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SAN DIEGO – Patients with pulmonary hypertension who undergo head and neck surgery face an increased risk of several postoperative complications, compared with their counterparts who do not have the condition. They also face an increase in total charges and length of stay.

Purestock/thinkstockphotos

The findings come from what is believed to be the first study of its kind to investigate the impact of pulmonary hypertension (PHTN) on major head and neck procedures. “PHTN is a common condition which affects the caliber of lung vasculature, with varied symptom presentation from shortness of breath to syncope, with an estimated prevalence of 2.5 to 7.1 million new cases each year worldwide,” one of the study authors, Nirali M. Patel, said at the Triological Society’s Combined Sections Meeting. “Due to improved therapeutic options, there is an enhanced survival of PHTN patients and higher prevalence of this disease. PHTN has some significant systemic implications. Therefore, cardiopulmonary clearance and a clear understanding of postoperative complications are very important.”

Previous studies have shown PHTN to be an independent predictor of morbidity and mortality in noncardiac procedures, said Ms. Patel, a fourth-year medical student at New Jersey Medical School, Newark. Furthermore, the rate of pulmonary complications is reported to be between 11% and 44.8% following radical head and neck cancer resection. “Despite these findings, there is currently a lack of information regarding perioperative morbidity and mortality of patients with PHTN undergoing major head and neck procedures,” she said.

The researchers queried the National Inpatient Survey from 2002 to 2013 for all cases of major head and neck surgery based on the ICD-9 codes for esophagectomy, glossectomy, laryngectomy, mandibulectomy, and pharyngectomy. They divided patients into two groups: those who had PHTN and those who did not, and performed demographic analyses as well as univariate and multivariate regression analyses.

Ms. Patel reported findings from a cohort of 46,311 patients. Of these, 46,073 had PHTN and 238 did not. The two groups were similar in age (a mean of 69 vs. 60 years in those with and without PHTN, respectively) and race (80% white vs. 79% white, respectively), but there were significantly fewer male patients in the PHTN group (57% vs. 70%; P less than .0001).

Several patient comorbidities were increased in the PHTN group, compared with the non-PHTN group, including coagulopathy (8.4% vs. 3.1%; P less than .0001), chronic heart failure (22.4% vs. 4.1%; P less than .0001), complicated diabetes (4.6% vs. 1.2%; P less than .0001), fluid and electrolyte disorders (30% vs. 18.3%; P less than .0001), and hypertension (63.3% vs. 43.7%; P less than .0001).

Postoperatively, patients with PHTN had a longer length of stay (a mean of 15.80 vs. 11.50 days, respectively; P less than .0001) as well as significantly higher total charges (a mean of $162,021.06 vs. $107,309.46, respectively; P less than .0001). When the researchers evaluated postoperative outcomes between the two cohorts, patients with PHTN had significantly higher rates of cardiac complications (9.2% vs. 3.5%; P less than .0001), iatrogenic pulmonary embolism (2.1% vs. 0.3%; P = .001), pulmonary edema (2.1% vs. 0.4%; P = .003), venous thrombotic events (4.6% vs. 1%; P less than. 0001), pulmonary insufficiency (17.2% vs. 9.7%; P less than .0001), and pneumonia (9.7% vs. 6%; P = .027), as well as higher rates of postoperative tracheostomy (8.4% vs. 4.5%; P = .007).

Multivariate analysis revealed that the following factors predicted in-hospital mortality: coagulopathy, chronic heart failure, fluid and electrolyte disorders, hyperlipidemia, hypertension, hypothyroidism, liver disease, obesity, paralysis, and renal failure. Despite these findings, there was no significant change in overall hospital mortality for those with PHTN, with an odds ratio of 1.055.

“Our study is not without its limitations, many of which are inherent to the use of a database, which is subject to errors in coding and sampling,” Ms. Patel noted at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “Despite these limitations, the study provides valuable information on the impact of PHTN on major head and neck procedures.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel N et al. Triological CSM, Abstracts.

SAN DIEGO – Patients with pulmonary hypertension who undergo head and neck surgery face an increased risk of several postoperative complications, compared with their counterparts who do not have the condition. They also face an increase in total charges and length of stay.

Purestock/thinkstockphotos

The findings come from what is believed to be the first study of its kind to investigate the impact of pulmonary hypertension (PHTN) on major head and neck procedures. “PHTN is a common condition which affects the caliber of lung vasculature, with varied symptom presentation from shortness of breath to syncope, with an estimated prevalence of 2.5 to 7.1 million new cases each year worldwide,” one of the study authors, Nirali M. Patel, said at the Triological Society’s Combined Sections Meeting. “Due to improved therapeutic options, there is an enhanced survival of PHTN patients and higher prevalence of this disease. PHTN has some significant systemic implications. Therefore, cardiopulmonary clearance and a clear understanding of postoperative complications are very important.”

Previous studies have shown PHTN to be an independent predictor of morbidity and mortality in noncardiac procedures, said Ms. Patel, a fourth-year medical student at New Jersey Medical School, Newark. Furthermore, the rate of pulmonary complications is reported to be between 11% and 44.8% following radical head and neck cancer resection. “Despite these findings, there is currently a lack of information regarding perioperative morbidity and mortality of patients with PHTN undergoing major head and neck procedures,” she said.

The researchers queried the National Inpatient Survey from 2002 to 2013 for all cases of major head and neck surgery based on the ICD-9 codes for esophagectomy, glossectomy, laryngectomy, mandibulectomy, and pharyngectomy. They divided patients into two groups: those who had PHTN and those who did not, and performed demographic analyses as well as univariate and multivariate regression analyses.

Ms. Patel reported findings from a cohort of 46,311 patients. Of these, 46,073 had PHTN and 238 did not. The two groups were similar in age (a mean of 69 vs. 60 years in those with and without PHTN, respectively) and race (80% white vs. 79% white, respectively), but there were significantly fewer male patients in the PHTN group (57% vs. 70%; P less than .0001).

Several patient comorbidities were increased in the PHTN group, compared with the non-PHTN group, including coagulopathy (8.4% vs. 3.1%; P less than .0001), chronic heart failure (22.4% vs. 4.1%; P less than .0001), complicated diabetes (4.6% vs. 1.2%; P less than .0001), fluid and electrolyte disorders (30% vs. 18.3%; P less than .0001), and hypertension (63.3% vs. 43.7%; P less than .0001).

Postoperatively, patients with PHTN had a longer length of stay (a mean of 15.80 vs. 11.50 days, respectively; P less than .0001) as well as significantly higher total charges (a mean of $162,021.06 vs. $107,309.46, respectively; P less than .0001). When the researchers evaluated postoperative outcomes between the two cohorts, patients with PHTN had significantly higher rates of cardiac complications (9.2% vs. 3.5%; P less than .0001), iatrogenic pulmonary embolism (2.1% vs. 0.3%; P = .001), pulmonary edema (2.1% vs. 0.4%; P = .003), venous thrombotic events (4.6% vs. 1%; P less than. 0001), pulmonary insufficiency (17.2% vs. 9.7%; P less than .0001), and pneumonia (9.7% vs. 6%; P = .027), as well as higher rates of postoperative tracheostomy (8.4% vs. 4.5%; P = .007).

Multivariate analysis revealed that the following factors predicted in-hospital mortality: coagulopathy, chronic heart failure, fluid and electrolyte disorders, hyperlipidemia, hypertension, hypothyroidism, liver disease, obesity, paralysis, and renal failure. Despite these findings, there was no significant change in overall hospital mortality for those with PHTN, with an odds ratio of 1.055.

“Our study is not without its limitations, many of which are inherent to the use of a database, which is subject to errors in coding and sampling,” Ms. Patel noted at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “Despite these limitations, the study provides valuable information on the impact of PHTN on major head and neck procedures.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel N et al. Triological CSM, Abstracts.

SAN DIEGO – Patients with pulmonary hypertension who undergo head and neck surgery face an increased risk of several postoperative complications, compared with their counterparts who do not have the condition. They also face an increase in total charges and length of stay.

Purestock/thinkstockphotos

The findings come from what is believed to be the first study of its kind to investigate the impact of pulmonary hypertension (PHTN) on major head and neck procedures. “PHTN is a common condition which affects the caliber of lung vasculature, with varied symptom presentation from shortness of breath to syncope, with an estimated prevalence of 2.5 to 7.1 million new cases each year worldwide,” one of the study authors, Nirali M. Patel, said at the Triological Society’s Combined Sections Meeting. “Due to improved therapeutic options, there is an enhanced survival of PHTN patients and higher prevalence of this disease. PHTN has some significant systemic implications. Therefore, cardiopulmonary clearance and a clear understanding of postoperative complications are very important.”

Previous studies have shown PHTN to be an independent predictor of morbidity and mortality in noncardiac procedures, said Ms. Patel, a fourth-year medical student at New Jersey Medical School, Newark. Furthermore, the rate of pulmonary complications is reported to be between 11% and 44.8% following radical head and neck cancer resection. “Despite these findings, there is currently a lack of information regarding perioperative morbidity and mortality of patients with PHTN undergoing major head and neck procedures,” she said.

The researchers queried the National Inpatient Survey from 2002 to 2013 for all cases of major head and neck surgery based on the ICD-9 codes for esophagectomy, glossectomy, laryngectomy, mandibulectomy, and pharyngectomy. They divided patients into two groups: those who had PHTN and those who did not, and performed demographic analyses as well as univariate and multivariate regression analyses.

Ms. Patel reported findings from a cohort of 46,311 patients. Of these, 46,073 had PHTN and 238 did not. The two groups were similar in age (a mean of 69 vs. 60 years in those with and without PHTN, respectively) and race (80% white vs. 79% white, respectively), but there were significantly fewer male patients in the PHTN group (57% vs. 70%; P less than .0001).

Several patient comorbidities were increased in the PHTN group, compared with the non-PHTN group, including coagulopathy (8.4% vs. 3.1%; P less than .0001), chronic heart failure (22.4% vs. 4.1%; P less than .0001), complicated diabetes (4.6% vs. 1.2%; P less than .0001), fluid and electrolyte disorders (30% vs. 18.3%; P less than .0001), and hypertension (63.3% vs. 43.7%; P less than .0001).

Postoperatively, patients with PHTN had a longer length of stay (a mean of 15.80 vs. 11.50 days, respectively; P less than .0001) as well as significantly higher total charges (a mean of $162,021.06 vs. $107,309.46, respectively; P less than .0001). When the researchers evaluated postoperative outcomes between the two cohorts, patients with PHTN had significantly higher rates of cardiac complications (9.2% vs. 3.5%; P less than .0001), iatrogenic pulmonary embolism (2.1% vs. 0.3%; P = .001), pulmonary edema (2.1% vs. 0.4%; P = .003), venous thrombotic events (4.6% vs. 1%; P less than. 0001), pulmonary insufficiency (17.2% vs. 9.7%; P less than .0001), and pneumonia (9.7% vs. 6%; P = .027), as well as higher rates of postoperative tracheostomy (8.4% vs. 4.5%; P = .007).

Multivariate analysis revealed that the following factors predicted in-hospital mortality: coagulopathy, chronic heart failure, fluid and electrolyte disorders, hyperlipidemia, hypertension, hypothyroidism, liver disease, obesity, paralysis, and renal failure. Despite these findings, there was no significant change in overall hospital mortality for those with PHTN, with an odds ratio of 1.055.

“Our study is not without its limitations, many of which are inherent to the use of a database, which is subject to errors in coding and sampling,” Ms. Patel noted at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “Despite these limitations, the study provides valuable information on the impact of PHTN on major head and neck procedures.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel N et al. Triological CSM, Abstracts.

In cases of lower gastrointestinal bleeding (LGIB), albumin and hemoglobin levels are the best independent predictors of severe bleeding, according to investigators.

These findings came from a sobering look at LGIB risk-prediction models. While some models could predict specific outcomes with reasonable accuracy, none of the models demonstrated broad predictive power, reported Natalie Tapaskar, MD, of the department of medicine at the University of Chicago, and her colleagues.

LGIB requires intensive resource utilization and proves fatal in 5%-15% of patients, which means timely and appropriate interventions are essential, especially for those with severe bleeding.

“There are limited data on accurately predicting the risk of adverse outcomes for hospitalized patients with LGIB,” the investigators wrote in Gastrointestinal Endoscopy, “especially in comparison to patients with upper gastrointestinal bleeding (UGIB), where tools such as the Glasgow-Blatchford Bleeding Score have been validated to accurately predict important clinical outcomes.”

To assess existing risk models for LGIB, the investigators performed a prospective observational study involving 170 patients with LGIB who underwent colonoscopy during April 2016–September 2017 at the University of Chicago Medical Center. Data were collected through comprehensive medical record review.

The primary outcome was severe bleeding. This was defined by acute bleeding during the first 24 hours of admission that required a transfusion of 2 or more units of packed red blood cells, and/or caused a 20% or greater decrease in hematocrit; and/or recurrent bleeding 24 hours after clinical stability, involving rectal bleeding with an additional drop in hematocrit of 20% or more, and/or readmission for LGIB within 1 week of discharge. Secondary outcomes included blood transfusion requirements, in-hospital recurrent bleeding, length of stay, ICU admission, intervention (surgery, interventional radiology, endoscopy), and the comparative predictive ability of seven clinical risk stratification models: AIMS65, Charlson Comorbidity Index, Glasgow-Blatchford, NOBLADS, Oakland, Sengupta, and Strate. Area under the receiver operating characteristic curve (AUC) was used to compare model predictive power. Risk of adverse outcomes was calculated by univariable and multivariable logistic regression.

