).

The researchers did find that Hispanic and non-Hispanic black individuals had more adverse sociodemographic factors and worse OS than non-Hispanic whites and people belonging to the “other” category.

However, when the population was stratified by the cumulative number of sociodemographic factors and the researchers adjusted for confounders, there was no consistent association between race/ethnicity and OS.

The researchers said this suggests the apparent impact of race/ethnicity on OS may be due to the disparate distribution of sociodemographic factors observed among the different races/ethnicities rather than the race/ethnicity construct itself.

“This [study] strongly suggests that there is a huge disparity in outcomes that could potentially be overcome by improving access and affordability of treatments,” Dr Costa said.

“With the recent emphasis on comparative effectiveness in oncology, it also becomes crucial that all variables affecting outcomes—including sociodemographic factors—are accounted for when comparisons between different therapeutic approaches and healthcare systems are made.”

Macrophage in a mouse

Image from Flickr

The US Food and Drug Administration (FDA) has granted orphan drug designation for dusquetide as a treatment for macrophage activation syndrome (MAS).

Dusquetide is an innate defense regulator, a new class of short, synthetic peptides that accelerate bacterial clearance and resolution of tissue damage while modulating inflammation following exposure to bacterial pathogens, radiation, chemotherapy, and other agents.

According to researchers, dusquetide has demonstrated preclinical efficacy and safety in several animal models.

In a mouse model of MAS, dusquetide was shown to reduce pancytopenia, inhibit IL-12 responses, and improve body weight maintenance.

SGX942, the drug product containing dusquetide, has demonstrated safety in a phase 1 study of 84 healthy volunteers.

In addition, SGX942 has demonstrated preliminary efficacy and safety in an exploratory phase 2 study of 111 patients with oral mucositis due to chemoradiation therapy for head and neck cancer.

SGX942 is being developed by Solgenix, Inc.

About orphan designation

The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.

The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the drug is approved.

About MAS

MAS is a life-threatening complication of rheumatic disease that, for unknown reasons, frequently occurs in individuals with systemic juvenile idiopathic arthritis. MAS also occurs in patients with systemic lupus erythematosus, Kawasaki disease, adult-onset Still’s disease, and various vasculitic syndromes.

MAS is characterized by pancytopenia, liver insufficiency, coagulopathy, and neurologic symptoms.

MAS is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and well-differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction. 

Macrophage in a mouse

Image from Flickr

The US Food and Drug Administration (FDA) has granted orphan drug designation for dusquetide as a treatment for macrophage activation syndrome (MAS).

Dusquetide is an innate defense regulator, a new class of short, synthetic peptides that accelerate bacterial clearance and resolution of tissue damage while modulating inflammation following exposure to bacterial pathogens, radiation, chemotherapy, and other agents.

According to researchers, dusquetide has demonstrated preclinical efficacy and safety in several animal models.

In a mouse model of MAS, dusquetide was shown to reduce pancytopenia, inhibit IL-12 responses, and improve body weight maintenance.

SGX942, the drug product containing dusquetide, has demonstrated safety in a phase 1 study of 84 healthy volunteers.

In addition, SGX942 has demonstrated preliminary efficacy and safety in an exploratory phase 2 study of 111 patients with oral mucositis due to chemoradiation therapy for head and neck cancer.

SGX942 is being developed by Solgenix, Inc.

About orphan designation

The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.

The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the drug is approved.

About MAS

MAS is a life-threatening complication of rheumatic disease that, for unknown reasons, frequently occurs in individuals with systemic juvenile idiopathic arthritis. MAS also occurs in patients with systemic lupus erythematosus, Kawasaki disease, adult-onset Still’s disease, and various vasculitic syndromes.

MAS is characterized by pancytopenia, liver insufficiency, coagulopathy, and neurologic symptoms.

MAS is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and well-differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction. 

Macrophage in a mouse

Image from Flickr

The US Food and Drug Administration (FDA) has granted orphan drug designation for dusquetide as a treatment for macrophage activation syndrome (MAS).

Dusquetide is an innate defense regulator, a new class of short, synthetic peptides that accelerate bacterial clearance and resolution of tissue damage while modulating inflammation following exposure to bacterial pathogens, radiation, chemotherapy, and other agents.

According to researchers, dusquetide has demonstrated preclinical efficacy and safety in several animal models.

In a mouse model of MAS, dusquetide was shown to reduce pancytopenia, inhibit IL-12 responses, and improve body weight maintenance.

SGX942, the drug product containing dusquetide, has demonstrated safety in a phase 1 study of 84 healthy volunteers.

In addition, SGX942 has demonstrated preliminary efficacy and safety in an exploratory phase 2 study of 111 patients with oral mucositis due to chemoradiation therapy for head and neck cancer.

SGX942 is being developed by Solgenix, Inc.

About orphan designation

The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.

The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the drug is approved.

About MAS

MAS is a life-threatening complication of rheumatic disease that, for unknown reasons, frequently occurs in individuals with systemic juvenile idiopathic arthritis. MAS also occurs in patients with systemic lupus erythematosus, Kawasaki disease, adult-onset Still’s disease, and various vasculitic syndromes.

MAS is characterized by pancytopenia, liver insufficiency, coagulopathy, and neurologic symptoms.

