People with metabolic dysfunction–associated fatty liver disease (MAFLD) – a newly defined condition – may be more likely to die from COVID-19, researchers say.

A cohort of people hospitalized for COVID-19 in Central Military Hospital, Mexico City, who met the criteria for MAFLD died at a higher rate than a control group without fatty liver disease, said Martín Uriel Vázquez-Medina, MSc, a researcher in the National Polytechnic Institute in Mexico City.

Patients who met only the criteria for the traditional classification, nonalcoholic fatty liver disease (NAFLD), also died of COVID-19 at a higher rate than the control group, but the difference was not statistically significant.

“It is important to screen for MAFLD,” Mr. Vázquez-Medina told this news organization. “It’s a new definition, but it has really helped us to identify which patients are going to get worse by COVID-19.”

The study was published in Hepatology Communications.
 

More evidence for clinical relevance of MAFLD

The finding lends support to an initiative to use MAFLD instead of NAFLD to identify patients whose liver steatosis poses a threat to their health, Mr. Vázquez-Medina said.

NAFLD affects as much as a quarter of the world’s population. No drugs have been approved to treat it. Some researchers have reasoned that the imprecision of the definition of NAFLD could be one reason for the lack of progress in treatment.

“NAFLD is something that doesn’t have positive criteria to be diagnosed,” said Mr. Vázquez-Medina. “You only say NAFLD when you don’t find hepatitis or another disease.”

In an article published in Gastroenterology, an international consensus panel proposed MAFLD as an alternative, arguing that a focus on metabolic dysfunction could more accurately reflect the pathogenesis of the disease and help stratify patients.

Previous research has suggested that patients with MAFLD have a higher risk of atherosclerotic cardiovascular disease and that the prevalence of colorectal adenomas is a higher in these patients, compared with patients with NAFLD.

The high prevalence of MAFLD in Mexico – about 30% – could help explain the country’s high rate of mortality from COVID-19, Mr. Vázquez-Medina said. Almost 6% of people diagnosed with COVID in Mexico have died from it, according to the Johns Hopkins University and Medical Center Coronavirus Resource Center.
 

Sorting COVID outcomes by liver steatosis

To understand the interaction of MAFLD, NAFLD, liver fibrosis, and COVID-19, Mr. Vázquez-Medina and his colleagues analyzed the records of all patients admitted to the Central Military Hospital with COVID-19 from April 4, 2020, to June 24, 2020.

They excluded patients for whom complete data were lacking or for whom a liver function test was not conducted in the first 24 hours of hospitalization. Also excluded were patients with significant consumption of alcohol (> 30 g/day for men and > 20 g/day for women) and those with a history of autoimmune liver disease, liver cancer, decompensated cirrhosis, platelet disorders, or myopathies.

The remaining patients were divided into three groups – 220 who met the criteria for MAFLD, 79 who met the criteria for NAFLD but not MAFLD, and 60 other patients as a control group.

The researchers defined MAFLD as the presence of liver steatosis detected with a noninvasive method and one of the following: overweight (body mass index, 25-29.9 kg/m2), type 2 diabetes, or the presence of two metabolic abnormalities (blood pressure > 140/90 mm Hg, plasma triglycerides > 150 mg/dL, plasma high-density lipoprotein cholesterol < 40 mg/dL in men and < 50 mg/dL in women, and prediabetes).

They defined NAFLD as the presence of liver steatosis without the other criteria for MAFLD.

The patients with MAFLD were the most likely to be intubated and were the most likely to die (intubation, 44.09%; mortality, 55%), followed by those with NAFLD (intubation, 40.51%; mortality, 51.9%) and those in the control group (intubation, 20%; mortality, 38.33%).

The difference in mortality between the MAFLD group and the control group was statistically significant (P = .02). The mortality difference between the NAFLD and the control group fell just short of statistical significance (P = .07).