Results showed that median patient age was 70 years. Most of the patients (80%) were African American and slightly more than half were female (58%). These demographic factors were not predictive of severe bleeding, which occurred in about half of the cases (52%). Upon admission, patients with severe bleeding were more likely to have chronic renal failure (30% vs. 17%; P = .05), lower albumin (3.6 g/dL vs. 3.95 g/dL; P less than .0001), lower hemoglobin (8.6 g/dL vs. 11.1 g/dL; P = .0001), lower systolic blood pressure (118 mm Hg vs. 132 mm Hg; P = .01), and higher creatinine (1.3 mg/dL vs. 1 mg/dL; P = .04). After adjustment for confounding variables, the strongest independent predictors of severe bleeding were low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02) and low hemoglobin (OR, 1.28 per 1-g/dL decrease; P = .0015).

*This story was updated on Jan. 31, 2019.
 

SOURCE: Tapaskar N et al. Gastrointest Endosc. 2018 Dec 18. doi: 10.1016/j.gie.2018.12.011.

In cases of lower gastrointestinal bleeding (LGIB), albumin and hemoglobin levels are the best independent predictors of severe bleeding, according to investigators.

These findings came from a sobering look at LGIB risk-prediction models. While some models could predict specific outcomes with reasonable accuracy, none of the models demonstrated broad predictive power, reported Natalie Tapaskar, MD, of the department of medicine at the University of Chicago, and her colleagues.

LGIB requires intensive resource utilization and proves fatal in 5%-15% of patients, which means timely and appropriate interventions are essential, especially for those with severe bleeding.

“There are limited data on accurately predicting the risk of adverse outcomes for hospitalized patients with LGIB,” the investigators wrote in Gastrointestinal Endoscopy, “especially in comparison to patients with upper gastrointestinal bleeding (UGIB), where tools such as the Glasgow-Blatchford Bleeding Score have been validated to accurately predict important clinical outcomes.”

To assess existing risk models for LGIB, the investigators performed a prospective observational study involving 170 patients with LGIB who underwent colonoscopy during April 2016–September 2017 at the University of Chicago Medical Center. Data were collected through comprehensive medical record review.

The primary outcome was severe bleeding. This was defined by acute bleeding during the first 24 hours of admission that required a transfusion of 2 or more units of packed red blood cells, and/or caused a 20% or greater decrease in hematocrit; and/or recurrent bleeding 24 hours after clinical stability, involving rectal bleeding with an additional drop in hematocrit of 20% or more, and/or readmission for LGIB within 1 week of discharge. Secondary outcomes included blood transfusion requirements, in-hospital recurrent bleeding, length of stay, ICU admission, intervention (surgery, interventional radiology, endoscopy), and the comparative predictive ability of seven clinical risk stratification models: AIMS65, Charlson Comorbidity Index, Glasgow-Blatchford, NOBLADS, Oakland, Sengupta, and Strate. Area under the receiver operating characteristic curve (AUC) was used to compare model predictive power. Risk of adverse outcomes was calculated by univariable and multivariable logistic regression.

Results showed that median patient age was 70 years. Most of the patients (80%) were African American and slightly more than half were female (58%). These demographic factors were not predictive of severe bleeding, which occurred in about half of the cases (52%). Upon admission, patients with severe bleeding were more likely to have chronic renal failure (30% vs. 17%; P = .05), lower albumin (3.6 g/dL vs. 3.95 g/dL; P less than .0001), lower hemoglobin (8.6 g/dL vs. 11.1 g/dL; P = .0001), lower systolic blood pressure (118 mm Hg vs. 132 mm Hg; P = .01), and higher creatinine (1.3 mg/dL vs. 1 mg/dL; P = .04). After adjustment for confounding variables, the strongest independent predictors of severe bleeding were low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02) and low hemoglobin (OR, 1.28 per 1-g/dL decrease; P = .0015).

*This story was updated on Jan. 31, 2019.
 

SOURCE: Tapaskar N et al. Gastrointest Endosc. 2018 Dec 18. doi: 10.1016/j.gie.2018.12.011.

In cases of lower gastrointestinal bleeding (LGIB), albumin and hemoglobin levels are the best independent predictors of severe bleeding, according to investigators.

These findings came from a sobering look at LGIB risk-prediction models. While some models could predict specific outcomes with reasonable accuracy, none of the models demonstrated broad predictive power, reported Natalie Tapaskar, MD, of the department of medicine at the University of Chicago, and her colleagues.

LGIB requires intensive resource utilization and proves fatal in 5%-15% of patients, which means timely and appropriate interventions are essential, especially for those with severe bleeding.

“There are limited data on accurately predicting the risk of adverse outcomes for hospitalized patients with LGIB,” the investigators wrote in Gastrointestinal Endoscopy, “especially in comparison to patients with upper gastrointestinal bleeding (UGIB), where tools such as the Glasgow-Blatchford Bleeding Score have been validated to accurately predict important clinical outcomes.”

To assess existing risk models for LGIB, the investigators performed a prospective observational study involving 170 patients with LGIB who underwent colonoscopy during April 2016–September 2017 at the University of Chicago Medical Center. Data were collected through comprehensive medical record review.

The primary outcome was severe bleeding. This was defined by acute bleeding during the first 24 hours of admission that required a transfusion of 2 or more units of packed red blood cells, and/or caused a 20% or greater decrease in hematocrit; and/or recurrent bleeding 24 hours after clinical stability, involving rectal bleeding with an additional drop in hematocrit of 20% or more, and/or readmission for LGIB within 1 week of discharge. Secondary outcomes included blood transfusion requirements, in-hospital recurrent bleeding, length of stay, ICU admission, intervention (surgery, interventional radiology, endoscopy), and the comparative predictive ability of seven clinical risk stratification models: AIMS65, Charlson Comorbidity Index, Glasgow-Blatchford, NOBLADS, Oakland, Sengupta, and Strate. Area under the receiver operating characteristic curve (AUC) was used to compare model predictive power. Risk of adverse outcomes was calculated by univariable and multivariable logistic regression.

Results showed that median patient age was 70 years. Most of the patients (80%) were African American and slightly more than half were female (58%). These demographic factors were not predictive of severe bleeding, which occurred in about half of the cases (52%). Upon admission, patients with severe bleeding were more likely to have chronic renal failure (30% vs. 17%; P = .05), lower albumin (3.6 g/dL vs. 3.95 g/dL; P less than .0001), lower hemoglobin (8.6 g/dL vs. 11.1 g/dL; P = .0001), lower systolic blood pressure (118 mm Hg vs. 132 mm Hg; P = .01), and higher creatinine (1.3 mg/dL vs. 1 mg/dL; P = .04). After adjustment for confounding variables, the strongest independent predictors of severe bleeding were low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02) and low hemoglobin (OR, 1.28 per 1-g/dL decrease; P = .0015).

*This story was updated on Jan. 31, 2019.
 

SOURCE: Tapaskar N et al. Gastrointest Endosc. 2018 Dec 18. doi: 10.1016/j.gie.2018.12.011.

Vice Admiral Jerome M. Adams, MD, MPH, is the 20th Surgeon General of the United States, a post created in 1871.

Dr. Adams holds degrees in biochemistry and psychology from the University of Maryland, Baltimore County; a master’s degree in public health from the University of California, Berkeley; and a medical degree from the Indiana University, Indianapolis. He is a board-certified anesthesiologist and associate clinical professor of anesthesia at Indiana University.

At the 2018 Executive Advisory Board meeting of the Doctors Company, Richard E. Anderson, MD, FACP, chairman and chief executive officer of the Doctors Company, spoke with Dr. Adams about the opioid epidemic’s enormous impact on communities and health services in the United States.

Dr. Anderson: Dr. Adams, you’ve been busy since taking over as Surgeon General of the United States. What are some of the key challenges that you’re facing in this office?

Dr. Adams: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10% of health is due to health care, 20% of health is genetics, and the rest is a combination of behavior and environment.

My motto is “better health through better partnerships,” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities.

You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now.

No. 1 is the opioid epidemic. It is a scourge across our country. A person dies every 12½ minutes from an opioid overdose and that’s far too many. Especially when we know that many of those deaths can be prevented.

Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities but it will create a more prosperous nation, also.

And finally, I’m raising awareness about the links between our nation’s health and our safety and security – particularly our national security. Unfortunately, 7 out of 10 young people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.

So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less-safe country right now because we’re an unhealthy country.
 

Dr. Anderson: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic?

Dr. Adams: Recently, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country – and others are attempting to replicate it.

We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example.

I’m also very happy to see that the prescribing of opioids is going down 20%-25% across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management.

Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “Those aren’t my patients,” but unfortunately when we look at the PDMP [prescription drug monitoring program] data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.

One thing that I really think we need to lean into as health care practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medication-assisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels.

We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress.

Still, any ER can prescribe up to 3 days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone.

We also have too many pregnant women who want help but can’t find any treatment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our ob/gyn and primary care sectors.

Ultimately, we need hospitals and health care leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it.

We also need to make sure we’re co-prescribing naloxone for those who are at risk for opioid overdose.
 

Dr. Anderson: Just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct?

Dr. Adams: I issued the first Surgeon General’s advisory from more than 10 years earlier this year to help folks understand that over half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in 4-5 minutes. We also know that most ambulances and first responders aren’t going to show up in 4-5 minutes.

If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory.

How can providers help? Well, they can coprescribe naloxone to folks on high morphine milligram equivalents (MME) who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment.

I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it.
 

Dr. Anderson: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point, or do you think there’s a long way to go before this starts to turn around?

Dr. Adams: When I talk about the opioid epidemic, I have two angles. No.1, I want to raise awareness about the opioid epidemic – the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever.

But in addition to raising awareness, I want to instill hope.

I was in Huntington, West Virginia, just a few weeks ago at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care.

We know that the folks who are at highest risk for overdose deaths are the ones who just overdosed. They come out of the ER where we’ve watched them for a few hours and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix.

If we can partner with law enforcement, then we can turn our opioid overdose rates around.

A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island.

Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this one life will now enable us to save many more.

Yet we still prescribe more than 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an overprescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down.

But another part of this epidemic was that we squeezed the balloon in one place and, as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up.

Well, it’s important for folks to know that, through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch points, heroin use is now going down in most places.

Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil.






 

Vice Admiral Jerome M. Adams, MD, MPH, is the 20th Surgeon General of the United States, a post created in 1871.

Dr. Adams holds degrees in biochemistry and psychology from the University of Maryland, Baltimore County; a master’s degree in public health from the University of California, Berkeley; and a medical degree from the Indiana University, Indianapolis. He is a board-certified anesthesiologist and associate clinical professor of anesthesia at Indiana University.

At the 2018 Executive Advisory Board meeting of the Doctors Company, Richard E. Anderson, MD, FACP, chairman and chief executive officer of the Doctors Company, spoke with Dr. Adams about the opioid epidemic’s enormous impact on communities and health services in the United States.

Dr. Anderson: Dr. Adams, you’ve been busy since taking over as Surgeon General of the United States. What are some of the key challenges that you’re facing in this office?

Dr. Adams: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10% of health is due to health care, 20% of health is genetics, and the rest is a combination of behavior and environment.

My motto is “better health through better partnerships,” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities.

You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now.

No. 1 is the opioid epidemic. It is a scourge across our country. A person dies every 12½ minutes from an opioid overdose and that’s far too many. Especially when we know that many of those deaths can be prevented.

Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities but it will create a more prosperous nation, also.

And finally, I’m raising awareness about the links between our nation’s health and our safety and security – particularly our national security. Unfortunately, 7 out of 10 young people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.

So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less-safe country right now because we’re an unhealthy country.
 

Dr. Anderson: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic?

Dr. Adams: Recently, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country – and others are attempting to replicate it.

We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example.

I’m also very happy to see that the prescribing of opioids is going down 20%-25% across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management.

Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “Those aren’t my patients,” but unfortunately when we look at the PDMP [prescription drug monitoring program] data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.

One thing that I really think we need to lean into as health care practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medication-assisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels.

We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress.

Still, any ER can prescribe up to 3 days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone.

We also have too many pregnant women who want help but can’t find any treatment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our ob/gyn and primary care sectors.

Ultimately, we need hospitals and health care leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it.

We also need to make sure we’re co-prescribing naloxone for those who are at risk for opioid overdose.
 

Dr. Anderson: Just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct?

Dr. Adams: I issued the first Surgeon General’s advisory from more than 10 years earlier this year to help folks understand that over half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in 4-5 minutes. We also know that most ambulances and first responders aren’t going to show up in 4-5 minutes.

If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory.

How can providers help? Well, they can coprescribe naloxone to folks on high morphine milligram equivalents (MME) who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment.

I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it.
 

Dr. Anderson: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point, or do you think there’s a long way to go before this starts to turn around?

Dr. Adams: When I talk about the opioid epidemic, I have two angles. No.1, I want to raise awareness about the opioid epidemic – the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever.

