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AGA Clinical Practice Update: Diagnosis of rumination syndrome
Additionally, promote diaphragmatic breathing to help manage the condition, advised authors of an expert review of clinical practice updates for rumination syndrome published in Clinical Gastroenterology and Hepatology.
“Patients, not unsurprisingly, typically use the word ‘vomiting’ to describe rumination events, and many patients are misdiagnosed as having refractory vomiting, gastroesophageal reflux disease, or gastroparesis,” Magnus Halland, MD, of the Mayo Clinic in Rochester, Minn., and colleagues wrote in the review. “A long delay in receiving a diagnosis is common and can lead to unnecessary testing, reduced quality of life, and even invasive procedures such as surgery or feeding tubes.”
Rumination syndrome differs from vomiting, the authors noted, because the retrograde flow of ingested gastric content does not have an acidic taste and may in fact taste like food or drink recently ingested. Rumination can occur without any preceding events, after a reflux episode or by the swallowing of air that causes gastric straining but typically happens within 1 hour to 2 hours after a meal. Patients can experience weight loss, dental erosions and caries, heartburn, nausea, bloating, diarrhea, abdominal pain, abdominal discomfort, and belching, among other symptoms, in the presence of rumination syndrome, the authors said.
Dr. Halland and his colleagues provided seven best practice recommendations for rumination syndrome in their updates, which include:
- Patients who show symptoms of consistent postprandial regurgitation, often misdiagnosed with refractory gastroesophageal reflux or vomiting, should be considered for rumination syndrome.
- Patients who have dysphagia, nausea, nocturnal regurgitation, or gastric symptoms outside of meals are less likely to have rumination syndrome, but those symptoms do not exclude the condition.
- Rome IV criteria are advised to diagnose rumination syndrome after medical work-up, which includes “persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing” not preceded by retching where patients fulfill these symptom criteria for 3 months with a minimum of 6 months of symptoms before diagnosis.
- Patients should receive first-line therapy for rumination syndrome consisting of diaphragmatic breathing with or without biofeedback.
- Patients should be referred to a speech therapist, gastroenterologist, psychologist, or other knowledgeable health practitioners to learn effective diaphragmatic breathing.
- Current limitations in the diagnosis of rumination syndrome include need for expertise and lack of standardized protocols, but “testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis.”
- Bacloflen (10 mg) taken three times daily is a “reasonable next step” for patients who do not respond to treatment.
The authors acknowledged that many questions, such as the pathophysiology and initiating factors of rumination syndrome, are unknown and noted future studies are needed to address epidemiology, develop validated tools for measuring symptoms, and study diaphragmatic breathing’s effect on reducing symptoms of rumination syndrome as well as the condition’s impact on quality of life.
“Indeed, the basic question of how subconsciously one can learn to regurgitate still needs to be answered,” Dr. Halland and his colleagues wrote.
The authors report no relevant conflicts of interest.
SOURCE: Halland M et al. Clin Gastroenterol Hepatol. 2018 Jun 11. doi: 10.1016/j.cgh.2018.05.049.
Additionally, promote diaphragmatic breathing to help manage the condition, advised authors of an expert review of clinical practice updates for rumination syndrome published in Clinical Gastroenterology and Hepatology.
“Patients, not unsurprisingly, typically use the word ‘vomiting’ to describe rumination events, and many patients are misdiagnosed as having refractory vomiting, gastroesophageal reflux disease, or gastroparesis,” Magnus Halland, MD, of the Mayo Clinic in Rochester, Minn., and colleagues wrote in the review. “A long delay in receiving a diagnosis is common and can lead to unnecessary testing, reduced quality of life, and even invasive procedures such as surgery or feeding tubes.”
Rumination syndrome differs from vomiting, the authors noted, because the retrograde flow of ingested gastric content does not have an acidic taste and may in fact taste like food or drink recently ingested. Rumination can occur without any preceding events, after a reflux episode or by the swallowing of air that causes gastric straining but typically happens within 1 hour to 2 hours after a meal. Patients can experience weight loss, dental erosions and caries, heartburn, nausea, bloating, diarrhea, abdominal pain, abdominal discomfort, and belching, among other symptoms, in the presence of rumination syndrome, the authors said.
Dr. Halland and his colleagues provided seven best practice recommendations for rumination syndrome in their updates, which include:
- Patients who show symptoms of consistent postprandial regurgitation, often misdiagnosed with refractory gastroesophageal reflux or vomiting, should be considered for rumination syndrome.
- Patients who have dysphagia, nausea, nocturnal regurgitation, or gastric symptoms outside of meals are less likely to have rumination syndrome, but those symptoms do not exclude the condition.
- Rome IV criteria are advised to diagnose rumination syndrome after medical work-up, which includes “persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing” not preceded by retching where patients fulfill these symptom criteria for 3 months with a minimum of 6 months of symptoms before diagnosis.
- Patients should receive first-line therapy for rumination syndrome consisting of diaphragmatic breathing with or without biofeedback.
- Patients should be referred to a speech therapist, gastroenterologist, psychologist, or other knowledgeable health practitioners to learn effective diaphragmatic breathing.
- Current limitations in the diagnosis of rumination syndrome include need for expertise and lack of standardized protocols, but “testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis.”
- Bacloflen (10 mg) taken three times daily is a “reasonable next step” for patients who do not respond to treatment.
The authors acknowledged that many questions, such as the pathophysiology and initiating factors of rumination syndrome, are unknown and noted future studies are needed to address epidemiology, develop validated tools for measuring symptoms, and study diaphragmatic breathing’s effect on reducing symptoms of rumination syndrome as well as the condition’s impact on quality of life.
“Indeed, the basic question of how subconsciously one can learn to regurgitate still needs to be answered,” Dr. Halland and his colleagues wrote.
The authors report no relevant conflicts of interest.
SOURCE: Halland M et al. Clin Gastroenterol Hepatol. 2018 Jun 11. doi: 10.1016/j.cgh.2018.05.049.
Additionally, promote diaphragmatic breathing to help manage the condition, advised authors of an expert review of clinical practice updates for rumination syndrome published in Clinical Gastroenterology and Hepatology.
“Patients, not unsurprisingly, typically use the word ‘vomiting’ to describe rumination events, and many patients are misdiagnosed as having refractory vomiting, gastroesophageal reflux disease, or gastroparesis,” Magnus Halland, MD, of the Mayo Clinic in Rochester, Minn., and colleagues wrote in the review. “A long delay in receiving a diagnosis is common and can lead to unnecessary testing, reduced quality of life, and even invasive procedures such as surgery or feeding tubes.”
Rumination syndrome differs from vomiting, the authors noted, because the retrograde flow of ingested gastric content does not have an acidic taste and may in fact taste like food or drink recently ingested. Rumination can occur without any preceding events, after a reflux episode or by the swallowing of air that causes gastric straining but typically happens within 1 hour to 2 hours after a meal. Patients can experience weight loss, dental erosions and caries, heartburn, nausea, bloating, diarrhea, abdominal pain, abdominal discomfort, and belching, among other symptoms, in the presence of rumination syndrome, the authors said.
Dr. Halland and his colleagues provided seven best practice recommendations for rumination syndrome in their updates, which include:
- Patients who show symptoms of consistent postprandial regurgitation, often misdiagnosed with refractory gastroesophageal reflux or vomiting, should be considered for rumination syndrome.
- Patients who have dysphagia, nausea, nocturnal regurgitation, or gastric symptoms outside of meals are less likely to have rumination syndrome, but those symptoms do not exclude the condition.
- Rome IV criteria are advised to diagnose rumination syndrome after medical work-up, which includes “persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing” not preceded by retching where patients fulfill these symptom criteria for 3 months with a minimum of 6 months of symptoms before diagnosis.
- Patients should receive first-line therapy for rumination syndrome consisting of diaphragmatic breathing with or without biofeedback.
- Patients should be referred to a speech therapist, gastroenterologist, psychologist, or other knowledgeable health practitioners to learn effective diaphragmatic breathing.
- Current limitations in the diagnosis of rumination syndrome include need for expertise and lack of standardized protocols, but “testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis.”
- Bacloflen (10 mg) taken three times daily is a “reasonable next step” for patients who do not respond to treatment.
The authors acknowledged that many questions, such as the pathophysiology and initiating factors of rumination syndrome, are unknown and noted future studies are needed to address epidemiology, develop validated tools for measuring symptoms, and study diaphragmatic breathing’s effect on reducing symptoms of rumination syndrome as well as the condition’s impact on quality of life.
“Indeed, the basic question of how subconsciously one can learn to regurgitate still needs to be answered,” Dr. Halland and his colleagues wrote.
The authors report no relevant conflicts of interest.
SOURCE: Halland M et al. Clin Gastroenterol Hepatol. 2018 Jun 11. doi: 10.1016/j.cgh.2018.05.049.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Trials need standardized reporting of pediatric fever after flu vaccine
Researchers found a lower rate of pediatric fever after applying a standard definition of fever across three different clinical trials of pediatric patients receiving influenza vaccinations, according to research published in the Pediatric Infectious Disease Journal.
Investigators in future studies must adopt a standardized definition of pediatric fever after an influenza vaccination. “Our study demonstrates the variability in results which occur due to minor differences in the definition of fever, methods of analysis and reporting of results,” Jean Li-Kim-Moy, MBBS, of the University of Sydney, and colleagues wrote.
Dr. Li-Kim-Moy and colleagues analyzed pediatric datasets from three different clinical trials using trivalent influenza vaccine (TIV); the primary trial included 3,317 children aged 6-35 months who were randomized to receive Fluarix at 0.25 mL or 0.5 mL, or receive 0.25 mL of Fluzone. The other two trials studied children receiving TIV between 6 months–17 years and 3-17 years. The researchers also performed a multivariable regression analysis to determine the relationship between immunogenicity, antipyretic use, and postvaccination fever.
The primary study initially reported the fever rate 0 days–3 days after vaccination was between 6% and 7%. After reporting the rate of fever separately for each dose and changing the criteria to “defining fever as greater than or equal to 38.0°C by any route of measurement” for the primary study, the researchers found a rate of any-cause fever was 3%-4% for the first dose and 4%-5% for the second dose. The rate of vaccine-related fever in the primary study was 3% for the first dose and 3%-4% for the second dose, with researchers noting vaccine-related fever occurred significantly earlier compared with any-cause fever (mean 1 days vs. 2 days after vaccination; P equals .04).
Impact of fever, antipyretics
The researchers also performed a pooled immunogenicity analysis of 5,902 children from all three trials and found a strong association between fever after vaccination and increased geometric mean titer (GMT) ratios (1.21-1.39; P less than or equal to .01) and an association between antipyretic use and reduced GMT ratios (0.80-0.87; P less than .0006).
“Our pooled analysis of the three trials demonstrated highly significant associations, for all strains, between postvaccination fever and up to 39% higher GMT; Similarly, strong evidence of associations in the opposite direction was found between postvaccination antipyretic use (days 0-3), adjusting for all other factors including fever, and decreased immunogenicity against all vaccine strains in children,” Dr. Li-Kim-Moy and colleagues said.
Antipyretic use was common in the primary study, occurring in one in six of the children, they said. These findings of “significant associations between fever and increased vaccine immunogenicity, and between antipyretic use and reduced immunogenicity in children after influenza vaccination” suggest the need for further study, especially because parents often give antipyretics if their children are febrile after vaccinations.