For intubation, the difference between the MAFLD and the control group was highly statistically significant (P = .001), and the difference between the NAFLD and the control group was also statistically significant (P = .01)

Patients with advanced fibrosis and either MAFLD or NAFLD were also more likely to die than patients in the control group with advanced fibrosis.

That’s why screening for MAFLD is important, Mr. Vázquez-Medina said.
 

Next steps and new questions

Future research should examine whether patients with MAFLD have elevated levels of biomarkers for inflammation, such as interleukin 6, Mr. Vázquez-Medina said. A “chronic low proinflammatory state” may be the key to understanding the vulnerability of patients to MAFLD to COVID-19, he speculated.

The metabolic traits associated with MAFLD could explain the higher mortality and intubation rates with COVID, said Rohit Loomba, MD, MHSc, a professor of medicine in the division of gastroenterology at the University of California, San Diego, who was not involved in the study.

“Hypertension, diabetes, and obesity increase the risk of complications from COVID in all patients, whether they have been diagnosed with NAFLD or not,” he told this news organization in an email.

Mr. Vasquez-Medina pointed out that the patients with MAFLD had a higher risk of mortality even after adjusting for age, sex, type 2 diabetes, hypertension, overweight, and obesity (BMI ≥ 30 kg/m2). MAFLD also was more strongly associated with a poor outcome than either hypertension alone or obesity alone. Only age emerged as a significant independent covariate in the study.

Dr. Loomba also questioned whether the regression model used in this study for liver steatosis was “fully reflective of NAFLD.”

The researchers identified liver steatosis with a diagnostic formula that used noninvasive clinical BMI and laboratory tests (alanine aminotransferase), citing a study that found the regression formula was better at diagnosing NAFLD than FibroScan.

Mr. Vázquez-Medina reported no relevant financial relationships. Dr. Loomba serves as a consultant to Aardvark Therapeutics, Altimmune, Anylam/Regeneron, Amgen, Arrowhead Pharmaceuticals, AstraZeneca, Bristol-Myers Squibb, CohBar, Eli Lilly, Galmed, Gilead, Glympse Bio, Hightide, Inipharma, Intercept, Inventiva, Ionis, Janssen, Madrigal, Metacrine, NGM Biopharmaceuticals, Novartis, Novo Nordisk, Merck, Pfizer, Sagimet, Theratechnologies, 89bio, Terns Pharmaceuticals, and Viking Therapeutics. He is co-founder of LipoNexus.

A version of this article first appeared on Medscape.com.

People with metabolic dysfunction–associated fatty liver disease (MAFLD) – a newly defined condition – may be more likely to die from COVID-19, researchers say.

A cohort of people hospitalized for COVID-19 in Central Military Hospital, Mexico City, who met the criteria for MAFLD died at a higher rate than a control group without fatty liver disease, said Martín Uriel Vázquez-Medina, MSc, a researcher in the National Polytechnic Institute in Mexico City.

Patients who met only the criteria for the traditional classification, nonalcoholic fatty liver disease (NAFLD), also died of COVID-19 at a higher rate than the control group, but the difference was not statistically significant.

“It is important to screen for MAFLD,” Mr. Vázquez-Medina told this news organization. “It’s a new definition, but it has really helped us to identify which patients are going to get worse by COVID-19.”

The study was published in Hepatology Communications.
 

More evidence for clinical relevance of MAFLD

The finding lends support to an initiative to use MAFLD instead of NAFLD to identify patients whose liver steatosis poses a threat to their health, Mr. Vázquez-Medina said.

NAFLD affects as much as a quarter of the world’s population. No drugs have been approved to treat it. Some researchers have reasoned that the imprecision of the definition of NAFLD could be one reason for the lack of progress in treatment.

“NAFLD is something that doesn’t have positive criteria to be diagnosed,” said Mr. Vázquez-Medina. “You only say NAFLD when you don’t find hepatitis or another disease.”

In an article published in Gastroenterology, an international consensus panel proposed MAFLD as an alternative, arguing that a focus on metabolic dysfunction could more accurately reflect the pathogenesis of the disease and help stratify patients.