But in addition to raising awareness, I want to instill hope.

I was in Huntington, West Virginia, just a few weeks ago at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care.

We know that the folks who are at highest risk for overdose deaths are the ones who just overdosed. They come out of the ER where we’ve watched them for a few hours and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix.

If we can partner with law enforcement, then we can turn our opioid overdose rates around.

A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island.

Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this one life will now enable us to save many more.

Yet we still prescribe more than 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an overprescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down.

But another part of this epidemic was that we squeezed the balloon in one place and, as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up.

Well, it’s important for folks to know that, through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch points, heroin use is now going down in most places.

Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil.






 

Vice Admiral Jerome M. Adams, MD, MPH, is the 20th Surgeon General of the United States, a post created in 1871.

Dr. Adams holds degrees in biochemistry and psychology from the University of Maryland, Baltimore County; a master’s degree in public health from the University of California, Berkeley; and a medical degree from the Indiana University, Indianapolis. He is a board-certified anesthesiologist and associate clinical professor of anesthesia at Indiana University.

At the 2018 Executive Advisory Board meeting of the Doctors Company, Richard E. Anderson, MD, FACP, chairman and chief executive officer of the Doctors Company, spoke with Dr. Adams about the opioid epidemic’s enormous impact on communities and health services in the United States.

Dr. Anderson: Dr. Adams, you’ve been busy since taking over as Surgeon General of the United States. What are some of the key challenges that you’re facing in this office?

Dr. Adams: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10% of health is due to health care, 20% of health is genetics, and the rest is a combination of behavior and environment.

My motto is “better health through better partnerships,” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities.

You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now.

No. 1 is the opioid epidemic. It is a scourge across our country. A person dies every 12½ minutes from an opioid overdose and that’s far too many. Especially when we know that many of those deaths can be prevented.

Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities but it will create a more prosperous nation, also.

And finally, I’m raising awareness about the links between our nation’s health and our safety and security – particularly our national security. Unfortunately, 7 out of 10 young people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.

So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less-safe country right now because we’re an unhealthy country.
 

Dr. Anderson: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic?

Dr. Adams: Recently, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country – and others are attempting to replicate it.

We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example.

I’m also very happy to see that the prescribing of opioids is going down 20%-25% across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management.

Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “Those aren’t my patients,” but unfortunately when we look at the PDMP [prescription drug monitoring program] data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.

One thing that I really think we need to lean into as health care practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medication-assisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels.

We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress.

Still, any ER can prescribe up to 3 days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone.

We also have too many pregnant women who want help but can’t find any treatment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our ob/gyn and primary care sectors.

Ultimately, we need hospitals and health care leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it.

We also need to make sure we’re co-prescribing naloxone for those who are at risk for opioid overdose.
 

Dr. Anderson: Just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct?

Dr. Adams: I issued the first Surgeon General’s advisory from more than 10 years earlier this year to help folks understand that over half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in 4-5 minutes. We also know that most ambulances and first responders aren’t going to show up in 4-5 minutes.

If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory.

How can providers help? Well, they can coprescribe naloxone to folks on high morphine milligram equivalents (MME) who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment.

I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it.
 

Dr. Anderson: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point, or do you think there’s a long way to go before this starts to turn around?

Dr. Adams: When I talk about the opioid epidemic, I have two angles. No.1, I want to raise awareness about the opioid epidemic – the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever.

But in addition to raising awareness, I want to instill hope.

I was in Huntington, West Virginia, just a few weeks ago at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care.

We know that the folks who are at highest risk for overdose deaths are the ones who just overdosed. They come out of the ER where we’ve watched them for a few hours and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix.

If we can partner with law enforcement, then we can turn our opioid overdose rates around.

A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island.

Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this one life will now enable us to save many more.

Yet we still prescribe more than 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an overprescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down.

But another part of this epidemic was that we squeezed the balloon in one place and, as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up.

Well, it’s important for folks to know that, through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch points, heroin use is now going down in most places.

Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil.






 

SNOWMASS, COLO. – The decades-long belief that aspirin is beneficial for primary prevention of cardiovascular events was utterly dashed by three major randomized clinical trials during the space of a few short weeks in autumn 2018.

“Is aspirin safe and effective for primary prevention? The short answer here is no,” Patrick T. O’Gara, MD, declared at the annual Cardiovascular Conference at Snowmass sponsored by the American College of Cardiology.

“Think of all those decades of aspirin therapy in the hopes of making ourselves healthier,” added Dr. O’Gara, professor of medicine at Harvard Medical School, Boston, and a past president of the American College of Cardiology.

He cited the results of three placebo-controlled randomized trials totaling more than 47,000 patients without known cardiovascular disease: ARRIVE, published in late September 2018, followed in October by ASPREE and ASCEND.

• ARRIVE. This double-blind study conducted in seven countries included 12,546 patients deemed at moderate cardiovascular risk, with an estimated 10-year cardiovascular event risk of 17%. Eligibility was restricted to men aged 55 and up and women aged 60 or older. After a median follow-up of 5 years, there was no difference between patients assigned to enteric-coated aspirin at 100 mg/day versus placebo in the incidence of major adverse cardiovascular events, with a hazard ratio of 0.96. However, GI bleeding events were 2.1-fold more common in the aspirin group (Lancet. 2018 Sep 22;392[10152]:1036-46).

• ASPREE. This double-blind trial, conducted in Australia and the United States, included 19,114 community-dwelling participants aged 70 years or older, or 65 years or older for Hispanics and blacks in the United States. After a median 4.7 years of follow-up, there was no difference in major adverse cardiovascular events between subjects randomized to 100 mg/day of enteric-coated aspirin and those on placebo. So, as in ARRIVE, no benefit. However, the rate of major hemorrhage was 38% greater in the aspirin group (N Engl J Med. 2018 Oct 18;379[16]:1509-18).

Moreover, the rate of all-cause mortality was 14% greater in the aspirin group, a statistically significant difference, compared with controls. Drilling down, the investigators showed that the major contributor to this excess mortality in the aspirin group was their 31% greater rate of cancer-related death (N Engl J Med. 2018 Oct 18;379[16]:1519-28).

“Remember, we used to think that taking aspirin reduced the incidence of GI cancer, and, in particular, colon adenocarcinoma? Well, here’s a very startling observation in 19,114 healthy elderly patients showing an increase in cancer-associated death with the use of aspirin,” commented Dr. O’Gara.

• ASCEND. This study randomized 15,480 subjects with diabetes but no known cardiovascular disease to 100 mg/day of aspirin or placebo and followed them for a mean of 7.4 years. There was a significant 12% relative risk reduction in the composite endpoint of serious vascular events in the aspirin group; however, the aspirin-treated patients also had a 29% greater rate of major bleeding events (N Engl J Med. 2018 Oct 18;379[16]:1529-39).

“So in dealing with our diabetic patients, we could perhaps say there is a small reduction in the risk of cardiovascular outcomes that is overwhelmed by more than a factor of two with regard to an increase in the risk of bleeding,” the cardiologist observed.

How did physicians get the aspirin story for primary prevention so wrong for so long? Dr. O’Gara pointed to the Physicians’ Health Study, conducted mainly back in the 1970s, as one of the benchmark studies that led to the widespread use of aspirin in this way.

“I think the aspirin story has now been put into sharp focus just within the course of the last 6 months and should force all of us to reassess what it is that we advise patients,” he concluded.

Dr. O’Gara’s presentation was the talk of the meeting, as many attendees hadn’t yet caught up with the latest aspirin data.

During an Q&A session, Robert A. Vogel, MD, a preventive cardiology authority at the University of Colorado, Denver, was asked, given the new emphasis placed upon coronary artery calcium as a supplemental risk assessment tool in the latest guidelines, at what magnitude of coronary artery calcium score in a patient with no history of coronary disease he would give aspirin for secondary prevention.

“I know I don’t know the answer to that question,” Dr. Vogel replied. “I no longer reflexively give aspirin to, say, a 60-year-old with a calcium score of 200. I will give a statin. Statins in my book are so effective and safe that my threshold for giving a statin in a 60-year-old is virtually nothing. But with a calcium score of 2,000 or 5,000, I worry just like you worry.”

He noted that the primary prevention patients in the three recent major trials were mostly 60-70 years of age or older. It’s safe to assume that by that point in life many of them had silent atherosclerosis and would have had a non-zero coronary artery calcium score, had they been tested. And yet, aspirin didn’t provide any net benefit in those groups, unlike the drug’s rock-solid proven value in patients who have actually experienced a cardiovascular event.

Dr. O’Gara reported receiving funding from the National Heart, Lung and Blood Institute, the National Institute of Dental and Craniofacial Research, from Medtronic in conjunction with the ongoing pivotal APOLLO transcatheter mitral valve replacement trial, and from Edwards Lifesciences for the ongoing EARLY TAVR trial.

[email protected]

This article was updated 1/31/19.

SNOWMASS, COLO. – The decades-long belief that aspirin is beneficial for primary prevention of cardiovascular events was utterly dashed by three major randomized clinical trials during the space of a few short weeks in autumn 2018.

“Is aspirin safe and effective for primary prevention? The short answer here is no,” Patrick T. O’Gara, MD, declared at the annual Cardiovascular Conference at Snowmass sponsored by the American College of Cardiology.

“Think of all those decades of aspirin therapy in the hopes of making ourselves healthier,” added Dr. O’Gara, professor of medicine at Harvard Medical School, Boston, and a past president of the American College of Cardiology.

He cited the results of three placebo-controlled randomized trials totaling more than 47,000 patients without known cardiovascular disease: ARRIVE, published in late September 2018, followed in October by ASPREE and ASCEND.

• ARRIVE. This double-blind study conducted in seven countries included 12,546 patients deemed at moderate cardiovascular risk, with an estimated 10-year cardiovascular event risk of 17%. Eligibility was restricted to men aged 55 and up and women aged 60 or older. After a median follow-up of 5 years, there was no difference between patients assigned to enteric-coated aspirin at 100 mg/day versus placebo in the incidence of major adverse cardiovascular events, with a hazard ratio of 0.96. However, GI bleeding events were 2.1-fold more common in the aspirin group (Lancet. 2018 Sep 22;392[10152]:1036-46).

• ASPREE. This double-blind trial, conducted in Australia and the United States, included 19,114 community-dwelling participants aged 70 years or older, or 65 years or older for Hispanics and blacks in the United States. After a median 4.7 years of follow-up, there was no difference in major adverse cardiovascular events between subjects randomized to 100 mg/day of enteric-coated aspirin and those on placebo. So, as in ARRIVE, no benefit. However, the rate of major hemorrhage was 38% greater in the aspirin group (N Engl J Med. 2018 Oct 18;379[16]:1509-18).

Moreover, the rate of all-cause mortality was 14% greater in the aspirin group, a statistically significant difference, compared with controls. Drilling down, the investigators showed that the major contributor to this excess mortality in the aspirin group was their 31% greater rate of cancer-related death (N Engl J Med. 2018 Oct 18;379[16]:1519-28).

“Remember, we used to think that taking aspirin reduced the incidence of GI cancer, and, in particular, colon adenocarcinoma? Well, here’s a very startling observation in 19,114 healthy elderly patients showing an increase in cancer-associated death with the use of aspirin,” commented Dr. O’Gara.

• ASCEND. This study randomized 15,480 subjects with diabetes but no known cardiovascular disease to 100 mg/day of aspirin or placebo and followed them for a mean of 7.4 years. There was a significant 12% relative risk reduction in the composite endpoint of serious vascular events in the aspirin group; however, the aspirin-treated patients also had a 29% greater rate of major bleeding events (N Engl J Med. 2018 Oct 18;379[16]:1529-39).

“So in dealing with our diabetic patients, we could perhaps say there is a small reduction in the risk of cardiovascular outcomes that is overwhelmed by more than a factor of two with regard to an increase in the risk of bleeding,” the cardiologist observed.

How did physicians get the aspirin story for primary prevention so wrong for so long? Dr. O’Gara pointed to the Physicians’ Health Study, conducted mainly back in the 1970s, as one of the benchmark studies that led to the widespread use of aspirin in this way.

“I think the aspirin story has now been put into sharp focus just within the course of the last 6 months and should force all of us to reassess what it is that we advise patients,” he concluded.

Dr. O’Gara’s presentation was the talk of the meeting, as many attendees hadn’t yet caught up with the latest aspirin data.

During an Q&A session, Robert A. Vogel, MD, a preventive cardiology authority at the University of Colorado, Denver, was asked, given the new emphasis placed upon coronary artery calcium as a supplemental risk assessment tool in the latest guidelines, at what magnitude of coronary artery calcium score in a patient with no history of coronary disease he would give aspirin for secondary prevention.

“I know I don’t know the answer to that question,” Dr. Vogel replied. “I no longer reflexively give aspirin to, say, a 60-year-old with a calcium score of 200. I will give a statin. Statins in my book are so effective and safe that my threshold for giving a statin in a 60-year-old is virtually nothing. But with a calcium score of 2,000 or 5,000, I worry just like you worry.”

He noted that the primary prevention patients in the three recent major trials were mostly 60-70 years of age or older. It’s safe to assume that by that point in life many of them had silent atherosclerosis and would have had a non-zero coronary artery calcium score, had they been tested. And yet, aspirin didn’t provide any net benefit in those groups, unlike the drug’s rock-solid proven value in patients who have actually experienced a cardiovascular event.