“There is uncertainty whether our findings, and those of others, on immunogenicity translate into clinically significant effects,” they wrote. “However, the fact that influenza vaccine, unlike many routine childhood vaccines, is only moderately protective may mean that modest reductions in antibody response are more likely to correlate to less protection.”
Dr. Wood reported receiving a fellowship from the National Health and Medical Research Council (NHMRC) and being an investigator for GlaxoSmithKline trials. Dr. Booy reported being an advisor for influenza vaccine manufacturing, an advisory board member, on the speaker’s bureau, and a researcher of vaccines for several manufacturers. The other authors reported no relevant conflicts of interest.
SOURCE: Li-Kim-Moy J et al. Pediatr Infect Dis J. 2018 Oct;37(10):971-5.
Researchers found a lower rate of pediatric fever after applying a standard definition of fever across three different clinical trials of pediatric patients receiving influenza vaccinations, according to research published in the Pediatric Infectious Disease Journal.
Investigators in future studies must adopt a standardized definition of pediatric fever after an influenza vaccination. “Our study demonstrates the variability in results which occur due to minor differences in the definition of fever, methods of analysis and reporting of results,” Jean Li-Kim-Moy, MBBS, of the University of Sydney, and colleagues wrote.
Dr. Li-Kim-Moy and colleagues analyzed pediatric datasets from three different clinical trials using trivalent influenza vaccine (TIV); the primary trial included 3,317 children aged 6-35 months who were randomized to receive Fluarix at 0.25 mL or 0.5 mL, or receive 0.25 mL of Fluzone. The other two trials studied children receiving TIV between 6 months–17 years and 3-17 years. The researchers also performed a multivariable regression analysis to determine the relationship between immunogenicity, antipyretic use, and postvaccination fever.
The primary study initially reported the fever rate 0 days–3 days after vaccination was between 6% and 7%. After reporting the rate of fever separately for each dose and changing the criteria to “defining fever as greater than or equal to 38.0°C by any route of measurement” for the primary study, the researchers found a rate of any-cause fever was 3%-4% for the first dose and 4%-5% for the second dose. The rate of vaccine-related fever in the primary study was 3% for the first dose and 3%-4% for the second dose, with researchers noting vaccine-related fever occurred significantly earlier compared with any-cause fever (mean 1 days vs. 2 days after vaccination; P equals .04).
Impact of fever, antipyretics
The researchers also performed a pooled immunogenicity analysis of 5,902 children from all three trials and found a strong association between fever after vaccination and increased geometric mean titer (GMT) ratios (1.21-1.39; P less than or equal to .01) and an association between antipyretic use and reduced GMT ratios (0.80-0.87; P less than .0006).
“Our pooled analysis of the three trials demonstrated highly significant associations, for all strains, between postvaccination fever and up to 39% higher GMT; Similarly, strong evidence of associations in the opposite direction was found between postvaccination antipyretic use (days 0-3), adjusting for all other factors including fever, and decreased immunogenicity against all vaccine strains in children,” Dr. Li-Kim-Moy and colleagues said.
Antipyretic use was common in the primary study, occurring in one in six of the children, they said. These findings of “significant associations between fever and increased vaccine immunogenicity, and between antipyretic use and reduced immunogenicity in children after influenza vaccination” suggest the need for further study, especially because parents often give antipyretics if their children are febrile after vaccinations.
“There is uncertainty whether our findings, and those of others, on immunogenicity translate into clinically significant effects,” they wrote. “However, the fact that influenza vaccine, unlike many routine childhood vaccines, is only moderately protective may mean that modest reductions in antibody response are more likely to correlate to less protection.”
Dr. Wood reported receiving a fellowship from the National Health and Medical Research Council (NHMRC) and being an investigator for GlaxoSmithKline trials. Dr. Booy reported being an advisor for influenza vaccine manufacturing, an advisory board member, on the speaker’s bureau, and a researcher of vaccines for several manufacturers. The other authors reported no relevant conflicts of interest.
SOURCE: Li-Kim-Moy J et al. Pediatr Infect Dis J. 2018 Oct;37(10):971-5.
Researchers found a lower rate of pediatric fever after applying a standard definition of fever across three different clinical trials of pediatric patients receiving influenza vaccinations, according to research published in the Pediatric Infectious Disease Journal.
Investigators in future studies must adopt a standardized definition of pediatric fever after an influenza vaccination. “Our study demonstrates the variability in results which occur due to minor differences in the definition of fever, methods of analysis and reporting of results,” Jean Li-Kim-Moy, MBBS, of the University of Sydney, and colleagues wrote.
Dr. Li-Kim-Moy and colleagues analyzed pediatric datasets from three different clinical trials using trivalent influenza vaccine (TIV); the primary trial included 3,317 children aged 6-35 months who were randomized to receive Fluarix at 0.25 mL or 0.5 mL, or receive 0.25 mL of Fluzone. The other two trials studied children receiving TIV between 6 months–17 years and 3-17 years. The researchers also performed a multivariable regression analysis to determine the relationship between immunogenicity, antipyretic use, and postvaccination fever.
The primary study initially reported the fever rate 0 days–3 days after vaccination was between 6% and 7%. After reporting the rate of fever separately for each dose and changing the criteria to “defining fever as greater than or equal to 38.0°C by any route of measurement” for the primary study, the researchers found a rate of any-cause fever was 3%-4% for the first dose and 4%-5% for the second dose. The rate of vaccine-related fever in the primary study was 3% for the first dose and 3%-4% for the second dose, with researchers noting vaccine-related fever occurred significantly earlier compared with any-cause fever (mean 1 days vs. 2 days after vaccination; P equals .04).
Impact of fever, antipyretics
The researchers also performed a pooled immunogenicity analysis of 5,902 children from all three trials and found a strong association between fever after vaccination and increased geometric mean titer (GMT) ratios (1.21-1.39; P less than or equal to .01) and an association between antipyretic use and reduced GMT ratios (0.80-0.87; P less than .0006).
“Our pooled analysis of the three trials demonstrated highly significant associations, for all strains, between postvaccination fever and up to 39% higher GMT; Similarly, strong evidence of associations in the opposite direction was found between postvaccination antipyretic use (days 0-3), adjusting for all other factors including fever, and decreased immunogenicity against all vaccine strains in children,” Dr. Li-Kim-Moy and colleagues said.
Antipyretic use was common in the primary study, occurring in one in six of the children, they said. These findings of “significant associations between fever and increased vaccine immunogenicity, and between antipyretic use and reduced immunogenicity in children after influenza vaccination” suggest the need for further study, especially because parents often give antipyretics if their children are febrile after vaccinations.
“There is uncertainty whether our findings, and those of others, on immunogenicity translate into clinically significant effects,” they wrote. “However, the fact that influenza vaccine, unlike many routine childhood vaccines, is only moderately protective may mean that modest reductions in antibody response are more likely to correlate to less protection.”
Dr. Wood reported receiving a fellowship from the National Health and Medical Research Council (NHMRC) and being an investigator for GlaxoSmithKline trials. Dr. Booy reported being an advisor for influenza vaccine manufacturing, an advisory board member, on the speaker’s bureau, and a researcher of vaccines for several manufacturers. The other authors reported no relevant conflicts of interest.
SOURCE: Li-Kim-Moy J et al. Pediatr Infect Dis J. 2018 Oct;37(10):971-5.
FROM THE PEDIATRIC INFECTIOUS DISEASE JOURNAL
Key clinical point: There is variability in reporting and analysis of pediatric fever rates after administration of the influenza vaccine.
Major finding: Applying the Brighton Collaboration standardized definition for vaccine-related fever to three clinical trials yielded significantly lower rates of fever (3%-4%), compared with the rates reported in the trials (6%-7%).
Study details: An analysis of pediatric fever data from three different clinical trials using Brighton Collaboration criteria.
Disclosures: Dr. Wood reported receiving a fellowship from the National Health and Medical Research Council and being an investigator for GlaxoSmithKline trials. Dr. Booy reported being an advisor for influenza vaccine manufacturing, an advisory board member, on the speaker’s bureau, and a researcher of vaccines for several manufacturers. The other authors reported no relevant conflicts of interest.
Source: Li-Kim-Moy J et al. Pediatr Infect Dis J. 2018 Oct;37(10):971-5.
Behavioral checklist IDs children at risk of depressive, anxiety disorders
disorders in later adolescent or adult life, according to research published in the Journal of Pediatrics.
“If confirmed, this observation could have very significant clinical and public health implications in the identification of children at the highest risk for the development of major depressive disorder,” Mai Uchida, MD, of the department of psychiatry at Massachusetts General Hospital in Boston, and colleagues wrote. “Early identification is the first step toward effectively allocating limited societal resources to help prevent illness progression and its associated impairments in children most in need.”
Dr. Uchida and her colleagues analyzed a sample of 537 children aged 6-17 years from two longitudinal studies of children and their parents with and without ADHD, excluding the ADHD probands in their analysis. Parents answered the CBCL, which consisted of behavioral questions translated into scores for subscales involving being anxious and/or depressed, withdrawn and/or depressed, social problems, thought problems, aggressive behavior, rule-breaking behavior, attention problems, and somatic complaints.
The sample was then divided into four groups; there were 172 children with parents who had a mood disorder but the children did not have CBCL anxiety/depression subsyndromal elevations (high risk group); 22 children without a parental history of mood disorder but had CBCL anxiety/depression subsyndromal elevations (subsyndromal major depressive disorder); 22 children with a parental history of mood disorder and CBCL anxiety/depression subsyndromal elevations (high-risk and subsyndromal major depressive disorder); and 186 children in a control group with no parental history of mood disorder or CBCL anxiety/depression subsyndromal elevations.
Compared with the control group, children with a history of parental mood disorders and children with baseline CBCL anxiety/depression subsyndromal elevations had intermediate risk of developing major depression and anxiety disorders. However, the highest risk was among children with both a parental history of mood disorder and baseline CBCL anxiety/depression subsyndromal elevations.
Using data from two previously collected longitudinal studies was a potential limitation of the study, Dr. Uchida and her associates said, but they noted the CBCL scale has predictive utility for identifying anxiety and depressive disorders in children later in life.
“Considering its simplicity, strong psychometric properties, and limited cost, the CBCL scale lends itself to be used by health professionals and educators in the community,” they wrote.
This study was partly supported by National Institutes of Health and the Massachusetts General Hospital Pediatric Psychopharmacology Council Fund. Joseph Biederman, MD, received research support from Lundbeck AS, Neurocentria, Pfizer, Shire, Sunovion, and others, and has relationships with multiple other associations and pharmaceutical companies. The other authors have no relevant financial disclosures.
SOURCE: Uchida M et al. J Pediatr. 2018 Oct;201:252-8.
disorders in later adolescent or adult life, according to research published in the Journal of Pediatrics.
“If confirmed, this observation could have very significant clinical and public health implications in the identification of children at the highest risk for the development of major depressive disorder,” Mai Uchida, MD, of the department of psychiatry at Massachusetts General Hospital in Boston, and colleagues wrote. “Early identification is the first step toward effectively allocating limited societal resources to help prevent illness progression and its associated impairments in children most in need.”