Previous research has suggested that patients with MAFLD have a higher risk of atherosclerotic cardiovascular disease and that the prevalence of colorectal adenomas is a higher in these patients, compared with patients with NAFLD.

The high prevalence of MAFLD in Mexico – about 30% – could help explain the country’s high rate of mortality from COVID-19, Mr. Vázquez-Medina said. Almost 6% of people diagnosed with COVID in Mexico have died from it, according to the Johns Hopkins University and Medical Center Coronavirus Resource Center.
 

Sorting COVID outcomes by liver steatosis

To understand the interaction of MAFLD, NAFLD, liver fibrosis, and COVID-19, Mr. Vázquez-Medina and his colleagues analyzed the records of all patients admitted to the Central Military Hospital with COVID-19 from April 4, 2020, to June 24, 2020.

They excluded patients for whom complete data were lacking or for whom a liver function test was not conducted in the first 24 hours of hospitalization. Also excluded were patients with significant consumption of alcohol (> 30 g/day for men and > 20 g/day for women) and those with a history of autoimmune liver disease, liver cancer, decompensated cirrhosis, platelet disorders, or myopathies.

The remaining patients were divided into three groups – 220 who met the criteria for MAFLD, 79 who met the criteria for NAFLD but not MAFLD, and 60 other patients as a control group.

The researchers defined MAFLD as the presence of liver steatosis detected with a noninvasive method and one of the following: overweight (body mass index, 25-29.9 kg/m2), type 2 diabetes, or the presence of two metabolic abnormalities (blood pressure > 140/90 mm Hg, plasma triglycerides > 150 mg/dL, plasma high-density lipoprotein cholesterol < 40 mg/dL in men and < 50 mg/dL in women, and prediabetes).

They defined NAFLD as the presence of liver steatosis without the other criteria for MAFLD.

The patients with MAFLD were the most likely to be intubated and were the most likely to die (intubation, 44.09%; mortality, 55%), followed by those with NAFLD (intubation, 40.51%; mortality, 51.9%) and those in the control group (intubation, 20%; mortality, 38.33%).

The difference in mortality between the MAFLD group and the control group was statistically significant (P = .02). The mortality difference between the NAFLD and the control group fell just short of statistical significance (P = .07).

For intubation, the difference between the MAFLD and the control group was highly statistically significant (P = .001), and the difference between the NAFLD and the control group was also statistically significant (P = .01)

Patients with advanced fibrosis and either MAFLD or NAFLD were also more likely to die than patients in the control group with advanced fibrosis.

That’s why screening for MAFLD is important, Mr. Vázquez-Medina said.
 

Next steps and new questions

Future research should examine whether patients with MAFLD have elevated levels of biomarkers for inflammation, such as interleukin 6, Mr. Vázquez-Medina said. A “chronic low proinflammatory state” may be the key to understanding the vulnerability of patients to MAFLD to COVID-19, he speculated.

The metabolic traits associated with MAFLD could explain the higher mortality and intubation rates with COVID, said Rohit Loomba, MD, MHSc, a professor of medicine in the division of gastroenterology at the University of California, San Diego, who was not involved in the study.

“Hypertension, diabetes, and obesity increase the risk of complications from COVID in all patients, whether they have been diagnosed with NAFLD or not,” he told this news organization in an email.

Mr. Vasquez-Medina pointed out that the patients with MAFLD had a higher risk of mortality even after adjusting for age, sex, type 2 diabetes, hypertension, overweight, and obesity (BMI ≥ 30 kg/m2). MAFLD also was more strongly associated with a poor outcome than either hypertension alone or obesity alone. Only age emerged as a significant independent covariate in the study.

Dr. Loomba also questioned whether the regression model used in this study for liver steatosis was “fully reflective of NAFLD.”

The researchers identified liver steatosis with a diagnostic formula that used noninvasive clinical BMI and laboratory tests (alanine aminotransferase), citing a study that found the regression formula was better at diagnosing NAFLD than FibroScan.