MAS is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and well-differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction. 

Click here to view some basic information about seizure first aid.

Click here to view some basic information about seizure first aid.

Click here to view some basic information about seizure first aid.

The American College of Surgeons (ACS) submitted a comment letter June 27 on the Centers for Medicare & Medicaid Services (CMS) proposed rule on implementation of certain provisions of MACRA. Specifically, the CMS set forth proposals on the two pathways by which MACRA replaces the sustainable growth rate (SGR) formula: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Among other issues, the ACS comments address the four components of MIPS: 1. quality, 2. resource use, 3. advancing care information, and 4. clinical practice improvement activities. The comments also address the criteria necessary for an APM model to be considered an “Advanced” APM, specifically: 1. use of certified electronic health records technology, 2. inclusion of quality measures comparable to MIPS, and 3. taking on more than nominal financial risk. Participation in an Advanced APM would exclude the clinician from participation in MIPS. For more information on the proposed rule or the comment letter, contact [email protected].

The American College of Surgeons (ACS) submitted a comment letter June 27 on the Centers for Medicare & Medicaid Services (CMS) proposed rule on implementation of certain provisions of MACRA. Specifically, the CMS set forth proposals on the two pathways by which MACRA replaces the sustainable growth rate (SGR) formula: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Among other issues, the ACS comments address the four components of MIPS: 1. quality, 2. resource use, 3. advancing care information, and 4. clinical practice improvement activities. The comments also address the criteria necessary for an APM model to be considered an “Advanced” APM, specifically: 1. use of certified electronic health records technology, 2. inclusion of quality measures comparable to MIPS, and 3. taking on more than nominal financial risk. Participation in an Advanced APM would exclude the clinician from participation in MIPS. For more information on the proposed rule or the comment letter, contact [email protected].

The American College of Surgeons (ACS) submitted a comment letter June 27 on the Centers for Medicare & Medicaid Services (CMS) proposed rule on implementation of certain provisions of MACRA. Specifically, the CMS set forth proposals on the two pathways by which MACRA replaces the sustainable growth rate (SGR) formula: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Among other issues, the ACS comments address the four components of MIPS: 1. quality, 2. resource use, 3. advancing care information, and 4. clinical practice improvement activities. The comments also address the criteria necessary for an APM model to be considered an “Advanced” APM, specifically: 1. use of certified electronic health records technology, 2. inclusion of quality measures comparable to MIPS, and 3. taking on more than nominal financial risk. Participation in an Advanced APM would exclude the clinician from participation in MIPS. For more information on the proposed rule or the comment letter, contact [email protected].

The American College of Surgeons (ACS) regulatory staff submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on June 16 regarding the 2017 Inpatient Prospective Payment System (IPPS) proposed rule. Learn more about the proposed rule here.. The notice and comment period, which began with the proposed rule’s release April 27, enables individuals and organizations to provide input on the changes the CMS plans to make. The CMS takes these comments into consideration as it crafts the final rule.

The IPPS outlines coverage criteria for Medicare Part A inpatient hospital claims. Because a large portion of surgical care is provided in the inpatient setting, the rule both directly and indirectly affects surgeons. The ACS comment letter included feedback on the CMS’s proposed changes to the Hospital Value-Based Purchasing Program and the Hospital Acquired Conditions Reduction Program, both pay-for-performance programs, and the Hospital Inpatient Quality Reporting Program, a pay-for-reporting program. For more information about the IPPS proposed rule, see the CMS fact sheet.

The American College of Surgeons (ACS) regulatory staff submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on June 16 regarding the 2017 Inpatient Prospective Payment System (IPPS) proposed rule. Learn more about the proposed rule here.. The notice and comment period, which began with the proposed rule’s release April 27, enables individuals and organizations to provide input on the changes the CMS plans to make. The CMS takes these comments into consideration as it crafts the final rule.

The IPPS outlines coverage criteria for Medicare Part A inpatient hospital claims. Because a large portion of surgical care is provided in the inpatient setting, the rule both directly and indirectly affects surgeons. The ACS comment letter included feedback on the CMS’s proposed changes to the Hospital Value-Based Purchasing Program and the Hospital Acquired Conditions Reduction Program, both pay-for-performance programs, and the Hospital Inpatient Quality Reporting Program, a pay-for-reporting program. For more information about the IPPS proposed rule, see the CMS fact sheet.

The American College of Surgeons (ACS) regulatory staff submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on June 16 regarding the 2017 Inpatient Prospective Payment System (IPPS) proposed rule. Learn more about the proposed rule here.. The notice and comment period, which began with the proposed rule’s release April 27, enables individuals and organizations to provide input on the changes the CMS plans to make. The CMS takes these comments into consideration as it crafts the final rule.

The IPPS outlines coverage criteria for Medicare Part A inpatient hospital claims. Because a large portion of surgical care is provided in the inpatient setting, the rule both directly and indirectly affects surgeons. The ACS comment letter included feedback on the CMS’s proposed changes to the Hospital Value-Based Purchasing Program and the Hospital Acquired Conditions Reduction Program, both pay-for-performance programs, and the Hospital Inpatient Quality Reporting Program, a pay-for-reporting program. For more information about the IPPS proposed rule, see the CMS fact sheet.