Dr. Uchida and her colleagues analyzed a sample of 537 children aged 6-17 years from two longitudinal studies of children and their parents with and without ADHD, excluding the ADHD probands in their analysis. Parents answered the CBCL, which consisted of behavioral questions translated into scores for subscales involving being anxious and/or depressed, withdrawn and/or depressed, social problems, thought problems, aggressive behavior, rule-breaking behavior, attention problems, and somatic complaints.
The sample was then divided into four groups; there were 172 children with parents who had a mood disorder but the children did not have CBCL anxiety/depression subsyndromal elevations (high risk group); 22 children without a parental history of mood disorder but had CBCL anxiety/depression subsyndromal elevations (subsyndromal major depressive disorder); 22 children with a parental history of mood disorder and CBCL anxiety/depression subsyndromal elevations (high-risk and subsyndromal major depressive disorder); and 186 children in a control group with no parental history of mood disorder or CBCL anxiety/depression subsyndromal elevations.
Compared with the control group, children with a history of parental mood disorders and children with baseline CBCL anxiety/depression subsyndromal elevations had intermediate risk of developing major depression and anxiety disorders. However, the highest risk was among children with both a parental history of mood disorder and baseline CBCL anxiety/depression subsyndromal elevations.
Using data from two previously collected longitudinal studies was a potential limitation of the study, Dr. Uchida and her associates said, but they noted the CBCL scale has predictive utility for identifying anxiety and depressive disorders in children later in life.
“Considering its simplicity, strong psychometric properties, and limited cost, the CBCL scale lends itself to be used by health professionals and educators in the community,” they wrote.
This study was partly supported by National Institutes of Health and the Massachusetts General Hospital Pediatric Psychopharmacology Council Fund. Joseph Biederman, MD, received research support from Lundbeck AS, Neurocentria, Pfizer, Shire, Sunovion, and others, and has relationships with multiple other associations and pharmaceutical companies. The other authors have no relevant financial disclosures.
SOURCE: Uchida M et al. J Pediatr. 2018 Oct;201:252-8.
disorders in later adolescent or adult life, according to research published in the Journal of Pediatrics.
“If confirmed, this observation could have very significant clinical and public health implications in the identification of children at the highest risk for the development of major depressive disorder,” Mai Uchida, MD, of the department of psychiatry at Massachusetts General Hospital in Boston, and colleagues wrote. “Early identification is the first step toward effectively allocating limited societal resources to help prevent illness progression and its associated impairments in children most in need.”
Dr. Uchida and her colleagues analyzed a sample of 537 children aged 6-17 years from two longitudinal studies of children and their parents with and without ADHD, excluding the ADHD probands in their analysis. Parents answered the CBCL, which consisted of behavioral questions translated into scores for subscales involving being anxious and/or depressed, withdrawn and/or depressed, social problems, thought problems, aggressive behavior, rule-breaking behavior, attention problems, and somatic complaints.
The sample was then divided into four groups; there were 172 children with parents who had a mood disorder but the children did not have CBCL anxiety/depression subsyndromal elevations (high risk group); 22 children without a parental history of mood disorder but had CBCL anxiety/depression subsyndromal elevations (subsyndromal major depressive disorder); 22 children with a parental history of mood disorder and CBCL anxiety/depression subsyndromal elevations (high-risk and subsyndromal major depressive disorder); and 186 children in a control group with no parental history of mood disorder or CBCL anxiety/depression subsyndromal elevations.
Compared with the control group, children with a history of parental mood disorders and children with baseline CBCL anxiety/depression subsyndromal elevations had intermediate risk of developing major depression and anxiety disorders. However, the highest risk was among children with both a parental history of mood disorder and baseline CBCL anxiety/depression subsyndromal elevations.
Using data from two previously collected longitudinal studies was a potential limitation of the study, Dr. Uchida and her associates said, but they noted the CBCL scale has predictive utility for identifying anxiety and depressive disorders in children later in life.
“Considering its simplicity, strong psychometric properties, and limited cost, the CBCL scale lends itself to be used by health professionals and educators in the community,” they wrote.
This study was partly supported by National Institutes of Health and the Massachusetts General Hospital Pediatric Psychopharmacology Council Fund. Joseph Biederman, MD, received research support from Lundbeck AS, Neurocentria, Pfizer, Shire, Sunovion, and others, and has relationships with multiple other associations and pharmaceutical companies. The other authors have no relevant financial disclosures.
SOURCE: Uchida M et al. J Pediatr. 2018 Oct;201:252-8.
FROM THE JOURNAL OF PEDIATRICS
Key clinical point: Children with elevated CBCL anxiety/depression scale scores at baseline as well as a parent with a major depressive disorder were at risk of developing a major depressive disorder or anxiety disorder at 10-year follow-up.
Major finding:
Study details: An analysis of 537 children in a sample from two longitudinal case studies of families with and without child and parental history of ADHD.
Disclosures: This study was partly supported by National Institutes of Health and the Massachusetts General Hospital Pediatric Psychopharmacology Council Fund. Joseph Biederman, MD, received research support from Neurocentria, Pfizer, Shire, Sunovion, and others, and has relationships with multiple other associations and pharmaceutical companies. The other authors have no relevant financial disclosures.
Source: Uchida M et al. J Pediatr. 2018 Oct;201:252-8.
Under new ACC-AHA criteria, more pregnant women at risk of hypertension, adverse outcomes
A total of 164 new diagnoses (5.6%) of lower range stage 1 hypertension were made when the revised American Heart Association and the American College of Cardiology (ACC-AHA) Task Force on Clinical Practice Guidelines for chronic hypertension in adults were applied to a population of 2,947 pregnant women.
These patients had a significantly increased risk of preeclampsia as well as an increased risk of gestational diabetes mellitus and preterm birth, compared with normotensive patients, according to a study published in Obstetrics & Gynecology.
Elizabeth F. Sutton, PhD, and her associates at Magee-Womens Research Institute in Pittsburgh, used data from a Eunice Kennedy Shriver National Institute of Child Health and Human Development study. It included 2,947 pregnant women with singleton pregnancies where 94% of women were normotensive prior to 25 weeks of gestation. The researchers identified 164 new cases (6%) of lower range stage 1 hypertension under the ACC-AHA guidelines. Patients were then randomized to receive 60 mg of aspirin (1,399 normotensive patients, 66 stage 1 hypertension patients) or placebo (1,384 normotensive patients, 98 stage 1 hypertension patients).
The women had their blood pressure (BP) measured at 25 weeks of gestation or prior, and those patients with a systolic BP between 130 mm Hg and 139 mm Hg or diastolic BP between 80 mm and 89 mm were reclassified as having stage 1 hypertension under the new ACC-AHA guidelines; outcomes were compared with normotensive women with a systolic BP of 130 mm Hg and diastolic BP of 80 mm Hg. The researchers also performed a sensitivity analysis that restricted enrollment to 1,661 women who were at 20 weeks of gestation or prior, they said.
“Of important note, as a result of eligibility criterion excluding women with chronic hypertension (greater than 135/85 mm Hg) at enrollment, the enrollment BP range within the stage 1 hypertension group was limited to lower range stage 1 hypertension, that is, 130-135, 80-85 mm Hg, or both,” Dr. Sutton and her colleagues wrote.
The researchers found a significantly increased risk of preeclampsia among hypertensive pregnant women in the placebo group (15%) compared with normotensive (5%) women (relative risk, 2.66; 95% confidence interval, 1.56-4.54; P less than .01). These patients also had an increased risk of gestational diabetes mellitus (6%) compared with normotensive (2.5%; P = .03) pregnant women as well as an increased risk of preterm birth (4% vs. 1%; P = .01). Among women with stage 1 hypertension who received low-dose aspirin, there were no significant differences regarding the rate of preeclampsia, gestational diabetes mellitus, or preterm birth risk.
“Although prepregnancy BPs would be ideal for diagnosis, prior studies have shown that women do not consistently seek primary care outside of pregnancy,” Dr. Sutton and her colleagues wrote. “In the United States, preconception care engagement rates are between 18% and 45% in reproductive-aged women; thus, early pregnancy BPs may be all that is available for the obstetrician.”
Limitations to the secondary analysis included the original study’s exclusion of BPs higher than 135/85 mm Hg and the small sample size of patients who met the new criteria for stage 1 hypertension. The researchers also noted an increased risk of preeclampsia among patients with intake systolic BP between 120 mm Hg and 129 mm Hg, “with a smaller magnitude of risk compared with stage 1 hypertension.
“These findings suggest preliminarily that when considering preeclampsia risk based on early pregnancy BP, perhaps BP could be considered as a continuous variable rather than categorical,” Dr. Sutton and her colleagues noted.
This study was supported in part by the American Heart Association and the Eunice Kennedy Shriver NICHD. The authors reported no relevant financial conflicts of interest.
SOURCE: Sutton EF et al. Obstet Gynecol. 2018 Oct doi: 10.1097/AOG.0000000000002870.
I have significant concerns that, were ob.gyns. to adopt the ACC-AHA guidelines for chronic hypertension in adults and apply them to pregnant women, it would have great implications, as about 25% of all pregnant women have these findings.
Under the new criteria, there would be an additional 1 million pregnant women diagnosed with prehypertension or stage 1 hypertension. The new criteria will not only overdiagnose prehypertension in these women, it will cause more women to receive antihypertension medications.
The ACC-AHA criteria apply only to patients who have their blood pressure (BP) recorded prior to pregnancy or prior to 20 weeks of gestation. This study included women at up to 25 weeks of gestation, which means some already had been developing the condition. The Sutton et al. data also do not follow the new ACC-AHA criteria because the criteria require two BP readings, and the current study shows only one elevation which is, in my opinion, more dangerous.
Any time new criteria and screening are introduced, there always should be preparations for what happens next. There is no doubt that the ACC-AHA criteria, performed using two BP readings, is associated with hypertension, but what should clinicians do with that information? Prospective studies aimed at evaluating whether a woman with hypertension prior to or early in pregnancy may benefit from more intensive screening and other interventions to prevent hypertensive disorders and gestational diabetes in pregnancy are needed.
Baha Sibai, MD, is a visiting professor in the department of obstetrics, gynecology, and reproductive sciences at The University of Texas Health Sciences Center at Houston. He was asked to comment on the study by Sutton et al. He reported no relevant financial conflicts of interest.
I have significant concerns that, were ob.gyns. to adopt the ACC-AHA guidelines for chronic hypertension in adults and apply them to pregnant women, it would have great implications, as about 25% of all pregnant women have these findings.
Under the new criteria, there would be an additional 1 million pregnant women diagnosed with prehypertension or stage 1 hypertension. The new criteria will not only overdiagnose prehypertension in these women, it will cause more women to receive antihypertension medications.
The ACC-AHA criteria apply only to patients who have their blood pressure (BP) recorded prior to pregnancy or prior to 20 weeks of gestation. This study included women at up to 25 weeks of gestation, which means some already had been developing the condition. The Sutton et al. data also do not follow the new ACC-AHA criteria because the criteria require two BP readings, and the current study shows only one elevation which is, in my opinion, more dangerous.