Mr. Vázquez-Medina reported no relevant financial relationships. Dr. Loomba serves as a consultant to Aardvark Therapeutics, Altimmune, Anylam/Regeneron, Amgen, Arrowhead Pharmaceuticals, AstraZeneca, Bristol-Myers Squibb, CohBar, Eli Lilly, Galmed, Gilead, Glympse Bio, Hightide, Inipharma, Intercept, Inventiva, Ionis, Janssen, Madrigal, Metacrine, NGM Biopharmaceuticals, Novartis, Novo Nordisk, Merck, Pfizer, Sagimet, Theratechnologies, 89bio, Terns Pharmaceuticals, and Viking Therapeutics. He is co-founder of LipoNexus.

A version of this article first appeared on Medscape.com.

People with metabolic dysfunction–associated fatty liver disease (MAFLD) – a newly defined condition – may be more likely to die from COVID-19, researchers say.

A cohort of people hospitalized for COVID-19 in Central Military Hospital, Mexico City, who met the criteria for MAFLD died at a higher rate than a control group without fatty liver disease, said Martín Uriel Vázquez-Medina, MSc, a researcher in the National Polytechnic Institute in Mexico City.

Patients who met only the criteria for the traditional classification, nonalcoholic fatty liver disease (NAFLD), also died of COVID-19 at a higher rate than the control group, but the difference was not statistically significant.

“It is important to screen for MAFLD,” Mr. Vázquez-Medina told this news organization. “It’s a new definition, but it has really helped us to identify which patients are going to get worse by COVID-19.”

The study was published in Hepatology Communications.
 

More evidence for clinical relevance of MAFLD

The finding lends support to an initiative to use MAFLD instead of NAFLD to identify patients whose liver steatosis poses a threat to their health, Mr. Vázquez-Medina said.

NAFLD affects as much as a quarter of the world’s population. No drugs have been approved to treat it. Some researchers have reasoned that the imprecision of the definition of NAFLD could be one reason for the lack of progress in treatment.

“NAFLD is something that doesn’t have positive criteria to be diagnosed,” said Mr. Vázquez-Medina. “You only say NAFLD when you don’t find hepatitis or another disease.”

In an article published in Gastroenterology, an international consensus panel proposed MAFLD as an alternative, arguing that a focus on metabolic dysfunction could more accurately reflect the pathogenesis of the disease and help stratify patients.

Previous research has suggested that patients with MAFLD have a higher risk of atherosclerotic cardiovascular disease and that the prevalence of colorectal adenomas is a higher in these patients, compared with patients with NAFLD.

The high prevalence of MAFLD in Mexico – about 30% – could help explain the country’s high rate of mortality from COVID-19, Mr. Vázquez-Medina said. Almost 6% of people diagnosed with COVID in Mexico have died from it, according to the Johns Hopkins University and Medical Center Coronavirus Resource Center.
 

Sorting COVID outcomes by liver steatosis

To understand the interaction of MAFLD, NAFLD, liver fibrosis, and COVID-19, Mr. Vázquez-Medina and his colleagues analyzed the records of all patients admitted to the Central Military Hospital with COVID-19 from April 4, 2020, to June 24, 2020.

They excluded patients for whom complete data were lacking or for whom a liver function test was not conducted in the first 24 hours of hospitalization. Also excluded were patients with significant consumption of alcohol (> 30 g/day for men and > 20 g/day for women) and those with a history of autoimmune liver disease, liver cancer, decompensated cirrhosis, platelet disorders, or myopathies.

The remaining patients were divided into three groups – 220 who met the criteria for MAFLD, 79 who met the criteria for NAFLD but not MAFLD, and 60 other patients as a control group.