Dr. O’Gara reported receiving funding from the National Heart, Lung and Blood Institute, the National Institute of Dental and Craniofacial Research, from Medtronic in conjunction with the ongoing pivotal APOLLO transcatheter mitral valve replacement trial, and from Edwards Lifesciences for the ongoing EARLY TAVR trial.

[email protected]

This article was updated 1/31/19.

SNOWMASS, COLO. – The decades-long belief that aspirin is beneficial for primary prevention of cardiovascular events was utterly dashed by three major randomized clinical trials during the space of a few short weeks in autumn 2018.

“Is aspirin safe and effective for primary prevention? The short answer here is no,” Patrick T. O’Gara, MD, declared at the annual Cardiovascular Conference at Snowmass sponsored by the American College of Cardiology.

“Think of all those decades of aspirin therapy in the hopes of making ourselves healthier,” added Dr. O’Gara, professor of medicine at Harvard Medical School, Boston, and a past president of the American College of Cardiology.

He cited the results of three placebo-controlled randomized trials totaling more than 47,000 patients without known cardiovascular disease: ARRIVE, published in late September 2018, followed in October by ASPREE and ASCEND.

• ARRIVE. This double-blind study conducted in seven countries included 12,546 patients deemed at moderate cardiovascular risk, with an estimated 10-year cardiovascular event risk of 17%. Eligibility was restricted to men aged 55 and up and women aged 60 or older. After a median follow-up of 5 years, there was no difference between patients assigned to enteric-coated aspirin at 100 mg/day versus placebo in the incidence of major adverse cardiovascular events, with a hazard ratio of 0.96. However, GI bleeding events were 2.1-fold more common in the aspirin group (Lancet. 2018 Sep 22;392[10152]:1036-46).

• ASPREE. This double-blind trial, conducted in Australia and the United States, included 19,114 community-dwelling participants aged 70 years or older, or 65 years or older for Hispanics and blacks in the United States. After a median 4.7 years of follow-up, there was no difference in major adverse cardiovascular events between subjects randomized to 100 mg/day of enteric-coated aspirin and those on placebo. So, as in ARRIVE, no benefit. However, the rate of major hemorrhage was 38% greater in the aspirin group (N Engl J Med. 2018 Oct 18;379[16]:1509-18).

Moreover, the rate of all-cause mortality was 14% greater in the aspirin group, a statistically significant difference, compared with controls. Drilling down, the investigators showed that the major contributor to this excess mortality in the aspirin group was their 31% greater rate of cancer-related death (N Engl J Med. 2018 Oct 18;379[16]:1519-28).

“Remember, we used to think that taking aspirin reduced the incidence of GI cancer, and, in particular, colon adenocarcinoma? Well, here’s a very startling observation in 19,114 healthy elderly patients showing an increase in cancer-associated death with the use of aspirin,” commented Dr. O’Gara.

• ASCEND. This study randomized 15,480 subjects with diabetes but no known cardiovascular disease to 100 mg/day of aspirin or placebo and followed them for a mean of 7.4 years. There was a significant 12% relative risk reduction in the composite endpoint of serious vascular events in the aspirin group; however, the aspirin-treated patients also had a 29% greater rate of major bleeding events (N Engl J Med. 2018 Oct 18;379[16]:1529-39).

“So in dealing with our diabetic patients, we could perhaps say there is a small reduction in the risk of cardiovascular outcomes that is overwhelmed by more than a factor of two with regard to an increase in the risk of bleeding,” the cardiologist observed.

How did physicians get the aspirin story for primary prevention so wrong for so long? Dr. O’Gara pointed to the Physicians’ Health Study, conducted mainly back in the 1970s, as one of the benchmark studies that led to the widespread use of aspirin in this way.

“I think the aspirin story has now been put into sharp focus just within the course of the last 6 months and should force all of us to reassess what it is that we advise patients,” he concluded.

Dr. O’Gara’s presentation was the talk of the meeting, as many attendees hadn’t yet caught up with the latest aspirin data.

During an Q&A session, Robert A. Vogel, MD, a preventive cardiology authority at the University of Colorado, Denver, was asked, given the new emphasis placed upon coronary artery calcium as a supplemental risk assessment tool in the latest guidelines, at what magnitude of coronary artery calcium score in a patient with no history of coronary disease he would give aspirin for secondary prevention.

“I know I don’t know the answer to that question,” Dr. Vogel replied. “I no longer reflexively give aspirin to, say, a 60-year-old with a calcium score of 200. I will give a statin. Statins in my book are so effective and safe that my threshold for giving a statin in a 60-year-old is virtually nothing. But with a calcium score of 2,000 or 5,000, I worry just like you worry.”

He noted that the primary prevention patients in the three recent major trials were mostly 60-70 years of age or older. It’s safe to assume that by that point in life many of them had silent atherosclerosis and would have had a non-zero coronary artery calcium score, had they been tested. And yet, aspirin didn’t provide any net benefit in those groups, unlike the drug’s rock-solid proven value in patients who have actually experienced a cardiovascular event.

Dr. O’Gara reported receiving funding from the National Heart, Lung and Blood Institute, the National Institute of Dental and Craniofacial Research, from Medtronic in conjunction with the ongoing pivotal APOLLO transcatheter mitral valve replacement trial, and from Edwards Lifesciences for the ongoing EARLY TAVR trial.

[email protected]

This article was updated 1/31/19.

Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.

In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
 

Where did you get your education?

I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.

Was your intention always to be a PA?

During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.

How did you become interested in hospital medicine?

When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.

What is your current role and title at Ochsner?

From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.

What are your areas of interest or research?

I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.

I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.

What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?

When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.

The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.

I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.

How does a hospitalist PA work differently from a PA in other care settings?

The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.

How does SHM support hospitalist PAs?

SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.

There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.

What’s on the horizon for NPs and PAs in hospital medicine?

One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.

One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.

But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.

Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.

In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
 

Where did you get your education?

I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.

Was your intention always to be a PA?

During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.

How did you become interested in hospital medicine?

When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.

What is your current role and title at Ochsner?

From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.

What are your areas of interest or research?

I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.

I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.

What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?

When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.

The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.

I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.

How does a hospitalist PA work differently from a PA in other care settings?

The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.

How does SHM support hospitalist PAs?

SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.

There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.

What’s on the horizon for NPs and PAs in hospital medicine?

One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.

One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.

But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.

Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.

In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
 

Where did you get your education?

I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.

Was your intention always to be a PA?

During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.

How did you become interested in hospital medicine?

When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.

What is your current role and title at Ochsner?

From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.

What are your areas of interest or research?

I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.

I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.

What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?

When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.

The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.

I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.

How does a hospitalist PA work differently from a PA in other care settings?

The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.

How does SHM support hospitalist PAs?

SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.

There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.

What’s on the horizon for NPs and PAs in hospital medicine?

One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.

One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.

But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.

The first update to U.S. medical-society guidelines for managing atrial fibrillation since 2014 raised the threshold for starting anticoagulant therapy in women, pegged the direct-acting oral anticoagulants (DOACs) as preferred over warfarin, and introduced for the first time weight loss as an important intervention tool for treating patients with an atrial arrhythmia.

Mitchel L. Zoler/MDedge News

On January 28, the American College of Cardiology, American Heart Association, and Heart Rhythm Society posted online a 2019 focused update (Circulation. 2019 Jan 28. doi: 10.1161/CIR.0000000000000665) to the 2014 atrial fibrillation (AF) management guidelines that the groups had previously published (J Am Coll Cardiol. 2014 Dec 2;64[21]:2246-80).

Perhaps the two most important changes, as well as the two that lead off the new document, were a pair of class I recommendations on using oral anticoagulation in AF patients.

One of these updates reset the threshold for initiating oral anticoagulant therapy in women from 2 points on the CHA2DS2-VASc scale to 3 points, while leaving the threshold for men unchanged at 2 points. This brought U.S. guidelines in line with European guidelines, set by the European Society of Cardiology in 2016 (Eur Heart J. 2016 Oct 7;37[38]:2893-962). It will now also mean that, because of the way the CHA2DS2-VASc score is calculated, women with AF who are at least 65 years old will no longer automatically get flagged as needing oral anticoagulant therapy.

“This is a really important shift. It’s recognition that female sex is not as important a risk factor [for AF-associated stroke] as once was thought,” commented Hugh Calkins, MD, professor of medicine at Johns Hopkins Medicine in Baltimore and a member of the panel that wrote the update. “This will change the number of women with AF who go on anticoagulation,” predicted Dr. Calkins, who directs the cardiac arrhythmia service at his center. “We have been struggling with the notion that all women 65 or older with AF had to be on an anticoagulant. Now a clinician has more leeway. In general, patients with AF remain underanticoagulated, but this clarifies practice and brings us in line with the European guidelines.”

The second important change to the anticoagulation recommendations was to specify the DOACs as recommended over warfarin in AF patients eligible for oral anticoagulation and without moderate to severe mitral stenosis or a mechanical heart valve, which also matches the 2016 European guidelines and updates the prior, 2014, U.S. guidelines, which didn’t even mention DOACs.

Prescribing a DOAC preferentially to AF patients has already become routine among electrophysiologists, but possibly not as routine among primary care physicians, so this change has the potential to shift practice, said Dr. Calkins. But the higher price for DOACs, compared with warfarin, can pose problems. “The cost of DOACs remains an issue that can be a serious limitation to some patients,” said Craig T. January, MD, professor of medicine at the University of Wisconsin in Madison and chair of the guideline-writing panel. He also bemoaned the absence of head-to-head comparisons of individual DOACs that could inform selecting among apixaban, dabigatran, edoxaban, and rivaroxaban.

Another notable change in the 2019 update was inclusion for the first time of weight loss as a recommended intervention, along with other risk factor modification, an addition that Dr. Calkins called “long overdue.”

Mitchel L. Zoler/MDedge News

“This is a new recommendation, and it will potentially be important,” said Dr. January, although the guidelines do not spell out how aggressive clinicians should be about having patients achieve weight loss, how much loss patients should achieve, or how they should do it. “There are a lot of observational data and basic science data suggesting the importance of weight loss. Most electrophysiologists already address weight loss. The problem is how to get patients to do it,” commented Vivek Reddy, MD, professor of medicine and director of cardiac arrhythmia services at Mount Sinai Hospital in New York.

Dr. Reddy expressed surprise over two other features of the updated guidelines. For the first time, the guidelines now address percutaneous left atrial appendage (LAA) occlusion and say: “Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation.” The guidelines’ text acknowledges that this runs counter to the Food and Drug Administration labeling for the Watchman LAA occlusion device, which restricts the device to patients “deemed suitable for long-term warfarin (mirroring the inclusion criteria for enrollment in the clinical trials) but had an appropriate rationale to seek a nonpharmacological alternative to warfarin.”

“We do not take a position on the FDA’s” actions, Dr. January said in an interview.

“The ACC, AHA, and HRS guidelines should reflect what the FDA decided,” Dr. Reddy said in an interview. “I’m a little surprised the guidelines said that anticoagulation had to be contraindicated.

The 2019 update also added a class IIb, “may be reasonable” recommendation for catheter ablation of AF in patients with heart failure with reduced ejection fraction.

“I think a IIb recommendation is unfair; I think it should be a IIa recommendation because there have been positive results from two large, randomized, multicenter trials – CASTLE-AF [Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF; N Engl J Med. 2018 Feb 1;378(5):417-27] and AATAC [Ablation vs Amiodarone for Treatment of AFib in Patients With CHF and an ICD; Circulation. 2016 Apr 26;133(7):1637-44], as well as positive results from several smaller randomized studies,” Dr. Reddy said. “I’m really surprised” that the recommendation was not stronger.

Dr. Calkins has been a consultant to Abbott, Altathera, AtriCare, Boehringer-Ingelheim, King, Medtronic, and St. Jude and has received research funding from Boehringer-Ingelheim, Boston Scientific, and St. Jude. Dr. January had no disclosures. Dr. Reddy has been a consultant to, received research funding from, or has an equity interest in more than three dozen companies.

[email protected]

The first update to U.S. medical-society guidelines for managing atrial fibrillation since 2014 raised the threshold for starting anticoagulant therapy in women, pegged the direct-acting oral anticoagulants (DOACs) as preferred over warfarin, and introduced for the first time weight loss as an important intervention tool for treating patients with an atrial arrhythmia.

Mitchel L. Zoler/MDedge News

On January 28, the American College of Cardiology, American Heart Association, and Heart Rhythm Society posted online a 2019 focused update (Circulation. 2019 Jan 28. doi: 10.1161/CIR.0000000000000665) to the 2014 atrial fibrillation (AF) management guidelines that the groups had previously published (J Am Coll Cardiol. 2014 Dec 2;64[21]:2246-80).

Perhaps the two most important changes, as well as the two that lead off the new document, were a pair of class I recommendations on using oral anticoagulation in AF patients.

One of these updates reset the threshold for initiating oral anticoagulant therapy in women from 2 points on the CHA2DS2-VASc scale to 3 points, while leaving the threshold for men unchanged at 2 points. This brought U.S. guidelines in line with European guidelines, set by the European Society of Cardiology in 2016 (Eur Heart J. 2016 Oct 7;37[38]:2893-962). It will now also mean that, because of the way the CHA2DS2-VASc score is calculated, women with AF who are at least 65 years old will no longer automatically get flagged as needing oral anticoagulant therapy.