Any time new criteria and screening are introduced, there always should be preparations for what happens next. There is no doubt that the ACC-AHA criteria, performed using two BP readings, is associated with hypertension, but what should clinicians do with that information? Prospective studies aimed at evaluating whether a woman with hypertension prior to or early in pregnancy may benefit from more intensive screening and other interventions to prevent hypertensive disorders and gestational diabetes in pregnancy are needed.
Baha Sibai, MD, is a visiting professor in the department of obstetrics, gynecology, and reproductive sciences at The University of Texas Health Sciences Center at Houston. He was asked to comment on the study by Sutton et al. He reported no relevant financial conflicts of interest.
I have significant concerns that, were ob.gyns. to adopt the ACC-AHA guidelines for chronic hypertension in adults and apply them to pregnant women, it would have great implications, as about 25% of all pregnant women have these findings.
Under the new criteria, there would be an additional 1 million pregnant women diagnosed with prehypertension or stage 1 hypertension. The new criteria will not only overdiagnose prehypertension in these women, it will cause more women to receive antihypertension medications.
The ACC-AHA criteria apply only to patients who have their blood pressure (BP) recorded prior to pregnancy or prior to 20 weeks of gestation. This study included women at up to 25 weeks of gestation, which means some already had been developing the condition. The Sutton et al. data also do not follow the new ACC-AHA criteria because the criteria require two BP readings, and the current study shows only one elevation which is, in my opinion, more dangerous.
Any time new criteria and screening are introduced, there always should be preparations for what happens next. There is no doubt that the ACC-AHA criteria, performed using two BP readings, is associated with hypertension, but what should clinicians do with that information? Prospective studies aimed at evaluating whether a woman with hypertension prior to or early in pregnancy may benefit from more intensive screening and other interventions to prevent hypertensive disorders and gestational diabetes in pregnancy are needed.
Baha Sibai, MD, is a visiting professor in the department of obstetrics, gynecology, and reproductive sciences at The University of Texas Health Sciences Center at Houston. He was asked to comment on the study by Sutton et al. He reported no relevant financial conflicts of interest.
A total of 164 new diagnoses (5.6%) of lower range stage 1 hypertension were made when the revised American Heart Association and the American College of Cardiology (ACC-AHA) Task Force on Clinical Practice Guidelines for chronic hypertension in adults were applied to a population of 2,947 pregnant women.
These patients had a significantly increased risk of preeclampsia as well as an increased risk of gestational diabetes mellitus and preterm birth, compared with normotensive patients, according to a study published in Obstetrics & Gynecology.
Elizabeth F. Sutton, PhD, and her associates at Magee-Womens Research Institute in Pittsburgh, used data from a Eunice Kennedy Shriver National Institute of Child Health and Human Development study. It included 2,947 pregnant women with singleton pregnancies where 94% of women were normotensive prior to 25 weeks of gestation. The researchers identified 164 new cases (6%) of lower range stage 1 hypertension under the ACC-AHA guidelines. Patients were then randomized to receive 60 mg of aspirin (1,399 normotensive patients, 66 stage 1 hypertension patients) or placebo (1,384 normotensive patients, 98 stage 1 hypertension patients).
The women had their blood pressure (BP) measured at 25 weeks of gestation or prior, and those patients with a systolic BP between 130 mm Hg and 139 mm Hg or diastolic BP between 80 mm and 89 mm were reclassified as having stage 1 hypertension under the new ACC-AHA guidelines; outcomes were compared with normotensive women with a systolic BP of 130 mm Hg and diastolic BP of 80 mm Hg. The researchers also performed a sensitivity analysis that restricted enrollment to 1,661 women who were at 20 weeks of gestation or prior, they said.
“Of important note, as a result of eligibility criterion excluding women with chronic hypertension (greater than 135/85 mm Hg) at enrollment, the enrollment BP range within the stage 1 hypertension group was limited to lower range stage 1 hypertension, that is, 130-135, 80-85 mm Hg, or both,” Dr. Sutton and her colleagues wrote.
The researchers found a significantly increased risk of preeclampsia among hypertensive pregnant women in the placebo group (15%) compared with normotensive (5%) women (relative risk, 2.66; 95% confidence interval, 1.56-4.54; P less than .01). These patients also had an increased risk of gestational diabetes mellitus (6%) compared with normotensive (2.5%; P = .03) pregnant women as well as an increased risk of preterm birth (4% vs. 1%; P = .01). Among women with stage 1 hypertension who received low-dose aspirin, there were no significant differences regarding the rate of preeclampsia, gestational diabetes mellitus, or preterm birth risk.
“Although prepregnancy BPs would be ideal for diagnosis, prior studies have shown that women do not consistently seek primary care outside of pregnancy,” Dr. Sutton and her colleagues wrote. “In the United States, preconception care engagement rates are between 18% and 45% in reproductive-aged women; thus, early pregnancy BPs may be all that is available for the obstetrician.”
Limitations to the secondary analysis included the original study’s exclusion of BPs higher than 135/85 mm Hg and the small sample size of patients who met the new criteria for stage 1 hypertension. The researchers also noted an increased risk of preeclampsia among patients with intake systolic BP between 120 mm Hg and 129 mm Hg, “with a smaller magnitude of risk compared with stage 1 hypertension.
“These findings suggest preliminarily that when considering preeclampsia risk based on early pregnancy BP, perhaps BP could be considered as a continuous variable rather than categorical,” Dr. Sutton and her colleagues noted.
This study was supported in part by the American Heart Association and the Eunice Kennedy Shriver NICHD. The authors reported no relevant financial conflicts of interest.
SOURCE: Sutton EF et al. Obstet Gynecol. 2018 Oct doi: 10.1097/AOG.0000000000002870.
A total of 164 new diagnoses (5.6%) of lower range stage 1 hypertension were made when the revised American Heart Association and the American College of Cardiology (ACC-AHA) Task Force on Clinical Practice Guidelines for chronic hypertension in adults were applied to a population of 2,947 pregnant women.
These patients had a significantly increased risk of preeclampsia as well as an increased risk of gestational diabetes mellitus and preterm birth, compared with normotensive patients, according to a study published in Obstetrics & Gynecology.
Elizabeth F. Sutton, PhD, and her associates at Magee-Womens Research Institute in Pittsburgh, used data from a Eunice Kennedy Shriver National Institute of Child Health and Human Development study. It included 2,947 pregnant women with singleton pregnancies where 94% of women were normotensive prior to 25 weeks of gestation. The researchers identified 164 new cases (6%) of lower range stage 1 hypertension under the ACC-AHA guidelines. Patients were then randomized to receive 60 mg of aspirin (1,399 normotensive patients, 66 stage 1 hypertension patients) or placebo (1,384 normotensive patients, 98 stage 1 hypertension patients).
The women had their blood pressure (BP) measured at 25 weeks of gestation or prior, and those patients with a systolic BP between 130 mm Hg and 139 mm Hg or diastolic BP between 80 mm and 89 mm were reclassified as having stage 1 hypertension under the new ACC-AHA guidelines; outcomes were compared with normotensive women with a systolic BP of 130 mm Hg and diastolic BP of 80 mm Hg. The researchers also performed a sensitivity analysis that restricted enrollment to 1,661 women who were at 20 weeks of gestation or prior, they said.
“Of important note, as a result of eligibility criterion excluding women with chronic hypertension (greater than 135/85 mm Hg) at enrollment, the enrollment BP range within the stage 1 hypertension group was limited to lower range stage 1 hypertension, that is, 130-135, 80-85 mm Hg, or both,” Dr. Sutton and her colleagues wrote.
The researchers found a significantly increased risk of preeclampsia among hypertensive pregnant women in the placebo group (15%) compared with normotensive (5%) women (relative risk, 2.66; 95% confidence interval, 1.56-4.54; P less than .01). These patients also had an increased risk of gestational diabetes mellitus (6%) compared with normotensive (2.5%; P = .03) pregnant women as well as an increased risk of preterm birth (4% vs. 1%; P = .01). Among women with stage 1 hypertension who received low-dose aspirin, there were no significant differences regarding the rate of preeclampsia, gestational diabetes mellitus, or preterm birth risk.
“Although prepregnancy BPs would be ideal for diagnosis, prior studies have shown that women do not consistently seek primary care outside of pregnancy,” Dr. Sutton and her colleagues wrote. “In the United States, preconception care engagement rates are between 18% and 45% in reproductive-aged women; thus, early pregnancy BPs may be all that is available for the obstetrician.”
Limitations to the secondary analysis included the original study’s exclusion of BPs higher than 135/85 mm Hg and the small sample size of patients who met the new criteria for stage 1 hypertension. The researchers also noted an increased risk of preeclampsia among patients with intake systolic BP between 120 mm Hg and 129 mm Hg, “with a smaller magnitude of risk compared with stage 1 hypertension.
“These findings suggest preliminarily that when considering preeclampsia risk based on early pregnancy BP, perhaps BP could be considered as a continuous variable rather than categorical,” Dr. Sutton and her colleagues noted.
This study was supported in part by the American Heart Association and the Eunice Kennedy Shriver NICHD. The authors reported no relevant financial conflicts of interest.
SOURCE: Sutton EF et al. Obstet Gynecol. 2018 Oct doi: 10.1097/AOG.0000000000002870.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point: gestational diabetes, and preterm birth.
Major finding: Pregnant women with newly diagnosed stage 1 hypertension not randomized to receive aspirin had a significantly higher risk of preeclampsia (15%) and a higher risk of gestational diabetes (6%) and preterm birth (4%), compared with normotensive pregnant women.
Study details: A secondary analysis of 2,947 women who were originally enrolled in a study by the Eunice Kennedy Shriver NICHD between 1989 and 1992.
Disclosures: This study was supported in part by the American Heart Association and the Eunice Kennedy Shriver NICHD. The authors reported no relevant financial conflicts of interest.
Source: Sutton EF et al. Obstet Gynecol. 2018 Oct doi:10.1097/AOG.0000000000002870.
Guidelines offer recommendations for hernia repair in obese patients
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
FROM SURGERY FOR OBESITY AND RELATED DISEASES
Physician burnout linked to patient safety
Physician burnout may jeopardize patient care, according to research published in JAMA Internal Medicine.
A review and meta-analysis suggested that physician burnout was associated with a higher risk of patient safety incidents, reduced patient satisfaction, and low professionalism.
Burnout was defined as “a response to prolonged exposure to occupational stress encompassing feelings of emotional exhaustion, depersonalization, and reduced professional efficacy.”
This research was conducted by Maria Panagioti, PhD, of the University of Manchester in the U.K., and her colleagues.
The researchers analyzed 47 studies on the topics of physician burnout and patient care, which included data from a pooled cohort of 42,473 physicians.
Nearly 45% of studies included physicians in their residency or early career (up to 5 years post-residency), and 55.3% included more experienced physicians. The studies included physicians in a hospital setting (63.8%), primary care setting (27.7%), or a mix of health care settings (8.5%).
The data indicated that physician burnout was significantly associated with:
- An increased risk of patient safety incidents—odds ratio [OR], 1.96 (P<0.001)
- Low professionalism—OR, 2.31 (P<0.001)
- Reduced patient satisfaction—OR, 2.28 (P<0.001).
The researchers noted that the reporting method had an impact on the results. According to physician report, burnout was associated with significantly increased risks of safety incidents (OR, 2.07) and low professionalism (OR, 2.67).