The researchers defined MAFLD as the presence of liver steatosis detected with a noninvasive method and one of the following: overweight (body mass index, 25-29.9 kg/m2), type 2 diabetes, or the presence of two metabolic abnormalities (blood pressure > 140/90 mm Hg, plasma triglycerides > 150 mg/dL, plasma high-density lipoprotein cholesterol < 40 mg/dL in men and < 50 mg/dL in women, and prediabetes).

They defined NAFLD as the presence of liver steatosis without the other criteria for MAFLD.

The patients with MAFLD were the most likely to be intubated and were the most likely to die (intubation, 44.09%; mortality, 55%), followed by those with NAFLD (intubation, 40.51%; mortality, 51.9%) and those in the control group (intubation, 20%; mortality, 38.33%).

The difference in mortality between the MAFLD group and the control group was statistically significant (P = .02). The mortality difference between the NAFLD and the control group fell just short of statistical significance (P = .07).

For intubation, the difference between the MAFLD and the control group was highly statistically significant (P = .001), and the difference between the NAFLD and the control group was also statistically significant (P = .01)

Patients with advanced fibrosis and either MAFLD or NAFLD were also more likely to die than patients in the control group with advanced fibrosis.

That’s why screening for MAFLD is important, Mr. Vázquez-Medina said.
 

Next steps and new questions

Future research should examine whether patients with MAFLD have elevated levels of biomarkers for inflammation, such as interleukin 6, Mr. Vázquez-Medina said. A “chronic low proinflammatory state” may be the key to understanding the vulnerability of patients to MAFLD to COVID-19, he speculated.

The metabolic traits associated with MAFLD could explain the higher mortality and intubation rates with COVID, said Rohit Loomba, MD, MHSc, a professor of medicine in the division of gastroenterology at the University of California, San Diego, who was not involved in the study.

“Hypertension, diabetes, and obesity increase the risk of complications from COVID in all patients, whether they have been diagnosed with NAFLD or not,” he told this news organization in an email.

Mr. Vasquez-Medina pointed out that the patients with MAFLD had a higher risk of mortality even after adjusting for age, sex, type 2 diabetes, hypertension, overweight, and obesity (BMI ≥ 30 kg/m2). MAFLD also was more strongly associated with a poor outcome than either hypertension alone or obesity alone. Only age emerged as a significant independent covariate in the study.

Dr. Loomba also questioned whether the regression model used in this study for liver steatosis was “fully reflective of NAFLD.”

The researchers identified liver steatosis with a diagnostic formula that used noninvasive clinical BMI and laboratory tests (alanine aminotransferase), citing a study that found the regression formula was better at diagnosing NAFLD than FibroScan.

Mr. Vázquez-Medina reported no relevant financial relationships. Dr. Loomba serves as a consultant to Aardvark Therapeutics, Altimmune, Anylam/Regeneron, Amgen, Arrowhead Pharmaceuticals, AstraZeneca, Bristol-Myers Squibb, CohBar, Eli Lilly, Galmed, Gilead, Glympse Bio, Hightide, Inipharma, Intercept, Inventiva, Ionis, Janssen, Madrigal, Metacrine, NGM Biopharmaceuticals, Novartis, Novo Nordisk, Merck, Pfizer, Sagimet, Theratechnologies, 89bio, Terns Pharmaceuticals, and Viking Therapeutics. He is co-founder of LipoNexus.

A version of this article first appeared on Medscape.com.

In patients with stage I lung cancer, adding noncancerous features from CT chest imaging predicts overall survival better than clinical characteristics alone, according to a paper published online in the American Journal of Roentgenology.

Modeling that incorporates noncancerous imaging features captured on chest computed tomography (CT) along with clinical features, when calculated before stereotactic body radiation therapy (SBRT) is administered, improves survival prediction, compared with modeling that relies only on clinical features, the authors report.

“The focus of the study was to look at the environment in which the cancer lives,” said senior author Florian J. Fintelmann, MD, radiologist at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School, both in Boston. “This is looking at parameters like the aortic diameter, body composition – that is, the quantification and characterization of adipose tissue and muscle – coronary artery calcifications, and emphysema quantification.”