“This is a really important shift. It’s recognition that female sex is not as important a risk factor [for AF-associated stroke] as once was thought,” commented Hugh Calkins, MD, professor of medicine at Johns Hopkins Medicine in Baltimore and a member of the panel that wrote the update. “This will change the number of women with AF who go on anticoagulation,” predicted Dr. Calkins, who directs the cardiac arrhythmia service at his center. “We have been struggling with the notion that all women 65 or older with AF had to be on an anticoagulant. Now a clinician has more leeway. In general, patients with AF remain underanticoagulated, but this clarifies practice and brings us in line with the European guidelines.”

The second important change to the anticoagulation recommendations was to specify the DOACs as recommended over warfarin in AF patients eligible for oral anticoagulation and without moderate to severe mitral stenosis or a mechanical heart valve, which also matches the 2016 European guidelines and updates the prior, 2014, U.S. guidelines, which didn’t even mention DOACs.

Prescribing a DOAC preferentially to AF patients has already become routine among electrophysiologists, but possibly not as routine among primary care physicians, so this change has the potential to shift practice, said Dr. Calkins. But the higher price for DOACs, compared with warfarin, can pose problems. “The cost of DOACs remains an issue that can be a serious limitation to some patients,” said Craig T. January, MD, professor of medicine at the University of Wisconsin in Madison and chair of the guideline-writing panel. He also bemoaned the absence of head-to-head comparisons of individual DOACs that could inform selecting among apixaban, dabigatran, edoxaban, and rivaroxaban.

Another notable change in the 2019 update was inclusion for the first time of weight loss as a recommended intervention, along with other risk factor modification, an addition that Dr. Calkins called “long overdue.”

Mitchel L. Zoler/MDedge News

“This is a new recommendation, and it will potentially be important,” said Dr. January, although the guidelines do not spell out how aggressive clinicians should be about having patients achieve weight loss, how much loss patients should achieve, or how they should do it. “There are a lot of observational data and basic science data suggesting the importance of weight loss. Most electrophysiologists already address weight loss. The problem is how to get patients to do it,” commented Vivek Reddy, MD, professor of medicine and director of cardiac arrhythmia services at Mount Sinai Hospital in New York.

Dr. Reddy expressed surprise over two other features of the updated guidelines. For the first time, the guidelines now address percutaneous left atrial appendage (LAA) occlusion and say: “Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation.” The guidelines’ text acknowledges that this runs counter to the Food and Drug Administration labeling for the Watchman LAA occlusion device, which restricts the device to patients “deemed suitable for long-term warfarin (mirroring the inclusion criteria for enrollment in the clinical trials) but had an appropriate rationale to seek a nonpharmacological alternative to warfarin.”

“We do not take a position on the FDA’s” actions, Dr. January said in an interview.

“The ACC, AHA, and HRS guidelines should reflect what the FDA decided,” Dr. Reddy said in an interview. “I’m a little surprised the guidelines said that anticoagulation had to be contraindicated.

The 2019 update also added a class IIb, “may be reasonable” recommendation for catheter ablation of AF in patients with heart failure with reduced ejection fraction.

“I think a IIb recommendation is unfair; I think it should be a IIa recommendation because there have been positive results from two large, randomized, multicenter trials – CASTLE-AF [Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF; N Engl J Med. 2018 Feb 1;378(5):417-27] and AATAC [Ablation vs Amiodarone for Treatment of AFib in Patients With CHF and an ICD; Circulation. 2016 Apr 26;133(7):1637-44], as well as positive results from several smaller randomized studies,” Dr. Reddy said. “I’m really surprised” that the recommendation was not stronger.

Dr. Calkins has been a consultant to Abbott, Altathera, AtriCare, Boehringer-Ingelheim, King, Medtronic, and St. Jude and has received research funding from Boehringer-Ingelheim, Boston Scientific, and St. Jude. Dr. January had no disclosures. Dr. Reddy has been a consultant to, received research funding from, or has an equity interest in more than three dozen companies.

[email protected]

The first update to U.S. medical-society guidelines for managing atrial fibrillation since 2014 raised the threshold for starting anticoagulant therapy in women, pegged the direct-acting oral anticoagulants (DOACs) as preferred over warfarin, and introduced for the first time weight loss as an important intervention tool for treating patients with an atrial arrhythmia.

Mitchel L. Zoler/MDedge News

On January 28, the American College of Cardiology, American Heart Association, and Heart Rhythm Society posted online a 2019 focused update (Circulation. 2019 Jan 28. doi: 10.1161/CIR.0000000000000665) to the 2014 atrial fibrillation (AF) management guidelines that the groups had previously published (J Am Coll Cardiol. 2014 Dec 2;64[21]:2246-80).

Perhaps the two most important changes, as well as the two that lead off the new document, were a pair of class I recommendations on using oral anticoagulation in AF patients.

One of these updates reset the threshold for initiating oral anticoagulant therapy in women from 2 points on the CHA2DS2-VASc scale to 3 points, while leaving the threshold for men unchanged at 2 points. This brought U.S. guidelines in line with European guidelines, set by the European Society of Cardiology in 2016 (Eur Heart J. 2016 Oct 7;37[38]:2893-962). It will now also mean that, because of the way the CHA2DS2-VASc score is calculated, women with AF who are at least 65 years old will no longer automatically get flagged as needing oral anticoagulant therapy.

“This is a really important shift. It’s recognition that female sex is not as important a risk factor [for AF-associated stroke] as once was thought,” commented Hugh Calkins, MD, professor of medicine at Johns Hopkins Medicine in Baltimore and a member of the panel that wrote the update. “This will change the number of women with AF who go on anticoagulation,” predicted Dr. Calkins, who directs the cardiac arrhythmia service at his center. “We have been struggling with the notion that all women 65 or older with AF had to be on an anticoagulant. Now a clinician has more leeway. In general, patients with AF remain underanticoagulated, but this clarifies practice and brings us in line with the European guidelines.”

The second important change to the anticoagulation recommendations was to specify the DOACs as recommended over warfarin in AF patients eligible for oral anticoagulation and without moderate to severe mitral stenosis or a mechanical heart valve, which also matches the 2016 European guidelines and updates the prior, 2014, U.S. guidelines, which didn’t even mention DOACs.

Prescribing a DOAC preferentially to AF patients has already become routine among electrophysiologists, but possibly not as routine among primary care physicians, so this change has the potential to shift practice, said Dr. Calkins. But the higher price for DOACs, compared with warfarin, can pose problems. “The cost of DOACs remains an issue that can be a serious limitation to some patients,” said Craig T. January, MD, professor of medicine at the University of Wisconsin in Madison and chair of the guideline-writing panel. He also bemoaned the absence of head-to-head comparisons of individual DOACs that could inform selecting among apixaban, dabigatran, edoxaban, and rivaroxaban.

Another notable change in the 2019 update was inclusion for the first time of weight loss as a recommended intervention, along with other risk factor modification, an addition that Dr. Calkins called “long overdue.”

Mitchel L. Zoler/MDedge News

“This is a new recommendation, and it will potentially be important,” said Dr. January, although the guidelines do not spell out how aggressive clinicians should be about having patients achieve weight loss, how much loss patients should achieve, or how they should do it. “There are a lot of observational data and basic science data suggesting the importance of weight loss. Most electrophysiologists already address weight loss. The problem is how to get patients to do it,” commented Vivek Reddy, MD, professor of medicine and director of cardiac arrhythmia services at Mount Sinai Hospital in New York.

Dr. Reddy expressed surprise over two other features of the updated guidelines. For the first time, the guidelines now address percutaneous left atrial appendage (LAA) occlusion and say: “Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation.” The guidelines’ text acknowledges that this runs counter to the Food and Drug Administration labeling for the Watchman LAA occlusion device, which restricts the device to patients “deemed suitable for long-term warfarin (mirroring the inclusion criteria for enrollment in the clinical trials) but had an appropriate rationale to seek a nonpharmacological alternative to warfarin.”

“We do not take a position on the FDA’s” actions, Dr. January said in an interview.

“The ACC, AHA, and HRS guidelines should reflect what the FDA decided,” Dr. Reddy said in an interview. “I’m a little surprised the guidelines said that anticoagulation had to be contraindicated.

The 2019 update also added a class IIb, “may be reasonable” recommendation for catheter ablation of AF in patients with heart failure with reduced ejection fraction.

“I think a IIb recommendation is unfair; I think it should be a IIa recommendation because there have been positive results from two large, randomized, multicenter trials – CASTLE-AF [Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF; N Engl J Med. 2018 Feb 1;378(5):417-27] and AATAC [Ablation vs Amiodarone for Treatment of AFib in Patients With CHF and an ICD; Circulation. 2016 Apr 26;133(7):1637-44], as well as positive results from several smaller randomized studies,” Dr. Reddy said. “I’m really surprised” that the recommendation was not stronger.

Dr. Calkins has been a consultant to Abbott, Altathera, AtriCare, Boehringer-Ingelheim, King, Medtronic, and St. Jude and has received research funding from Boehringer-Ingelheim, Boston Scientific, and St. Jude. Dr. January had no disclosures. Dr. Reddy has been a consultant to, received research funding from, or has an equity interest in more than three dozen companies.

[email protected]

Samir S. Shah, MD, MSCE, director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, believes that pediatric and adult hospitalists have much to learn from each other. And he aims to promote that mutual education in his new role as editor in chief of the Journal of Hospital Medicine.

Dr. Shah is the first pediatric hospitalist to hold this position for JHM, the official journal of the Society of Hospital Medicine. He says his new position, which became effective Jan. 1, is primed for fostering interaction between pediatric and adult hospitalists. “Pediatric hospital medicine is such a vibrant community of its own. There are many opportunities for partnership and collaboration between adult and pediatric hospitalists,” he said.

The field of pediatric hospital medicine has started down the path toward becoming recognized as a board-certified subspecialty.¹ “That will place a greater emphasis on our role in fellowship training, which is important to ensure that pediatric hospitalists have a clearly defined skill set,” Dr. Shah said. “So much of what we learn in medical school is oriented to the medical care of adults. If you go into pediatrics, you’ve already had a fair amount of grounding in the healthy physiology and common diseases of adults. Pediatric hospital medicine fellowships offer an opportunity to refine clinical skill sets, as well as develop new skills in domains such as research and leadership.”
 

An emphasis on diversity

Although he has praised the innovative work of his predecessors, Mark Williams, MD, MHM, and Andrew Auerbach, MD, MPH, MHM, in shepherding the journal to its current strong position, Dr. Shah brings ideas for new features and directions.

“We as a field really benefit from a diversity of skill sets and perspectives. I’m excited to create processes to ensure equity and diversity in everything we do, starting with adding more women and more pediatric hospitalists to the journal’s leadership team, as well as purposefully developing a diverse leadership pipeline for the journal and for the field,” he said.

“We are intentionally reaching out to pediatricians to emphasize the extent to which JHM is invested in their field. For example, we have increased by seven the number of pediatricians as part of the JHM leadership team.” But pediatric hospitalists have always seen JHM as a home for their work, and Dr. Shah himself has published a couple dozen research papers in the journal. “It has always felt to me like a welcoming place,” he said.

“The great thing for me is that I’m not doing this alone. We have a marvelous crew of senior deputy editors, deputy editors, associate editors, and advisors. The opportunity I have is to leverage the phenomenal expertise and enthusiasm of this exceptional team.”

The journal under Dr. Auerbach’s lead created an editorial fellowship program offering opportunities for 1-year mentored exposure to the publication of academic scholarship and to different aspects of how a medical journal works. “We’re excited to continue investing in this program and included an editorial about it and an application form in the January 2019 issue of the Journal,” Dr. Shah said. He encourages editorial fellowship applications from physicians who historically have been underrepresented in academic medicine leadership.

“We’re also creating a column on leadership and professional development so that leaders in different fields can share their perspective and wisdom with our readers. We’ll be presenting a new, shorter review format; distilling clinical practice guidelines; and working on redesigning the journal’s web presence. We believe that our readers interact with the journal differently than they did five years ago, and increasingly are leveraging social media,” he said.

“I’m eager to broaden the scope of the journal. In the past, we focused on quality, value in health care and transitions of care in and out of the hospital, which are important topics. But I’m also excited about the adoption of new technologies, how to evaluate them and incorporate them into medical practice – things like Apple Watch for measuring heart rhythm,” Dr. Shah.

He wants to explore other technology-related topics like alarm fatigue and the use of monitors. Another big subject is the management of health of populations under new, emerging, risk-based payment models, with their pressures on health systems to take greater responsibility for risk. JHM is a medical journal and an official society journal, Dr. Shah said. “But our readership and submitters are not limited to hospitalists. As editor in chief, I’m here to make sure the journal is relevant to our members and to our other constituencies.”