However, according to system reports, there was no significant association between physician burnout and safety incidents (OR, 1.00) or low professionalism (OR, 1.15).
Another factor that impacted results was physician experience. The association between burnout and low professionalism was significantly larger in studies of residents and early career physicians (OR, 3.39) than in studies of middle- and late-career physicians (OR, 1.73).
The researchers noted that this review had its limitations, including variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed.
This research was funded by the United Kingdom National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. Study authors reported no relevant conflicts of interest.
Physician burnout may jeopardize patient care, according to research published in JAMA Internal Medicine.
A review and meta-analysis suggested that physician burnout was associated with a higher risk of patient safety incidents, reduced patient satisfaction, and low professionalism.
Burnout was defined as “a response to prolonged exposure to occupational stress encompassing feelings of emotional exhaustion, depersonalization, and reduced professional efficacy.”
This research was conducted by Maria Panagioti, PhD, of the University of Manchester in the U.K., and her colleagues.
The researchers analyzed 47 studies on the topics of physician burnout and patient care, which included data from a pooled cohort of 42,473 physicians.
Nearly 45% of studies included physicians in their residency or early career (up to 5 years post-residency), and 55.3% included more experienced physicians. The studies included physicians in a hospital setting (63.8%), primary care setting (27.7%), or a mix of health care settings (8.5%).
The data indicated that physician burnout was significantly associated with:
- An increased risk of patient safety incidents—odds ratio [OR], 1.96 (P<0.001)
- Low professionalism—OR, 2.31 (P<0.001)
- Reduced patient satisfaction—OR, 2.28 (P<0.001).
The researchers noted that the reporting method had an impact on the results. According to physician report, burnout was associated with significantly increased risks of safety incidents (OR, 2.07) and low professionalism (OR, 2.67).
However, according to system reports, there was no significant association between physician burnout and safety incidents (OR, 1.00) or low professionalism (OR, 1.15).
Another factor that impacted results was physician experience. The association between burnout and low professionalism was significantly larger in studies of residents and early career physicians (OR, 3.39) than in studies of middle- and late-career physicians (OR, 1.73).
The researchers noted that this review had its limitations, including variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed.
This research was funded by the United Kingdom National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. Study authors reported no relevant conflicts of interest.
Physician burnout may jeopardize patient care, according to research published in JAMA Internal Medicine.
A review and meta-analysis suggested that physician burnout was associated with a higher risk of patient safety incidents, reduced patient satisfaction, and low professionalism.
Burnout was defined as “a response to prolonged exposure to occupational stress encompassing feelings of emotional exhaustion, depersonalization, and reduced professional efficacy.”
This research was conducted by Maria Panagioti, PhD, of the University of Manchester in the U.K., and her colleagues.
The researchers analyzed 47 studies on the topics of physician burnout and patient care, which included data from a pooled cohort of 42,473 physicians.
Nearly 45% of studies included physicians in their residency or early career (up to 5 years post-residency), and 55.3% included more experienced physicians. The studies included physicians in a hospital setting (63.8%), primary care setting (27.7%), or a mix of health care settings (8.5%).
The data indicated that physician burnout was significantly associated with:
- An increased risk of patient safety incidents—odds ratio [OR], 1.96 (P<0.001)
- Low professionalism—OR, 2.31 (P<0.001)
- Reduced patient satisfaction—OR, 2.28 (P<0.001).
The researchers noted that the reporting method had an impact on the results. According to physician report, burnout was associated with significantly increased risks of safety incidents (OR, 2.07) and low professionalism (OR, 2.67).
However, according to system reports, there was no significant association between physician burnout and safety incidents (OR, 1.00) or low professionalism (OR, 1.15).
Another factor that impacted results was physician experience. The association between burnout and low professionalism was significantly larger in studies of residents and early career physicians (OR, 3.39) than in studies of middle- and late-career physicians (OR, 1.73).
The researchers noted that this review had its limitations, including variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed.
This research was funded by the United Kingdom National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. Study authors reported no relevant conflicts of interest.
Elevated type 2 diabetes risk seen in PsA patients
Patients with incident psoriatic arthritis are at a significantly increased risk of developing type 2 diabetes when compared against patients with psoriasis alone and with the general population, according to recent research published in Rheumatology.
Rachel Charlton, PhD, of the department of pharmacy and pharmacology at the University of Bath (England), and her colleagues performed an analysis of 6,783 incident cases of psoriatic arthritis (PsA) from the U.K. Clinical Practice Research Datalink who were diagnosed during 1998-2014. Patients were between 18 years and 89 years old with a median age of 49 years at PsA diagnosis.
In the study, the researchers randomly matched PsA cases at a 1:4 ratio to either a cohort of general population patients with no PsA, psoriasis, or inflammatory arthritis or a cohort of patients with psoriasis but no PsA or inflammatory arthritis. Patients were followed from match to the point where they either no longer met inclusion criteria for the cohort or received a diagnosis of type 2 diabetes, cerebrovascular disease (CVD), ischemic heart disease (IHD), or peripheral vascular disease (PVD) with a mean follow-up duration of approximately 5.5 years across all patient groups.
Patients in the PsA group had a significantly higher incidence of type 2 diabetes, compared with the general population (adjusted relative risk, 1.40; 95% confidence interval, 1.15-1.70; P = .0007) and psoriasis groups (adjusted RR, 1.53; 95% CI, 1.19-1.97; P = .0009). In the PsA group, risk of CVD (adjusted RR, 1.24; 95% CI, 0.99-1.56; P = .06), IHD (adjusted RR, 1.27; 95% CI, 1.05-1.54; P = .02), and PVD (adjusted RR, 1.40; 95% CI, 1.02-1.92; P = .04) were significantly higher than in the general population but not when compared with the psoriasis group. The overall risk of cardiovascular disease (including CVD, IHD, and PVD) for the PsA group was significantly higher (adjusted RR, 1.29; 95% CI, 1.12-1.48; P = .0005), compared with the general population.
“These results support the proposal in existing clinical guidelines that, in order to reduce cardiovascular risk in patients with PsA, it is important to treat inflammatory disease as well as to screen and treat traditional risk factors early in the disease course,” Ms. Charlton and her colleagues wrote in their study.
This study was funded by a grant from the National Institute for Health Research in the United Kingdom. The authors reported no relevant conflicts of interest.
SOURCE: Charlton RA et al. Rheumatology. 2018 Sep 6. doi: 10.1093/rheumatology/key286.
Patients with incident psoriatic arthritis are at a significantly increased risk of developing type 2 diabetes when compared against patients with psoriasis alone and with the general population, according to recent research published in Rheumatology.
Rachel Charlton, PhD, of the department of pharmacy and pharmacology at the University of Bath (England), and her colleagues performed an analysis of 6,783 incident cases of psoriatic arthritis (PsA) from the U.K. Clinical Practice Research Datalink who were diagnosed during 1998-2014. Patients were between 18 years and 89 years old with a median age of 49 years at PsA diagnosis.
In the study, the researchers randomly matched PsA cases at a 1:4 ratio to either a cohort of general population patients with no PsA, psoriasis, or inflammatory arthritis or a cohort of patients with psoriasis but no PsA or inflammatory arthritis. Patients were followed from match to the point where they either no longer met inclusion criteria for the cohort or received a diagnosis of type 2 diabetes, cerebrovascular disease (CVD), ischemic heart disease (IHD), or peripheral vascular disease (PVD) with a mean follow-up duration of approximately 5.5 years across all patient groups.
Patients in the PsA group had a significantly higher incidence of type 2 diabetes, compared with the general population (adjusted relative risk, 1.40; 95% confidence interval, 1.15-1.70; P = .0007) and psoriasis groups (adjusted RR, 1.53; 95% CI, 1.19-1.97; P = .0009). In the PsA group, risk of CVD (adjusted RR, 1.24; 95% CI, 0.99-1.56; P = .06), IHD (adjusted RR, 1.27; 95% CI, 1.05-1.54; P = .02), and PVD (adjusted RR, 1.40; 95% CI, 1.02-1.92; P = .04) were significantly higher than in the general population but not when compared with the psoriasis group. The overall risk of cardiovascular disease (including CVD, IHD, and PVD) for the PsA group was significantly higher (adjusted RR, 1.29; 95% CI, 1.12-1.48; P = .0005), compared with the general population.
“These results support the proposal in existing clinical guidelines that, in order to reduce cardiovascular risk in patients with PsA, it is important to treat inflammatory disease as well as to screen and treat traditional risk factors early in the disease course,” Ms. Charlton and her colleagues wrote in their study.
This study was funded by a grant from the National Institute for Health Research in the United Kingdom. The authors reported no relevant conflicts of interest.
SOURCE: Charlton RA et al. Rheumatology. 2018 Sep 6. doi: 10.1093/rheumatology/key286.
Patients with incident psoriatic arthritis are at a significantly increased risk of developing type 2 diabetes when compared against patients with psoriasis alone and with the general population, according to recent research published in Rheumatology.
Rachel Charlton, PhD, of the department of pharmacy and pharmacology at the University of Bath (England), and her colleagues performed an analysis of 6,783 incident cases of psoriatic arthritis (PsA) from the U.K. Clinical Practice Research Datalink who were diagnosed during 1998-2014. Patients were between 18 years and 89 years old with a median age of 49 years at PsA diagnosis.
In the study, the researchers randomly matched PsA cases at a 1:4 ratio to either a cohort of general population patients with no PsA, psoriasis, or inflammatory arthritis or a cohort of patients with psoriasis but no PsA or inflammatory arthritis. Patients were followed from match to the point where they either no longer met inclusion criteria for the cohort or received a diagnosis of type 2 diabetes, cerebrovascular disease (CVD), ischemic heart disease (IHD), or peripheral vascular disease (PVD) with a mean follow-up duration of approximately 5.5 years across all patient groups.
Patients in the PsA group had a significantly higher incidence of type 2 diabetes, compared with the general population (adjusted relative risk, 1.40; 95% confidence interval, 1.15-1.70; P = .0007) and psoriasis groups (adjusted RR, 1.53; 95% CI, 1.19-1.97; P = .0009). In the PsA group, risk of CVD (adjusted RR, 1.24; 95% CI, 0.99-1.56; P = .06), IHD (adjusted RR, 1.27; 95% CI, 1.05-1.54; P = .02), and PVD (adjusted RR, 1.40; 95% CI, 1.02-1.92; P = .04) were significantly higher than in the general population but not when compared with the psoriasis group. The overall risk of cardiovascular disease (including CVD, IHD, and PVD) for the PsA group was significantly higher (adjusted RR, 1.29; 95% CI, 1.12-1.48; P = .0005), compared with the general population.
“These results support the proposal in existing clinical guidelines that, in order to reduce cardiovascular risk in patients with PsA, it is important to treat inflammatory disease as well as to screen and treat traditional risk factors early in the disease course,” Ms. Charlton and her colleagues wrote in their study.
This study was funded by a grant from the National Institute for Health Research in the United Kingdom. The authors reported no relevant conflicts of interest.
SOURCE: Charlton RA et al. Rheumatology. 2018 Sep 6. doi: 10.1093/rheumatology/key286.
FROM RHEUMATOLOGY
Key clinical point: It is important to treat inflammatory disease as well as to screen and treat traditional cardiovascular risk factors early in the course of PsA.
Major finding: (adjusted RR = 1.53) and a general population control group (adjusted RR = 1.40).
Study details: An analysis of 6,783 patients with psoriatic arthritis in the U.K. Clinical Practice Research Datalink who were diagnosed between 1998 and 2014.
Disclosures: This study was funded by a grant from the National Institute for Health Research in the United Kingdom. The authors reported no relevant conflicts of interest.
Source: Charlton RA et al. Rheumatology. 2018 Sep 6. doi: 10.1093/rheumatology/key286.
Pediatricians fall short on transition to adult care
Many adolescent patients, both with and without special health care needs, are not receiving guidance from their physicians about transitioning to adult care, according to recent findings published in Pediatrics.
Lydie A. Lebrun-Harris, PhD, of the Maternal and Child Health Bureau at the Health Resources and Services Administration, and her colleagues examined data from 20,708 youth aged 12-17 years with and without special health care needs obtained from the 2016 National Survey of Children’s Health. The aim was to determine the current level of transition planning to adult care from a pediatric or other health care provider (HCP).
Parents and caregivers were asked whether a doctor or HCP had spent time alone with the adolescent during the last year, had discussed the transition to adult care, and had actively helped the adolescent “gain self-care skills or understand changes in health care” when they reached the age of 18 years.
Overall, 17% of youth with special health care needs and 14% of youth without met all three transition elements.
The figures were higher for individual measures. For instance, 44% of youth with special health care needs spent time alone with an HCP within the past year, 41% discussed transition to an adult provider, and 69% reported an HCP had worked with them to understand health care changes and gain self-care skills.
Youth without special health care needs were more likely to discus the shift to adult care with HCPs than those with special needs, but special needs youth were more likely to have met the other two transition measurements (P less than .001).
Being older (aged 15-17 years) were associated with an increased prevalence of meeting the overall transition measure and the individual elements among both youth with and without special health care needs.
“Findings from this study underscore the urgent need for HCPs to work with youth independently and in collaboration with their parents and/or caregivers throughout the adolescent years to improve transition planning,” Dr. Lebrun-Harris and her colleagues wrote.
The study was supported by the Health Resources and Services Administration and the National Alliance to Advance Adolescent Health. The authors reported having no relevant conflicts of interest.
SOURCE: Lebrun-Harris LA et al. Pediatrics. 2018 Sep 17. doi: 10.1542/peds.2018-0194.
While researchers and clinicians have been discussing how to improve the poor health outcomes seen in the transition from pediatric to adult care for youth with special health care needs for decades, there has been little improvement, Megumi J. Okumura, MD, wrote in an accompanying editorial.
In 2016, 41% of youth with special health care needs had a discussion about the transition from pediatric to adult care, a figure that is “largely unchanged from 2010,” she noted.
One hurdle is the lack of a gold standard for measuring an ideal transition. Is it successful scheduling of an appointment with adult provider or having a job and being able to manage one’s own disease?
“Until our health system supports pediatric providers in offering adequate transition planning, it will be difficult to expect any uptick in these measures. In addition, we still need to understand why some adolescents fail in their transition and transfer and how to develop the appropriate interventions to improve health outcomes for these patients,” Dr. Okumura wrote.
Dr. Okumura is with the division of general pediatrics at the University of California, San Francisco. These comments are adapted from an accompanying editorial (Pediatrics. 2018 Sep 17. doi: 10.1542/peds.2018-2245). She reported having no relevant conflicts of interest.
While researchers and clinicians have been discussing how to improve the poor health outcomes seen in the transition from pediatric to adult care for youth with special health care needs for decades, there has been little improvement, Megumi J. Okumura, MD, wrote in an accompanying editorial.
In 2016, 41% of youth with special health care needs had a discussion about the transition from pediatric to adult care, a figure that is “largely unchanged from 2010,” she noted.
One hurdle is the lack of a gold standard for measuring an ideal transition. Is it successful scheduling of an appointment with adult provider or having a job and being able to manage one’s own disease?
“Until our health system supports pediatric providers in offering adequate transition planning, it will be difficult to expect any uptick in these measures. In addition, we still need to understand why some adolescents fail in their transition and transfer and how to develop the appropriate interventions to improve health outcomes for these patients,” Dr. Okumura wrote.
Dr. Okumura is with the division of general pediatrics at the University of California, San Francisco. These comments are adapted from an accompanying editorial (Pediatrics. 2018 Sep 17. doi: 10.1542/peds.2018-2245). She reported having no relevant conflicts of interest.
While researchers and clinicians have been discussing how to improve the poor health outcomes seen in the transition from pediatric to adult care for youth with special health care needs for decades, there has been little improvement, Megumi J. Okumura, MD, wrote in an accompanying editorial.
In 2016, 41% of youth with special health care needs had a discussion about the transition from pediatric to adult care, a figure that is “largely unchanged from 2010,” she noted.
One hurdle is the lack of a gold standard for measuring an ideal transition. Is it successful scheduling of an appointment with adult provider or having a job and being able to manage one’s own disease?
“Until our health system supports pediatric providers in offering adequate transition planning, it will be difficult to expect any uptick in these measures. In addition, we still need to understand why some adolescents fail in their transition and transfer and how to develop the appropriate interventions to improve health outcomes for these patients,” Dr. Okumura wrote.
Dr. Okumura is with the division of general pediatrics at the University of California, San Francisco. These comments are adapted from an accompanying editorial (Pediatrics. 2018 Sep 17. doi: 10.1542/peds.2018-2245). She reported having no relevant conflicts of interest.
Many adolescent patients, both with and without special health care needs, are not receiving guidance from their physicians about transitioning to adult care, according to recent findings published in Pediatrics.
Lydie A. Lebrun-Harris, PhD, of the Maternal and Child Health Bureau at the Health Resources and Services Administration, and her colleagues examined data from 20,708 youth aged 12-17 years with and without special health care needs obtained from the 2016 National Survey of Children’s Health. The aim was to determine the current level of transition planning to adult care from a pediatric or other health care provider (HCP).
Parents and caregivers were asked whether a doctor or HCP had spent time alone with the adolescent during the last year, had discussed the transition to adult care, and had actively helped the adolescent “gain self-care skills or understand changes in health care” when they reached the age of 18 years.
Overall, 17% of youth with special health care needs and 14% of youth without met all three transition elements.
The figures were higher for individual measures. For instance, 44% of youth with special health care needs spent time alone with an HCP within the past year, 41% discussed transition to an adult provider, and 69% reported an HCP had worked with them to understand health care changes and gain self-care skills.
Youth without special health care needs were more likely to discus the shift to adult care with HCPs than those with special needs, but special needs youth were more likely to have met the other two transition measurements (P less than .001).
Being older (aged 15-17 years) were associated with an increased prevalence of meeting the overall transition measure and the individual elements among both youth with and without special health care needs.
“Findings from this study underscore the urgent need for HCPs to work with youth independently and in collaboration with their parents and/or caregivers throughout the adolescent years to improve transition planning,” Dr. Lebrun-Harris and her colleagues wrote.
The study was supported by the Health Resources and Services Administration and the National Alliance to Advance Adolescent Health. The authors reported having no relevant conflicts of interest.
SOURCE: Lebrun-Harris LA et al. Pediatrics. 2018 Sep 17. doi: 10.1542/peds.2018-0194.
Many adolescent patients, both with and without special health care needs, are not receiving guidance from their physicians about transitioning to adult care, according to recent findings published in Pediatrics.
Lydie A. Lebrun-Harris, PhD, of the Maternal and Child Health Bureau at the Health Resources and Services Administration, and her colleagues examined data from 20,708 youth aged 12-17 years with and without special health care needs obtained from the 2016 National Survey of Children’s Health. The aim was to determine the current level of transition planning to adult care from a pediatric or other health care provider (HCP).
Parents and caregivers were asked whether a doctor or HCP had spent time alone with the adolescent during the last year, had discussed the transition to adult care, and had actively helped the adolescent “gain self-care skills or understand changes in health care” when they reached the age of 18 years.
Overall, 17% of youth with special health care needs and 14% of youth without met all three transition elements.
The figures were higher for individual measures. For instance, 44% of youth with special health care needs spent time alone with an HCP within the past year, 41% discussed transition to an adult provider, and 69% reported an HCP had worked with them to understand health care changes and gain self-care skills.
Youth without special health care needs were more likely to discus the shift to adult care with HCPs than those with special needs, but special needs youth were more likely to have met the other two transition measurements (P less than .001).
Being older (aged 15-17 years) were associated with an increased prevalence of meeting the overall transition measure and the individual elements among both youth with and without special health care needs.
“Findings from this study underscore the urgent need for HCPs to work with youth independently and in collaboration with their parents and/or caregivers throughout the adolescent years to improve transition planning,” Dr. Lebrun-Harris and her colleagues wrote.
The study was supported by the Health Resources and Services Administration and the National Alliance to Advance Adolescent Health. The authors reported having no relevant conflicts of interest.
SOURCE: Lebrun-Harris LA et al. Pediatrics. 2018 Sep 17. doi: 10.1542/peds.2018-0194.
FROM PEDIATRICS
Key clinical point:
Major finding: In total, 17% of youth with special health care needs and 14% of youth without received support for the transition to adult care.
Study details: A nationally representative exploratory analysis of transition planning from pediatric to adult health care for 20,708 adolescents from the 2016 National Survey of Children’s Health.
Disclosures: The study was supported by the Health Resources and Services Administration and the National Alliance to Advance Adolescent Health. The authors reported having no relevant conflicts of interest.
Source: Lebrun-Harris LA et al. Pediatrics. 2018 Sep 17. doi: 10.1542/peds.2018-0194.
How to screen for, manage FASD in a medical home
providing early intervention and accessing community resources, according to a clinical report from the American Academy of Pediatrics.
After the AAP released its guidelines on fetal alcohol spectrum disorder (FASD) in 2015, some pediatricians asked for further guidance on how to care for patients with FASD within the medical home, as many had a knowledge gap on how to best manage these patients.
“For some pediatricians, it can seem like a daunting task to care for an individual with an FASD, but there are aspects of integrated care and providing a medical home that can be instituted as with all children with complex medical diagnoses,” wrote Renee M. Turchi, MD, MPH, of the department of pediatrics at St. Christopher’s Hospital for Children and Drexel Dornsife School of Public Health in Philadelphia, and her colleagues on the AAP Committee on Substance Abuse and the Council on Children with Disabilities. Their report is in Pediatrics. “In addition, not recognizing an FASD can lead to inadequate treatment and less-than-optimal outcomes for the patient and family.”
Dr. Turchi and her colleagues released the FASD clinical report with “strategies to support families who are interacting with early intervention services, the educational system, the behavioral and/or mental health system, other community resources, and the transition to adult-oriented heath care systems when appropriate.” They noted the prevalence of FASD is increasing, with 1 in 10 pregnant women using alcohol within the past 30 days and 1 in 33 pregnant women reporting binge drinking in the past 30 days. They reaffirmed the AAP’s endorsement from the 2015 clinical report on FASD regarding abstinence of alcohol for pregnant women, emphasizing that there is no amount or kind of alcohol that is risk free during pregnancy, nor is there a time in pregnancy when drinking alcohol is risk free.