Dr. Shah joined JHM’s editorial leadership team in 2009, then he became its deputy editor in 2012 and its senior deputy editor in 2015. A founding associate editor of the Journal of the Pediatric Infectious Diseases Society, he has also served on the editorial board of JAMA Pediatrics. He is editor or coeditor of 12 books in the fields of pediatrics and infectious diseases, including coauthoring “The Philadelphia Guide: Inpatient Pediatrics for McGraw-Hill Education” while still a fellow in academic general pediatrics and pediatric infectious diseases at Children’s Hospital of Philadelphia (CHOP) and, more recently, “Pediatric Infectious Diseases: Essentials for Practice,” a textbook for the pediatric generalist.
 

Broad scope of activities

Dr. Shah started practicing pediatric hospital medicine in 2001 during his fellowship training. He joined the faculty at CHOP and the University of Pennsylvania, also in Philadelphia, in 2005. In 2011 he arrived at Cincinnati Children’s Hospital, a facility with more than 600 beds that’s affiliated with the University of Cincinnati, where he is professor in the department of pediatrics and holds the James M. Ewell Endowed Chair, to lead a newly created division of hospital medicine. That division now includes more than 55 physician faculty members, 10 nurse practitioners, and nine 3-year fellows.

Collectively the staff represent a broad scope of clinical and research activities along with consulting and surgical comanagement roles and a unique service staffed by med/peds hospitalists for adult patients who have been followed at the hospital since they were children. “Years ago, those patients would not have survived beyond childhood, but with medical advances, they have. Although they continue to benefit from pediatric expertise, these adults also require internal medicine expertise for their adult health needs,” he explained. Examples include patients with neurologic impairments, dependence on medical technology, or congenital heart defects.

Dr. Shah’s own schedule is 28% clinical. He also serves as the hospital’s chief metrics officer, and his research interests include serious infectious diseases, such as pneumonia and meningitis. He is studying the comparative effectiveness of different antibiotic treatments for community-acquired pneumonia and how to improve outcomes for hospital-acquired pneumonia.

Dr. Shah has tried to be deliberate in leading efforts to grow researchers within the field, both nationally and locally. He serves as the chair of the National Childhood Pneumonia Guidelines Committee of the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society, and he also is vice chair of the Pediatric Research in Inpatient Settings (PRIS) Network, which facilitates multicenter cost-effectiveness studies among its 120 hospital members. For example, a series of studies funded by the Patient- Centered Outcomes Research Institute has demonstrated the comparable effectiveness of oral and intravenous antibiotics for osteomyelitis and complicated pneumonia.
 

Sustainable positions

When he was asked whether he felt pediatric hospitalists face particular challenges in trying to take their place in the burgeoning field of hospital medicine, Dr. Shah said he and his colleagues don’t really think of it in those terms. “Hospital medicine is such a dynamic field. For example, pediatric hospital medicine has charted its own course by pursuing subspecialty certification and fellowship training. Yet support from the field broadly has been quite strong, and SHM has embraced pediatricians, who serve on its board of directors and on numerous committees.”

SHM’s commitment to supporting pediatric hospital medicine practice and research includes its cosponsorship, with the Academic Pediatric Association and the American Academy of Pediatrics, an annual pediatric hospital medicine educational and research conference, which will next be held July 25-28, 2019, in Seattle. “In my recent meetings with society leaders I have seen exceptional enthusiasm for increasing the presence of pediatric hospitalists in the society’s work. Many pediatric hospitalists already attend SHM’s annual meeting and submit their research, but we all recognize that a strong pediatric presence is important for the society.”

Dr. Shah credits Cincinnati Children’s Hospital for supporting a sustainable work schedule for its hospitalists and for a team-oriented culture that emphasizes both professional and personal development and encourages a diversity of skill sets and perspectives, skills development, and additional training. “Individuals are recognized for their achievements within and beyond the confines of the hospital. The mentorship structure we set up here is incredible. Each faculty member has a primary mentor, a peer mentor, and access to a career development committee. Additionally, there is broad participation in clinical operations, educational scholarship, research, and quality improvement.”

Dr. Shah’s professional interests in academics, research, and infectious diseases trace back in part to a thesis project he did on neonatal infections while in medical school at Yale University, New Haven, Conn. “I was working with basic sciences in a hematology lab under the direction of the neonatologist Dr. Patrick Gallagher, whose research focused on pediatric blood cell membrane disorders.” Dr. Gallagher, who directs the Yale Center for Blood Disorders, had a keen interest in infections in infants, Dr. Shah recalled.

“He would share with me interesting cases from his practice. What particularly captured my attention was realizing how the research I could do might have a direct impact on patients and families.” Thus inspired to do an additional year of medical school training at Yale before graduating in 1998, Dr. Shah used that year to focus on research, including a placement at the Centers for Disease Control and Prevention to investigate infectious disease outbreaks, which offered real-world mysteries to solve.

“When I was a resident, pediatric hospital medicine had not yet been recognized as a specialty. But during my fellowships, most of my work was focused on the inpatient side of medicine,” he said. That made hospital medicine a natural career path.

Dr. Shah describes himself as a devoted soccer fan with season tickets for himself, his wife, and their three children to the Major League Soccer team FC Cincinnati. He’s also a movie buff and a former avid bicyclist who’s now trying to get back into cycling. He encourages readers of The Hospitalist to contact him with input on any aspect of the Journal of Hospital Medicine. Email him at [email protected] and follow him on Twitter: @samirshahmd.

Reference

1. Barrett DJ et al. Pediatric hospital medicine: A proposed new subspecialty. Pediatrics. 2017 March;139(3):e20161823.

Samir S. Shah, MD, MSCE, director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, believes that pediatric and adult hospitalists have much to learn from each other. And he aims to promote that mutual education in his new role as editor in chief of the Journal of Hospital Medicine.

Dr. Shah is the first pediatric hospitalist to hold this position for JHM, the official journal of the Society of Hospital Medicine. He says his new position, which became effective Jan. 1, is primed for fostering interaction between pediatric and adult hospitalists. “Pediatric hospital medicine is such a vibrant community of its own. There are many opportunities for partnership and collaboration between adult and pediatric hospitalists,” he said.

The field of pediatric hospital medicine has started down the path toward becoming recognized as a board-certified subspecialty.¹ “That will place a greater emphasis on our role in fellowship training, which is important to ensure that pediatric hospitalists have a clearly defined skill set,” Dr. Shah said. “So much of what we learn in medical school is oriented to the medical care of adults. If you go into pediatrics, you’ve already had a fair amount of grounding in the healthy physiology and common diseases of adults. Pediatric hospital medicine fellowships offer an opportunity to refine clinical skill sets, as well as develop new skills in domains such as research and leadership.”
 

An emphasis on diversity

Although he has praised the innovative work of his predecessors, Mark Williams, MD, MHM, and Andrew Auerbach, MD, MPH, MHM, in shepherding the journal to its current strong position, Dr. Shah brings ideas for new features and directions.

“We as a field really benefit from a diversity of skill sets and perspectives. I’m excited to create processes to ensure equity and diversity in everything we do, starting with adding more women and more pediatric hospitalists to the journal’s leadership team, as well as purposefully developing a diverse leadership pipeline for the journal and for the field,” he said.

“We are intentionally reaching out to pediatricians to emphasize the extent to which JHM is invested in their field. For example, we have increased by seven the number of pediatricians as part of the JHM leadership team.” But pediatric hospitalists have always seen JHM as a home for their work, and Dr. Shah himself has published a couple dozen research papers in the journal. “It has always felt to me like a welcoming place,” he said.

“The great thing for me is that I’m not doing this alone. We have a marvelous crew of senior deputy editors, deputy editors, associate editors, and advisors. The opportunity I have is to leverage the phenomenal expertise and enthusiasm of this exceptional team.”

The journal under Dr. Auerbach’s lead created an editorial fellowship program offering opportunities for 1-year mentored exposure to the publication of academic scholarship and to different aspects of how a medical journal works. “We’re excited to continue investing in this program and included an editorial about it and an application form in the January 2019 issue of the Journal,” Dr. Shah said. He encourages editorial fellowship applications from physicians who historically have been underrepresented in academic medicine leadership.

“We’re also creating a column on leadership and professional development so that leaders in different fields can share their perspective and wisdom with our readers. We’ll be presenting a new, shorter review format; distilling clinical practice guidelines; and working on redesigning the journal’s web presence. We believe that our readers interact with the journal differently than they did five years ago, and increasingly are leveraging social media,” he said.

“I’m eager to broaden the scope of the journal. In the past, we focused on quality, value in health care and transitions of care in and out of the hospital, which are important topics. But I’m also excited about the adoption of new technologies, how to evaluate them and incorporate them into medical practice – things like Apple Watch for measuring heart rhythm,” Dr. Shah.

He wants to explore other technology-related topics like alarm fatigue and the use of monitors. Another big subject is the management of health of populations under new, emerging, risk-based payment models, with their pressures on health systems to take greater responsibility for risk. JHM is a medical journal and an official society journal, Dr. Shah said. “But our readership and submitters are not limited to hospitalists. As editor in chief, I’m here to make sure the journal is relevant to our members and to our other constituencies.”

Dr. Shah joined JHM’s editorial leadership team in 2009, then he became its deputy editor in 2012 and its senior deputy editor in 2015. A founding associate editor of the Journal of the Pediatric Infectious Diseases Society, he has also served on the editorial board of JAMA Pediatrics. He is editor or coeditor of 12 books in the fields of pediatrics and infectious diseases, including coauthoring “The Philadelphia Guide: Inpatient Pediatrics for McGraw-Hill Education” while still a fellow in academic general pediatrics and pediatric infectious diseases at Children’s Hospital of Philadelphia (CHOP) and, more recently, “Pediatric Infectious Diseases: Essentials for Practice,” a textbook for the pediatric generalist.
 

Broad scope of activities

Dr. Shah started practicing pediatric hospital medicine in 2001 during his fellowship training. He joined the faculty at CHOP and the University of Pennsylvania, also in Philadelphia, in 2005. In 2011 he arrived at Cincinnati Children’s Hospital, a facility with more than 600 beds that’s affiliated with the University of Cincinnati, where he is professor in the department of pediatrics and holds the James M. Ewell Endowed Chair, to lead a newly created division of hospital medicine. That division now includes more than 55 physician faculty members, 10 nurse practitioners, and nine 3-year fellows.

Collectively the staff represent a broad scope of clinical and research activities along with consulting and surgical comanagement roles and a unique service staffed by med/peds hospitalists for adult patients who have been followed at the hospital since they were children. “Years ago, those patients would not have survived beyond childhood, but with medical advances, they have. Although they continue to benefit from pediatric expertise, these adults also require internal medicine expertise for their adult health needs,” he explained. Examples include patients with neurologic impairments, dependence on medical technology, or congenital heart defects.

Dr. Shah’s own schedule is 28% clinical. He also serves as the hospital’s chief metrics officer, and his research interests include serious infectious diseases, such as pneumonia and meningitis. He is studying the comparative effectiveness of different antibiotic treatments for community-acquired pneumonia and how to improve outcomes for hospital-acquired pneumonia.

Dr. Shah has tried to be deliberate in leading efforts to grow researchers within the field, both nationally and locally. He serves as the chair of the National Childhood Pneumonia Guidelines Committee of the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society, and he also is vice chair of the Pediatric Research in Inpatient Settings (PRIS) Network, which facilitates multicenter cost-effectiveness studies among its 120 hospital members. For example, a series of studies funded by the Patient- Centered Outcomes Research Institute has demonstrated the comparable effectiveness of oral and intravenous antibiotics for osteomyelitis and complicated pneumonia.
 

Sustainable positions

When he was asked whether he felt pediatric hospitalists face particular challenges in trying to take their place in the burgeoning field of hospital medicine, Dr. Shah said he and his colleagues don’t really think of it in those terms. “Hospital medicine is such a dynamic field. For example, pediatric hospital medicine has charted its own course by pursuing subspecialty certification and fellowship training. Yet support from the field broadly has been quite strong, and SHM has embraced pediatricians, who serve on its board of directors and on numerous committees.”

SHM’s commitment to supporting pediatric hospital medicine practice and research includes its cosponsorship, with the Academic Pediatric Association and the American Academy of Pediatrics, an annual pediatric hospital medicine educational and research conference, which will next be held July 25-28, 2019, in Seattle. “In my recent meetings with society leaders I have seen exceptional enthusiasm for increasing the presence of pediatric hospitalists in the society’s work. Many pediatric hospitalists already attend SHM’s annual meeting and submit their research, but we all recognize that a strong pediatric presence is important for the society.”

Dr. Shah credits Cincinnati Children’s Hospital for supporting a sustainable work schedule for its hospitalists and for a team-oriented culture that emphasizes both professional and personal development and encourages a diversity of skill sets and perspectives, skills development, and additional training. “Individuals are recognized for their achievements within and beyond the confines of the hospital. The mentorship structure we set up here is incredible. Each faculty member has a primary mentor, a peer mentor, and access to a career development committee. Additionally, there is broad participation in clinical operations, educational scholarship, research, and quality improvement.”

Dr. Shah’s professional interests in academics, research, and infectious diseases trace back in part to a thesis project he did on neonatal infections while in medical school at Yale University, New Haven, Conn. “I was working with basic sciences in a hematology lab under the direction of the neonatologist Dr. Patrick Gallagher, whose research focused on pediatric blood cell membrane disorders.” Dr. Gallagher, who directs the Yale Center for Blood Disorders, had a keen interest in infections in infants, Dr. Shah recalled.