Providers in a medical home should communicate any prenatal alcohol exposure (PAE) to obstetric providers so they can review risk factors, optimize screening, and monitor children, Dr. Turchi and her colleagues said. They also should understand the diagnostic criteria and classifications for FASDs, including physical features such as low weight, short palpebral features, smooth philtrum, a thin upper lip, abnormalities in the central nervous system, and any alcohol use during pregnancy. Any child – regardless of age – is a candidate for universal PAE screening at initial visits or when “additional cognitive and behavioral concerns arise.”
The federal Child Abuse Prevention and Treatment Act “does not require clinicians to report to child protective services if a child has been exposed prenatally to alcohol (i.e., for a positive PAE screening result). Referral to child protective services is required if the child has been diagnosed with an FASD in the period between birth and 3 years. The intent of this referral is to develop safe care and possible treatment plans for the infant and caregiver if needed, not to initiate punitive actions,” according to the report. States have their own definitions about child abuse and neglect, so the report encourages providers to know the mandates and reporting laws in the states where they practice.
Monitoring children in a medical home for the signs and symptoms of FASD is important, the authors said, because research has shown an increased chance at reducing adverse life outcomes if a child is diagnosed before age 6 and is in a stable home with access to support services.
Management of children with FASD is individual, as symptoms for each child will uniquely present not just in terms of physical issues such as growth or congenital defects affecting the heart, eyes, kidneys, or bones, but also as developmental, cognitive, and behavioral problems. Children with FASD also may receive a concomitant diagnosis when evaluated, such as ADHD or depression, that will require additional accommodation. The use of evidence-based diagnostic and standard screening approaches and referring when necessary will help reevaluate whether a child has a condition such as ADHD, oppositional defiant disorder, or another diagnosis, or is displaying symptoms of FASD such as a receptive or expressive language disorder.
Pediatricians must work together with the families, educational professionals, the mental health community, and therapists to help manage FASD in children. In cases where a child is in foster care, partnering with the foster care partners and child welfare agencies to gain access to the medical information of the biological parents is important to determine whether there is parental history of substance abuse and to provide appropriate treatment and interventions.
“Given the complex array of systems and services requiring navigation and coordination for children with an FASD and their families, a high-quality primary care medical home with partnerships with families, specialists, therapists, mental and/or behavioral health professionals, and community partners is critical, as it is for all children with special health care needs,” Dr. Turchi and her colleagues said.
The authors reported no relevant conflicts of interest.
SOURCE: Turchi RM et al. Pediatrics. 2018 Sept 10. doi:10.1542/peds.2018-2333.
providing early intervention and accessing community resources, according to a clinical report from the American Academy of Pediatrics.
After the AAP released its guidelines on fetal alcohol spectrum disorder (FASD) in 2015, some pediatricians asked for further guidance on how to care for patients with FASD within the medical home, as many had a knowledge gap on how to best manage these patients.
“For some pediatricians, it can seem like a daunting task to care for an individual with an FASD, but there are aspects of integrated care and providing a medical home that can be instituted as with all children with complex medical diagnoses,” wrote Renee M. Turchi, MD, MPH, of the department of pediatrics at St. Christopher’s Hospital for Children and Drexel Dornsife School of Public Health in Philadelphia, and her colleagues on the AAP Committee on Substance Abuse and the Council on Children with Disabilities. Their report is in Pediatrics. “In addition, not recognizing an FASD can lead to inadequate treatment and less-than-optimal outcomes for the patient and family.”
Dr. Turchi and her colleagues released the FASD clinical report with “strategies to support families who are interacting with early intervention services, the educational system, the behavioral and/or mental health system, other community resources, and the transition to adult-oriented heath care systems when appropriate.” They noted the prevalence of FASD is increasing, with 1 in 10 pregnant women using alcohol within the past 30 days and 1 in 33 pregnant women reporting binge drinking in the past 30 days. They reaffirmed the AAP’s endorsement from the 2015 clinical report on FASD regarding abstinence of alcohol for pregnant women, emphasizing that there is no amount or kind of alcohol that is risk free during pregnancy, nor is there a time in pregnancy when drinking alcohol is risk free.
Providers in a medical home should communicate any prenatal alcohol exposure (PAE) to obstetric providers so they can review risk factors, optimize screening, and monitor children, Dr. Turchi and her colleagues said. They also should understand the diagnostic criteria and classifications for FASDs, including physical features such as low weight, short palpebral features, smooth philtrum, a thin upper lip, abnormalities in the central nervous system, and any alcohol use during pregnancy. Any child – regardless of age – is a candidate for universal PAE screening at initial visits or when “additional cognitive and behavioral concerns arise.”
The federal Child Abuse Prevention and Treatment Act “does not require clinicians to report to child protective services if a child has been exposed prenatally to alcohol (i.e., for a positive PAE screening result). Referral to child protective services is required if the child has been diagnosed with an FASD in the period between birth and 3 years. The intent of this referral is to develop safe care and possible treatment plans for the infant and caregiver if needed, not to initiate punitive actions,” according to the report. States have their own definitions about child abuse and neglect, so the report encourages providers to know the mandates and reporting laws in the states where they practice.
Monitoring children in a medical home for the signs and symptoms of FASD is important, the authors said, because research has shown an increased chance at reducing adverse life outcomes if a child is diagnosed before age 6 and is in a stable home with access to support services.
Management of children with FASD is individual, as symptoms for each child will uniquely present not just in terms of physical issues such as growth or congenital defects affecting the heart, eyes, kidneys, or bones, but also as developmental, cognitive, and behavioral problems. Children with FASD also may receive a concomitant diagnosis when evaluated, such as ADHD or depression, that will require additional accommodation. The use of evidence-based diagnostic and standard screening approaches and referring when necessary will help reevaluate whether a child has a condition such as ADHD, oppositional defiant disorder, or another diagnosis, or is displaying symptoms of FASD such as a receptive or expressive language disorder.
Pediatricians must work together with the families, educational professionals, the mental health community, and therapists to help manage FASD in children. In cases where a child is in foster care, partnering with the foster care partners and child welfare agencies to gain access to the medical information of the biological parents is important to determine whether there is parental history of substance abuse and to provide appropriate treatment and interventions.
“Given the complex array of systems and services requiring navigation and coordination for children with an FASD and their families, a high-quality primary care medical home with partnerships with families, specialists, therapists, mental and/or behavioral health professionals, and community partners is critical, as it is for all children with special health care needs,” Dr. Turchi and her colleagues said.
The authors reported no relevant conflicts of interest.
SOURCE: Turchi RM et al. Pediatrics. 2018 Sept 10. doi:10.1542/peds.2018-2333.
providing early intervention and accessing community resources, according to a clinical report from the American Academy of Pediatrics.
After the AAP released its guidelines on fetal alcohol spectrum disorder (FASD) in 2015, some pediatricians asked for further guidance on how to care for patients with FASD within the medical home, as many had a knowledge gap on how to best manage these patients.
“For some pediatricians, it can seem like a daunting task to care for an individual with an FASD, but there are aspects of integrated care and providing a medical home that can be instituted as with all children with complex medical diagnoses,” wrote Renee M. Turchi, MD, MPH, of the department of pediatrics at St. Christopher’s Hospital for Children and Drexel Dornsife School of Public Health in Philadelphia, and her colleagues on the AAP Committee on Substance Abuse and the Council on Children with Disabilities. Their report is in Pediatrics. “In addition, not recognizing an FASD can lead to inadequate treatment and less-than-optimal outcomes for the patient and family.”
Dr. Turchi and her colleagues released the FASD clinical report with “strategies to support families who are interacting with early intervention services, the educational system, the behavioral and/or mental health system, other community resources, and the transition to adult-oriented heath care systems when appropriate.” They noted the prevalence of FASD is increasing, with 1 in 10 pregnant women using alcohol within the past 30 days and 1 in 33 pregnant women reporting binge drinking in the past 30 days. They reaffirmed the AAP’s endorsement from the 2015 clinical report on FASD regarding abstinence of alcohol for pregnant women, emphasizing that there is no amount or kind of alcohol that is risk free during pregnancy, nor is there a time in pregnancy when drinking alcohol is risk free.
Providers in a medical home should communicate any prenatal alcohol exposure (PAE) to obstetric providers so they can review risk factors, optimize screening, and monitor children, Dr. Turchi and her colleagues said. They also should understand the diagnostic criteria and classifications for FASDs, including physical features such as low weight, short palpebral features, smooth philtrum, a thin upper lip, abnormalities in the central nervous system, and any alcohol use during pregnancy. Any child – regardless of age – is a candidate for universal PAE screening at initial visits or when “additional cognitive and behavioral concerns arise.”
The federal Child Abuse Prevention and Treatment Act “does not require clinicians to report to child protective services if a child has been exposed prenatally to alcohol (i.e., for a positive PAE screening result). Referral to child protective services is required if the child has been diagnosed with an FASD in the period between birth and 3 years. The intent of this referral is to develop safe care and possible treatment plans for the infant and caregiver if needed, not to initiate punitive actions,” according to the report. States have their own definitions about child abuse and neglect, so the report encourages providers to know the mandates and reporting laws in the states where they practice.
Monitoring children in a medical home for the signs and symptoms of FASD is important, the authors said, because research has shown an increased chance at reducing adverse life outcomes if a child is diagnosed before age 6 and is in a stable home with access to support services.
Management of children with FASD is individual, as symptoms for each child will uniquely present not just in terms of physical issues such as growth or congenital defects affecting the heart, eyes, kidneys, or bones, but also as developmental, cognitive, and behavioral problems. Children with FASD also may receive a concomitant diagnosis when evaluated, such as ADHD or depression, that will require additional accommodation. The use of evidence-based diagnostic and standard screening approaches and referring when necessary will help reevaluate whether a child has a condition such as ADHD, oppositional defiant disorder, or another diagnosis, or is displaying symptoms of FASD such as a receptive or expressive language disorder.
Pediatricians must work together with the families, educational professionals, the mental health community, and therapists to help manage FASD in children. In cases where a child is in foster care, partnering with the foster care partners and child welfare agencies to gain access to the medical information of the biological parents is important to determine whether there is parental history of substance abuse and to provide appropriate treatment and interventions.
“Given the complex array of systems and services requiring navigation and coordination for children with an FASD and their families, a high-quality primary care medical home with partnerships with families, specialists, therapists, mental and/or behavioral health professionals, and community partners is critical, as it is for all children with special health care needs,” Dr. Turchi and her colleagues said.
The authors reported no relevant conflicts of interest.
SOURCE: Turchi RM et al. Pediatrics. 2018 Sept 10. doi:10.1542/peds.2018-2333.
FROM PEDIATRICS
Burnout may jeopardize patient care
because of depersonalization of care, according to recent research published in JAMA Internal Medicine.
“The primary conclusion of this review is that physician burnout might jeopardize patient care,” Maria Panagioti, PhD, from the National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre at the University of Manchester (United Kingdom) and her colleagues wrote in their study. “Physician wellness and quality of patient care are critical [as are] complementary dimensions of health care organization efficiency.”
Dr. Panagioti and her colleagues performed a search of the MEDLINE, EMBASE, CINAHL, and PsycInfo databases and found 47 eligible studies on the topics of physician burnout and patient care, which altogether included data from a pooled cohort of 42,473 physicians. The physicians were median 38 years old, with 44.7% of studies looking at physicians in residency or early career (up to 5 years post residency) and 55.3% of studies examining experienced physicians. The meta-analysis also evaluated physicians in a hospital setting (63.8%), primary care (13.8%), and across various different health care settings (8.5%).
The researchers found physicians with burnout were significantly associated with higher rates of patient safety issues (odds ratio, 1.96; 95% confidence interval, 1.59-2.40), reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68), and lower quality of care (OR, 2.31; 95% CI, 1.87-2.85). System-reported instances of patient safety issues and low professionalism were not statistically significant, but the subgroup differences did reach statistical significance (Cohen Q, 8.14; P = .007). Among residents and physicians in their early career, there was a greater association between burnout and low professionalism (OR, 3.39; 95% CI, 2.38-4.40), compared with physicians in the middle or later in their career (OR, 1.73; 95% CI, 1.46-2.01; Cohen Q, 7.27; P = .003).
“Investments in organizational strategies to jointly monitor and improve physician wellness and patient care outcomes are needed,” Dr. Panagioti and her colleagues wrote in the study. “Interventions aimed at improving the culture of health care organizations, as well as interventions focused on individual physicians but supported and funded by health care organizations, are beneficial.”
Researchers noted the study quality was low to moderate. Variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed were potential limitations in the study, they reported.
The study was funded by the United Kingdom NIHR School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. The authors report no relevant conflicts of interest.
SOURCE: Panagioti M et al. JAMA Intern Med. 2018 Sept 4. doi: 10.1001/jamainternmed.2018.3713.
Because of a lack of funding for research into burnout and the immediate need for change based on the effect it has on patient care seen in Pangioti et al., the question of how to address physician burnout should be answered with quality improvement programs aimed at making immediate changes in health care settings, Mark Linzer, MD, wrote in a related editorial.
“Resonating with these concepts, I propose that, for the burnout prevention and wellness field, we encourage quality improvement projects of high standards: multiple sites, concurrent control groups, longitudinal design, and blinding when feasible, with assessment of outcomes and costs,” he wrote. “These studies can point us toward what we will evaluate in larger trials and allow a place for the rapidly developing information base to be viewed and thus become part of the developing science of work conditions, burnout reduction, and the anticipated result on quality and safety.”
There are research questions that have yet to be answered on this topic, he added, such as to what extent do factors like workflow redesign, use and upkeep of electronic medical records, and chaotic workplaces affect burnout. Further, regulatory environments may play a role, and it is still not known whether reducing burnout among physicians will also reduce burnout among staff. Future studies should also look at how burnout affects trainees and female physicians, he suggested.
“The link between burnout and adverse patient outcomes is stronger, thanks to the work of Panagioti and colleagues,” Dr. Linzer said. “With close to half of U.S. physicians experiencing symptoms of burnout, more work is needed to understand how to reduce it and what we can expect from doing so.”
Dr. Linzer is from the Hennepin Healthcare Systems in Minneapolis. These comments summarize his editorial regarding the findings of Pangioti et al. He reported support for Wellness Champion training by the American College of Physicians and the Association of Chiefs and Leaders in General Internal Medicine and that he has received support for American Medical Association research projects.
Because of a lack of funding for research into burnout and the immediate need for change based on the effect it has on patient care seen in Pangioti et al., the question of how to address physician burnout should be answered with quality improvement programs aimed at making immediate changes in health care settings, Mark Linzer, MD, wrote in a related editorial.
“Resonating with these concepts, I propose that, for the burnout prevention and wellness field, we encourage quality improvement projects of high standards: multiple sites, concurrent control groups, longitudinal design, and blinding when feasible, with assessment of outcomes and costs,” he wrote. “These studies can point us toward what we will evaluate in larger trials and allow a place for the rapidly developing information base to be viewed and thus become part of the developing science of work conditions, burnout reduction, and the anticipated result on quality and safety.”
There are research questions that have yet to be answered on this topic, he added, such as to what extent do factors like workflow redesign, use and upkeep of electronic medical records, and chaotic workplaces affect burnout. Further, regulatory environments may play a role, and it is still not known whether reducing burnout among physicians will also reduce burnout among staff. Future studies should also look at how burnout affects trainees and female physicians, he suggested.
“The link between burnout and adverse patient outcomes is stronger, thanks to the work of Panagioti and colleagues,” Dr. Linzer said. “With close to half of U.S. physicians experiencing symptoms of burnout, more work is needed to understand how to reduce it and what we can expect from doing so.”
Dr. Linzer is from the Hennepin Healthcare Systems in Minneapolis. These comments summarize his editorial regarding the findings of Pangioti et al. He reported support for Wellness Champion training by the American College of Physicians and the Association of Chiefs and Leaders in General Internal Medicine and that he has received support for American Medical Association research projects.
Because of a lack of funding for research into burnout and the immediate need for change based on the effect it has on patient care seen in Pangioti et al., the question of how to address physician burnout should be answered with quality improvement programs aimed at making immediate changes in health care settings, Mark Linzer, MD, wrote in a related editorial.
“Resonating with these concepts, I propose that, for the burnout prevention and wellness field, we encourage quality improvement projects of high standards: multiple sites, concurrent control groups, longitudinal design, and blinding when feasible, with assessment of outcomes and costs,” he wrote. “These studies can point us toward what we will evaluate in larger trials and allow a place for the rapidly developing information base to be viewed and thus become part of the developing science of work conditions, burnout reduction, and the anticipated result on quality and safety.”
There are research questions that have yet to be answered on this topic, he added, such as to what extent do factors like workflow redesign, use and upkeep of electronic medical records, and chaotic workplaces affect burnout. Further, regulatory environments may play a role, and it is still not known whether reducing burnout among physicians will also reduce burnout among staff. Future studies should also look at how burnout affects trainees and female physicians, he suggested.
“The link between burnout and adverse patient outcomes is stronger, thanks to the work of Panagioti and colleagues,” Dr. Linzer said. “With close to half of U.S. physicians experiencing symptoms of burnout, more work is needed to understand how to reduce it and what we can expect from doing so.”
Dr. Linzer is from the Hennepin Healthcare Systems in Minneapolis. These comments summarize his editorial regarding the findings of Pangioti et al. He reported support for Wellness Champion training by the American College of Physicians and the Association of Chiefs and Leaders in General Internal Medicine and that he has received support for American Medical Association research projects.
because of depersonalization of care, according to recent research published in JAMA Internal Medicine.
“The primary conclusion of this review is that physician burnout might jeopardize patient care,” Maria Panagioti, PhD, from the National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre at the University of Manchester (United Kingdom) and her colleagues wrote in their study. “Physician wellness and quality of patient care are critical [as are] complementary dimensions of health care organization efficiency.”
Dr. Panagioti and her colleagues performed a search of the MEDLINE, EMBASE, CINAHL, and PsycInfo databases and found 47 eligible studies on the topics of physician burnout and patient care, which altogether included data from a pooled cohort of 42,473 physicians. The physicians were median 38 years old, with 44.7% of studies looking at physicians in residency or early career (up to 5 years post residency) and 55.3% of studies examining experienced physicians. The meta-analysis also evaluated physicians in a hospital setting (63.8%), primary care (13.8%), and across various different health care settings (8.5%).
The researchers found physicians with burnout were significantly associated with higher rates of patient safety issues (odds ratio, 1.96; 95% confidence interval, 1.59-2.40), reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68), and lower quality of care (OR, 2.31; 95% CI, 1.87-2.85). System-reported instances of patient safety issues and low professionalism were not statistically significant, but the subgroup differences did reach statistical significance (Cohen Q, 8.14; P = .007). Among residents and physicians in their early career, there was a greater association between burnout and low professionalism (OR, 3.39; 95% CI, 2.38-4.40), compared with physicians in the middle or later in their career (OR, 1.73; 95% CI, 1.46-2.01; Cohen Q, 7.27; P = .003).
“Investments in organizational strategies to jointly monitor and improve physician wellness and patient care outcomes are needed,” Dr. Panagioti and her colleagues wrote in the study. “Interventions aimed at improving the culture of health care organizations, as well as interventions focused on individual physicians but supported and funded by health care organizations, are beneficial.”
Researchers noted the study quality was low to moderate. Variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed were potential limitations in the study, they reported.
The study was funded by the United Kingdom NIHR School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. The authors report no relevant conflicts of interest.
SOURCE: Panagioti M et al. JAMA Intern Med. 2018 Sept 4. doi: 10.1001/jamainternmed.2018.3713.
because of depersonalization of care, according to recent research published in JAMA Internal Medicine.
“The primary conclusion of this review is that physician burnout might jeopardize patient care,” Maria Panagioti, PhD, from the National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre at the University of Manchester (United Kingdom) and her colleagues wrote in their study. “Physician wellness and quality of patient care are critical [as are] complementary dimensions of health care organization efficiency.”
Dr. Panagioti and her colleagues performed a search of the MEDLINE, EMBASE, CINAHL, and PsycInfo databases and found 47 eligible studies on the topics of physician burnout and patient care, which altogether included data from a pooled cohort of 42,473 physicians. The physicians were median 38 years old, with 44.7% of studies looking at physicians in residency or early career (up to 5 years post residency) and 55.3% of studies examining experienced physicians. The meta-analysis also evaluated physicians in a hospital setting (63.8%), primary care (13.8%), and across various different health care settings (8.5%).
The researchers found physicians with burnout were significantly associated with higher rates of patient safety issues (odds ratio, 1.96; 95% confidence interval, 1.59-2.40), reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68), and lower quality of care (OR, 2.31; 95% CI, 1.87-2.85). System-reported instances of patient safety issues and low professionalism were not statistically significant, but the subgroup differences did reach statistical significance (Cohen Q, 8.14; P = .007). Among residents and physicians in their early career, there was a greater association between burnout and low professionalism (OR, 3.39; 95% CI, 2.38-4.40), compared with physicians in the middle or later in their career (OR, 1.73; 95% CI, 1.46-2.01; Cohen Q, 7.27; P = .003).
“Investments in organizational strategies to jointly monitor and improve physician wellness and patient care outcomes are needed,” Dr. Panagioti and her colleagues wrote in the study. “Interventions aimed at improving the culture of health care organizations, as well as interventions focused on individual physicians but supported and funded by health care organizations, are beneficial.”
Researchers noted the study quality was low to moderate. Variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed were potential limitations in the study, they reported.
The study was funded by the United Kingdom NIHR School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. The authors report no relevant conflicts of interest.
SOURCE: Panagioti M et al. JAMA Intern Med. 2018 Sept 4. doi: 10.1001/jamainternmed.2018.3713.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Burnout among physicians was associated with lower quality of care because of unprofessionalism, reduced patient satisfaction, and an increased risk of patient safety issues.
Major finding: Physicians with burnout were significantly associated with higher rates of patient safety issues (odds ratio, 1.96; 95% confidence interval, 1.59-2.40), reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68), and lower quality of care (OR, 2.31; 95% CI, 1.87-2.85).
Study details: A systematic review and meta-analysis of 42,473 physicians from 47 different studies.
Disclosures: The study was funded by the United Kingdom National Institute of Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. The authors reported no relevant conflicts of interest.
Source: Panagioti M et al. JAMA Intern Med. 2018 Sept 4. doi: 10.1001/jamainternmed.2018.3713.