“He would share with me interesting cases from his practice. What particularly captured my attention was realizing how the research I could do might have a direct impact on patients and families.” Thus inspired to do an additional year of medical school training at Yale before graduating in 1998, Dr. Shah used that year to focus on research, including a placement at the Centers for Disease Control and Prevention to investigate infectious disease outbreaks, which offered real-world mysteries to solve.

“When I was a resident, pediatric hospital medicine had not yet been recognized as a specialty. But during my fellowships, most of my work was focused on the inpatient side of medicine,” he said. That made hospital medicine a natural career path.

Dr. Shah describes himself as a devoted soccer fan with season tickets for himself, his wife, and their three children to the Major League Soccer team FC Cincinnati. He’s also a movie buff and a former avid bicyclist who’s now trying to get back into cycling. He encourages readers of The Hospitalist to contact him with input on any aspect of the Journal of Hospital Medicine. Email him at [email protected] and follow him on Twitter: @samirshahmd.

Reference

1. Barrett DJ et al. Pediatric hospital medicine: A proposed new subspecialty. Pediatrics. 2017 March;139(3):e20161823.

Samir S. Shah, MD, MSCE, director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, believes that pediatric and adult hospitalists have much to learn from each other. And he aims to promote that mutual education in his new role as editor in chief of the Journal of Hospital Medicine.

Dr. Shah is the first pediatric hospitalist to hold this position for JHM, the official journal of the Society of Hospital Medicine. He says his new position, which became effective Jan. 1, is primed for fostering interaction between pediatric and adult hospitalists. “Pediatric hospital medicine is such a vibrant community of its own. There are many opportunities for partnership and collaboration between adult and pediatric hospitalists,” he said.

The field of pediatric hospital medicine has started down the path toward becoming recognized as a board-certified subspecialty.¹ “That will place a greater emphasis on our role in fellowship training, which is important to ensure that pediatric hospitalists have a clearly defined skill set,” Dr. Shah said. “So much of what we learn in medical school is oriented to the medical care of adults. If you go into pediatrics, you’ve already had a fair amount of grounding in the healthy physiology and common diseases of adults. Pediatric hospital medicine fellowships offer an opportunity to refine clinical skill sets, as well as develop new skills in domains such as research and leadership.”
 

An emphasis on diversity

Although he has praised the innovative work of his predecessors, Mark Williams, MD, MHM, and Andrew Auerbach, MD, MPH, MHM, in shepherding the journal to its current strong position, Dr. Shah brings ideas for new features and directions.

“We as a field really benefit from a diversity of skill sets and perspectives. I’m excited to create processes to ensure equity and diversity in everything we do, starting with adding more women and more pediatric hospitalists to the journal’s leadership team, as well as purposefully developing a diverse leadership pipeline for the journal and for the field,” he said.

“We are intentionally reaching out to pediatricians to emphasize the extent to which JHM is invested in their field. For example, we have increased by seven the number of pediatricians as part of the JHM leadership team.” But pediatric hospitalists have always seen JHM as a home for their work, and Dr. Shah himself has published a couple dozen research papers in the journal. “It has always felt to me like a welcoming place,” he said.

“The great thing for me is that I’m not doing this alone. We have a marvelous crew of senior deputy editors, deputy editors, associate editors, and advisors. The opportunity I have is to leverage the phenomenal expertise and enthusiasm of this exceptional team.”

The journal under Dr. Auerbach’s lead created an editorial fellowship program offering opportunities for 1-year mentored exposure to the publication of academic scholarship and to different aspects of how a medical journal works. “We’re excited to continue investing in this program and included an editorial about it and an application form in the January 2019 issue of the Journal,” Dr. Shah said. He encourages editorial fellowship applications from physicians who historically have been underrepresented in academic medicine leadership.

“We’re also creating a column on leadership and professional development so that leaders in different fields can share their perspective and wisdom with our readers. We’ll be presenting a new, shorter review format; distilling clinical practice guidelines; and working on redesigning the journal’s web presence. We believe that our readers interact with the journal differently than they did five years ago, and increasingly are leveraging social media,” he said.

“I’m eager to broaden the scope of the journal. In the past, we focused on quality, value in health care and transitions of care in and out of the hospital, which are important topics. But I’m also excited about the adoption of new technologies, how to evaluate them and incorporate them into medical practice – things like Apple Watch for measuring heart rhythm,” Dr. Shah.

He wants to explore other technology-related topics like alarm fatigue and the use of monitors. Another big subject is the management of health of populations under new, emerging, risk-based payment models, with their pressures on health systems to take greater responsibility for risk. JHM is a medical journal and an official society journal, Dr. Shah said. “But our readership and submitters are not limited to hospitalists. As editor in chief, I’m here to make sure the journal is relevant to our members and to our other constituencies.”

Dr. Shah joined JHM’s editorial leadership team in 2009, then he became its deputy editor in 2012 and its senior deputy editor in 2015. A founding associate editor of the Journal of the Pediatric Infectious Diseases Society, he has also served on the editorial board of JAMA Pediatrics. He is editor or coeditor of 12 books in the fields of pediatrics and infectious diseases, including coauthoring “The Philadelphia Guide: Inpatient Pediatrics for McGraw-Hill Education” while still a fellow in academic general pediatrics and pediatric infectious diseases at Children’s Hospital of Philadelphia (CHOP) and, more recently, “Pediatric Infectious Diseases: Essentials for Practice,” a textbook for the pediatric generalist.
 

Broad scope of activities

Dr. Shah started practicing pediatric hospital medicine in 2001 during his fellowship training. He joined the faculty at CHOP and the University of Pennsylvania, also in Philadelphia, in 2005. In 2011 he arrived at Cincinnati Children’s Hospital, a facility with more than 600 beds that’s affiliated with the University of Cincinnati, where he is professor in the department of pediatrics and holds the James M. Ewell Endowed Chair, to lead a newly created division of hospital medicine. That division now includes more than 55 physician faculty members, 10 nurse practitioners, and nine 3-year fellows.

Collectively the staff represent a broad scope of clinical and research activities along with consulting and surgical comanagement roles and a unique service staffed by med/peds hospitalists for adult patients who have been followed at the hospital since they were children. “Years ago, those patients would not have survived beyond childhood, but with medical advances, they have. Although they continue to benefit from pediatric expertise, these adults also require internal medicine expertise for their adult health needs,” he explained. Examples include patients with neurologic impairments, dependence on medical technology, or congenital heart defects.

Dr. Shah’s own schedule is 28% clinical. He also serves as the hospital’s chief metrics officer, and his research interests include serious infectious diseases, such as pneumonia and meningitis. He is studying the comparative effectiveness of different antibiotic treatments for community-acquired pneumonia and how to improve outcomes for hospital-acquired pneumonia.

Dr. Shah has tried to be deliberate in leading efforts to grow researchers within the field, both nationally and locally. He serves as the chair of the National Childhood Pneumonia Guidelines Committee of the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society, and he also is vice chair of the Pediatric Research in Inpatient Settings (PRIS) Network, which facilitates multicenter cost-effectiveness studies among its 120 hospital members. For example, a series of studies funded by the Patient- Centered Outcomes Research Institute has demonstrated the comparable effectiveness of oral and intravenous antibiotics for osteomyelitis and complicated pneumonia.
 

Sustainable positions

When he was asked whether he felt pediatric hospitalists face particular challenges in trying to take their place in the burgeoning field of hospital medicine, Dr. Shah said he and his colleagues don’t really think of it in those terms. “Hospital medicine is such a dynamic field. For example, pediatric hospital medicine has charted its own course by pursuing subspecialty certification and fellowship training. Yet support from the field broadly has been quite strong, and SHM has embraced pediatricians, who serve on its board of directors and on numerous committees.”

SHM’s commitment to supporting pediatric hospital medicine practice and research includes its cosponsorship, with the Academic Pediatric Association and the American Academy of Pediatrics, an annual pediatric hospital medicine educational and research conference, which will next be held July 25-28, 2019, in Seattle. “In my recent meetings with society leaders I have seen exceptional enthusiasm for increasing the presence of pediatric hospitalists in the society’s work. Many pediatric hospitalists already attend SHM’s annual meeting and submit their research, but we all recognize that a strong pediatric presence is important for the society.”

Dr. Shah credits Cincinnati Children’s Hospital for supporting a sustainable work schedule for its hospitalists and for a team-oriented culture that emphasizes both professional and personal development and encourages a diversity of skill sets and perspectives, skills development, and additional training. “Individuals are recognized for their achievements within and beyond the confines of the hospital. The mentorship structure we set up here is incredible. Each faculty member has a primary mentor, a peer mentor, and access to a career development committee. Additionally, there is broad participation in clinical operations, educational scholarship, research, and quality improvement.”

Dr. Shah’s professional interests in academics, research, and infectious diseases trace back in part to a thesis project he did on neonatal infections while in medical school at Yale University, New Haven, Conn. “I was working with basic sciences in a hematology lab under the direction of the neonatologist Dr. Patrick Gallagher, whose research focused on pediatric blood cell membrane disorders.” Dr. Gallagher, who directs the Yale Center for Blood Disorders, had a keen interest in infections in infants, Dr. Shah recalled.

“He would share with me interesting cases from his practice. What particularly captured my attention was realizing how the research I could do might have a direct impact on patients and families.” Thus inspired to do an additional year of medical school training at Yale before graduating in 1998, Dr. Shah used that year to focus on research, including a placement at the Centers for Disease Control and Prevention to investigate infectious disease outbreaks, which offered real-world mysteries to solve.

“When I was a resident, pediatric hospital medicine had not yet been recognized as a specialty. But during my fellowships, most of my work was focused on the inpatient side of medicine,” he said. That made hospital medicine a natural career path.

Dr. Shah describes himself as a devoted soccer fan with season tickets for himself, his wife, and their three children to the Major League Soccer team FC Cincinnati. He’s also a movie buff and a former avid bicyclist who’s now trying to get back into cycling. He encourages readers of The Hospitalist to contact him with input on any aspect of the Journal of Hospital Medicine. Email him at [email protected] and follow him on Twitter: @samirshahmd.

Reference

1. Barrett DJ et al. Pediatric hospital medicine: A proposed new subspecialty. Pediatrics. 2017 March;139(3):e20161823.

Age, symptom severity, and serum glucose do not influence the benefit of endovascular thrombectomy for patients with stroke, according to research published online ahead of print Jan. 28 in JAMA Neurology. The location of the arterial occlusive lesion and the imaging technique used to select patients for the procedure also do not influence the therapy’s benefits, the researchers said. Although the proportional benefit of thrombectomy plus medical management is uniform across subgroups, compared with medical management alone, patients may have different amounts of absolute benefit.

The results of the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial, which were published in 2018, indicated that endovascular thrombectomy provided clinical benefits for patients with acute ischemic stroke if administered at 6-16 hours after stroke onset. As part of the trial’s prespecified analyses, Maarten G. Lansberg, MD, PhD, associate professor of neurology and neurological sciences at Stanford (Calif.) University Medical Center in California, and his colleagues sought to determine whether thrombectomy had uniform benefit among various patient subgroups (e.g., elderly people, patients with mild symptoms, and those who present late after onset).

A total of 296 patients were enrolled in the randomized, open-label, blinded-endpoint DEFUSE 3 trial at 38 sites in the United States. Eligible participants had acute ischemic stroke resulting from an occlusion of the internal carotid artery or middle cerebral artery and evidence of salvageable tissue on perfusion CT or MRI. In all, 182 patients met these criteria and were randomized and included in the intention-to-treat analysis. The researchers stopped DEFUSE 3 early because of efficacy.

The study’s primary endpoint was functional outcome at day 90, as measured with the modified Rankin Scale. Dr. Lansberg and his colleagues performed multivariate ordinal logistic regression to calculate the adjusted proportional association between endovascular treatment and clinical outcome among participants of various ages, baseline stroke severities, periods between onset and treatment, locations of the arterial occlusion, and imaging modalities, such as CT or MRI, used to identify salvageable tissue.

The population’s median age was 70 years, and 51% of participants were women. The median National Institutes of Health Stroke Scale score was 16. When the researchers considered the whole sample, they found that younger age, lower baseline NIHSS score, and lower serum glucose level independently predicted better functional outcome. The common odds ratio for improved functional outcome with endovascular therapy, adjusted for these variables, was 3.1. Age, NIHSS score, time to randomization, imaging modality, and location of the arterial occlusion did not interact significantly with treatment effect.

“Our results indicate that advanced age, up to 90 years, should not be considered a contraindication to thrombectomy, provided that the patient is fully independent prior to stroke onset,” said the researchers. “Although age did not modify the treatment effect, it was a strong independent predictor of 90-day disability, which is consistent with prior studies of both tissue plasminogen activator and endovascular therapy.”

The trial’s small sample size may have allowed small differences between groups to pass unnoticed, said the reseachers. Other trials of late-window thrombectomy will be required to validate these results, they concluded.

The National Institute for Neurological Disorders and Stroke supported the study through grants. Several investigators received consulting fees from and hold shares in iSchemaView, which manufactures the software that the investigators used for postprocessing of CT and MRI perfusion studies. Other authors received consulting fees from various pharmaceutical and medical device companies, including Genentech, Medtronic, Pfizer, and Stryker Neurovascular.

[email protected]

SOURCE: Lansberg MG et al. JAMA Neurol. 2019 Jan 28. doi: 10.1001/jamaneurol.2018.4587.

Age, symptom severity, and serum glucose do not influence the benefit of endovascular thrombectomy for patients with stroke, according to research published online ahead of print Jan. 28 in JAMA Neurology. The location of the arterial occlusive lesion and the imaging technique used to select patients for the procedure also do not influence the therapy’s benefits, the researchers said. Although the proportional benefit of thrombectomy plus medical management is uniform across subgroups, compared with medical management alone, patients may have different amounts of absolute benefit.

The results of the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial, which were published in 2018, indicated that endovascular thrombectomy provided clinical benefits for patients with acute ischemic stroke if administered at 6-16 hours after stroke onset. As part of the trial’s prespecified analyses, Maarten G. Lansberg, MD, PhD, associate professor of neurology and neurological sciences at Stanford (Calif.) University Medical Center in California, and his colleagues sought to determine whether thrombectomy had uniform benefit among various patient subgroups (e.g., elderly people, patients with mild symptoms, and those who present late after onset).

A total of 296 patients were enrolled in the randomized, open-label, blinded-endpoint DEFUSE 3 trial at 38 sites in the United States. Eligible participants had acute ischemic stroke resulting from an occlusion of the internal carotid artery or middle cerebral artery and evidence of salvageable tissue on perfusion CT or MRI. In all, 182 patients met these criteria and were randomized and included in the intention-to-treat analysis. The researchers stopped DEFUSE 3 early because of efficacy.

The study’s primary endpoint was functional outcome at day 90, as measured with the modified Rankin Scale. Dr. Lansberg and his colleagues performed multivariate ordinal logistic regression to calculate the adjusted proportional association between endovascular treatment and clinical outcome among participants of various ages, baseline stroke severities, periods between onset and treatment, locations of the arterial occlusion, and imaging modalities, such as CT or MRI, used to identify salvageable tissue.

The population’s median age was 70 years, and 51% of participants were women. The median National Institutes of Health Stroke Scale score was 16. When the researchers considered the whole sample, they found that younger age, lower baseline NIHSS score, and lower serum glucose level independently predicted better functional outcome. The common odds ratio for improved functional outcome with endovascular therapy, adjusted for these variables, was 3.1. Age, NIHSS score, time to randomization, imaging modality, and location of the arterial occlusion did not interact significantly with treatment effect.

“Our results indicate that advanced age, up to 90 years, should not be considered a contraindication to thrombectomy, provided that the patient is fully independent prior to stroke onset,” said the researchers. “Although age did not modify the treatment effect, it was a strong independent predictor of 90-day disability, which is consistent with prior studies of both tissue plasminogen activator and endovascular therapy.”

The trial’s small sample size may have allowed small differences between groups to pass unnoticed, said the reseachers. Other trials of late-window thrombectomy will be required to validate these results, they concluded.

The National Institute for Neurological Disorders and Stroke supported the study through grants. Several investigators received consulting fees from and hold shares in iSchemaView, which manufactures the software that the investigators used for postprocessing of CT and MRI perfusion studies. Other authors received consulting fees from various pharmaceutical and medical device companies, including Genentech, Medtronic, Pfizer, and Stryker Neurovascular.

[email protected]

SOURCE: Lansberg MG et al. JAMA Neurol. 2019 Jan 28. doi: 10.1001/jamaneurol.2018.4587.

Age, symptom severity, and serum glucose do not influence the benefit of endovascular thrombectomy for patients with stroke, according to research published online ahead of print Jan. 28 in JAMA Neurology. The location of the arterial occlusive lesion and the imaging technique used to select patients for the procedure also do not influence the therapy’s benefits, the researchers said. Although the proportional benefit of thrombectomy plus medical management is uniform across subgroups, compared with medical management alone, patients may have different amounts of absolute benefit.

The results of the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial, which were published in 2018, indicated that endovascular thrombectomy provided clinical benefits for patients with acute ischemic stroke if administered at 6-16 hours after stroke onset. As part of the trial’s prespecified analyses, Maarten G. Lansberg, MD, PhD, associate professor of neurology and neurological sciences at Stanford (Calif.) University Medical Center in California, and his colleagues sought to determine whether thrombectomy had uniform benefit among various patient subgroups (e.g., elderly people, patients with mild symptoms, and those who present late after onset).

A total of 296 patients were enrolled in the randomized, open-label, blinded-endpoint DEFUSE 3 trial at 38 sites in the United States. Eligible participants had acute ischemic stroke resulting from an occlusion of the internal carotid artery or middle cerebral artery and evidence of salvageable tissue on perfusion CT or MRI. In all, 182 patients met these criteria and were randomized and included in the intention-to-treat analysis. The researchers stopped DEFUSE 3 early because of efficacy.

The study’s primary endpoint was functional outcome at day 90, as measured with the modified Rankin Scale. Dr. Lansberg and his colleagues performed multivariate ordinal logistic regression to calculate the adjusted proportional association between endovascular treatment and clinical outcome among participants of various ages, baseline stroke severities, periods between onset and treatment, locations of the arterial occlusion, and imaging modalities, such as CT or MRI, used to identify salvageable tissue.

The population’s median age was 70 years, and 51% of participants were women. The median National Institutes of Health Stroke Scale score was 16. When the researchers considered the whole sample, they found that younger age, lower baseline NIHSS score, and lower serum glucose level independently predicted better functional outcome. The common odds ratio for improved functional outcome with endovascular therapy, adjusted for these variables, was 3.1. Age, NIHSS score, time to randomization, imaging modality, and location of the arterial occlusion did not interact significantly with treatment effect.

“Our results indicate that advanced age, up to 90 years, should not be considered a contraindication to thrombectomy, provided that the patient is fully independent prior to stroke onset,” said the researchers. “Although age did not modify the treatment effect, it was a strong independent predictor of 90-day disability, which is consistent with prior studies of both tissue plasminogen activator and endovascular therapy.”

The trial’s small sample size may have allowed small differences between groups to pass unnoticed, said the reseachers. Other trials of late-window thrombectomy will be required to validate these results, they concluded.

The National Institute for Neurological Disorders and Stroke supported the study through grants. Several investigators received consulting fees from and hold shares in iSchemaView, which manufactures the software that the investigators used for postprocessing of CT and MRI perfusion studies. Other authors received consulting fees from various pharmaceutical and medical device companies, including Genentech, Medtronic, Pfizer, and Stryker Neurovascular.

[email protected]

SOURCE: Lansberg MG et al. JAMA Neurol. 2019 Jan 28. doi: 10.1001/jamaneurol.2018.4587.

Physicians who are also mothers have a higher risk of burnout and mood and anxiety disorders if they are also caring for someone with a serious illness or disability outside of work, according to a cross-sectional survey reported in a letter in JAMA Internal Medicine.

PeopleImages/E+/Getty Images

“Our findings highlight the additional caregiving responsibilities of some women physicians and the potential consequences of these additional responsibilities for their behavioral health and careers,” wrote Veronica Yank, MD, of the department of medicine at the University of California, San Francisco, and her colleagues.

“To reduce burnout and improve workforce retention, health care systems should develop new approaches to identify and address the needs of these physician mothers,” they wrote.

The researchers used data from a June-July 2016 online survey of respondents from the Physicians Moms Group online community. Approximately 16,059 members saw the posting for the survey, and 5,613 United States–based mothers participated.

Among the questions was one on non–work related caregiving responsibilities that asked whether the respondent provided “regular care or assistance to a friend or family member with a serious health problem, long-term illness or disability” during the last year. Other questions assessed alcohol and drug use, history of a mood or anxiety disorder, career satisfaction and burnout.

Among the 16.4% of respondents who had additional caregiving responsibilities outside of work for someone chronically or seriously ill or disabled, nearly half (48.3%) said they cared for ill parents, 16.9% for children or infants, 7.7% for a partner, and 28.6% for another relative. In addition, 16.7% of respondents had such caregiving responsibilities for more than one person.

The women with these extra caregiving responsibilities were 21% more likely to have a mood or anxiety disorder (adjusted relative risk, 1.21; P = .02) and 25% more likely to report burnout (aRR, 1.25; P = .007), compared with those who did not have such extra responsibilities.

There were no significant differences, however, on rates of career satisfaction, risky drinking behaviors, or substance abuse between physician mothers who did have additional caregiving responsibilities and those who did not.

Among the study’s limitations were its cross-sectional nature, use of a convenience sample that may not be generalizable or representative, and lack of data on fathers or non-parent physicians for comparison.

SOURCE: Yank V et al. JAMA Intern Med. 2019 Jan 28. doi: 10.1001/jamainternmed.2018.6411.

Physicians who are also mothers have a higher risk of burnout and mood and anxiety disorders if they are also caring for someone with a serious illness or disability outside of work, according to a cross-sectional survey reported in a letter in JAMA Internal Medicine.

PeopleImages/E+/Getty Images

“Our findings highlight the additional caregiving responsibilities of some women physicians and the potential consequences of these additional responsibilities for their behavioral health and careers,” wrote Veronica Yank, MD, of the department of medicine at the University of California, San Francisco, and her colleagues.

“To reduce burnout and improve workforce retention, health care systems should develop new approaches to identify and address the needs of these physician mothers,” they wrote.

The researchers used data from a June-July 2016 online survey of respondents from the Physicians Moms Group online community. Approximately 16,059 members saw the posting for the survey, and 5,613 United States–based mothers participated.

Among the questions was one on non–work related caregiving responsibilities that asked whether the respondent provided “regular care or assistance to a friend or family member with a serious health problem, long-term illness or disability” during the last year. Other questions assessed alcohol and drug use, history of a mood or anxiety disorder, career satisfaction and burnout.

Among the 16.4% of respondents who had additional caregiving responsibilities outside of work for someone chronically or seriously ill or disabled, nearly half (48.3%) said they cared for ill parents, 16.9% for children or infants, 7.7% for a partner, and 28.6% for another relative. In addition, 16.7% of respondents had such caregiving responsibilities for more than one person.

The women with these extra caregiving responsibilities were 21% more likely to have a mood or anxiety disorder (adjusted relative risk, 1.21; P = .02) and 25% more likely to report burnout (aRR, 1.25; P = .007), compared with those who did not have such extra responsibilities.

There were no significant differences, however, on rates of career satisfaction, risky drinking behaviors, or substance abuse between physician mothers who did have additional caregiving responsibilities and those who did not.

Among the study’s limitations were its cross-sectional nature, use of a convenience sample that may not be generalizable or representative, and lack of data on fathers or non-parent physicians for comparison.

SOURCE: Yank V et al. JAMA Intern Med. 2019 Jan 28. doi: 10.1001/jamainternmed.2018.6411.

Physicians who are also mothers have a higher risk of burnout and mood and anxiety disorders if they are also caring for someone with a serious illness or disability outside of work, according to a cross-sectional survey reported in a letter in JAMA Internal Medicine.

PeopleImages/E+/Getty Images

“Our findings highlight the additional caregiving responsibilities of some women physicians and the potential consequences of these additional responsibilities for their behavioral health and careers,” wrote Veronica Yank, MD, of the department of medicine at the University of California, San Francisco, and her colleagues.

“To reduce burnout and improve workforce retention, health care systems should develop new approaches to identify and address the needs of these physician mothers,” they wrote.

The researchers used data from a June-July 2016 online survey of respondents from the Physicians Moms Group online community. Approximately 16,059 members saw the posting for the survey, and 5,613 United States–based mothers participated.

Among the questions was one on non–work related caregiving responsibilities that asked whether the respondent provided “regular care or assistance to a friend or family member with a serious health problem, long-term illness or disability” during the last year. Other questions assessed alcohol and drug use, history of a mood or anxiety disorder, career satisfaction and burnout.

Among the 16.4% of respondents who had additional caregiving responsibilities outside of work for someone chronically or seriously ill or disabled, nearly half (48.3%) said they cared for ill parents, 16.9% for children or infants, 7.7% for a partner, and 28.6% for another relative. In addition, 16.7% of respondents had such caregiving responsibilities for more than one person.

The women with these extra caregiving responsibilities were 21% more likely to have a mood or anxiety disorder (adjusted relative risk, 1.21; P = .02) and 25% more likely to report burnout (aRR, 1.25; P = .007), compared with those who did not have such extra responsibilities.

There were no significant differences, however, on rates of career satisfaction, risky drinking behaviors, or substance abuse between physician mothers who did have additional caregiving responsibilities and those who did not.

Among the study’s limitations were its cross-sectional nature, use of a convenience sample that may not be generalizable or representative, and lack of data on fathers or non-parent physicians for comparison.

SOURCE: Yank V et al. JAMA Intern Med. 2019 Jan 28. doi: 10.1001/jamainternmed.2018.6411.

Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?

Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.

Study design: Double-blind, placebo-controlled study.

Setting: Six emergency departments at U.S. tertiary-care hospitals.

Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.

Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.

Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
 

Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.

Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?

Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.

Study design: Double-blind, placebo-controlled study.

Setting: Six emergency departments at U.S. tertiary-care hospitals.

Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.

Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.

Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
 

Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.

Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?

Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.

Study design: Double-blind, placebo-controlled study.

Setting: Six emergency departments at U.S. tertiary-care hospitals.

Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.

Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.

Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
 

Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.