CT images are used by radiation oncologists to determine where the radiation should be delivered. “There is more information from these images that we can utilize,” he said.

Survival estimates in patients with state I lung cancer now rely on biological age, ECOG (Eastern Cooperative Oncology Group) score, and the presence of comorbidities, Dr. Fintelmann said.

This retrospective investigation involved 282 patients with a median age of 75 years. There were 168 women and 114 men. All patients had stage I lung cancer and were treated with SBRT between January 2009 and June 2017.

Courtesy Florian J. Fintelman, MD

A version of this article first appeared on Medscape.com.

In patients with stage I lung cancer, adding noncancerous features from CT chest imaging predicts overall survival better than clinical characteristics alone, according to a paper published online in the American Journal of Roentgenology.

Modeling that incorporates noncancerous imaging features captured on chest computed tomography (CT) along with clinical features, when calculated before stereotactic body radiation therapy (SBRT) is administered, improves survival prediction, compared with modeling that relies only on clinical features, the authors report.

“The focus of the study was to look at the environment in which the cancer lives,” said senior author Florian J. Fintelmann, MD, radiologist at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School, both in Boston. “This is looking at parameters like the aortic diameter, body composition – that is, the quantification and characterization of adipose tissue and muscle – coronary artery calcifications, and emphysema quantification.”

CT images are used by radiation oncologists to determine where the radiation should be delivered. “There is more information from these images that we can utilize,” he said.

Survival estimates in patients with state I lung cancer now rely on biological age, ECOG (Eastern Cooperative Oncology Group) score, and the presence of comorbidities, Dr. Fintelmann said.

This retrospective investigation involved 282 patients with a median age of 75 years. There were 168 women and 114 men. All patients had stage I lung cancer and were treated with SBRT between January 2009 and June 2017.

Courtesy Florian J. Fintelman, MD

A version of this article first appeared on Medscape.com.

In patients with stage I lung cancer, adding noncancerous features from CT chest imaging predicts overall survival better than clinical characteristics alone, according to a paper published online in the American Journal of Roentgenology.

Modeling that incorporates noncancerous imaging features captured on chest computed tomography (CT) along with clinical features, when calculated before stereotactic body radiation therapy (SBRT) is administered, improves survival prediction, compared with modeling that relies only on clinical features, the authors report.

“The focus of the study was to look at the environment in which the cancer lives,” said senior author Florian J. Fintelmann, MD, radiologist at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School, both in Boston. “This is looking at parameters like the aortic diameter, body composition – that is, the quantification and characterization of adipose tissue and muscle – coronary artery calcifications, and emphysema quantification.”

CT images are used by radiation oncologists to determine where the radiation should be delivered. “There is more information from these images that we can utilize,” he said.

Survival estimates in patients with state I lung cancer now rely on biological age, ECOG (Eastern Cooperative Oncology Group) score, and the presence of comorbidities, Dr. Fintelmann said.

This retrospective investigation involved 282 patients with a median age of 75 years. There were 168 women and 114 men. All patients had stage I lung cancer and were treated with SBRT between January 2009 and June 2017.

Courtesy Florian J. Fintelman, MD

A version of this article first appeared on Medscape.com.

Is fear of missing an infection – call it “FOMI” – leading you to overprescribe antibiotics to your patients?   

Inappropriate use of antibiotics can result in adverse events and toxicity, superinfections such as Clostridioides difficile and Methicillin-resistant Staphylococcus aureus, excess mortality and costs, and resistance to the drugs.   

All that has been well-known for years, and antibiotic resistance has become a leading public health concern. So why are physicians continuing to overprescribe the drugs?

Speaking at the 2022 annual Internal Medicine Meeting of the American College of Physicians, James “Brad” Cutrell, MD, medical director of antimicrobial stewardship, University of Texas Southwestern Medical Center, Dallas, said clinicians in the United States and elsewhere appear to be falling into a three-part fallacy when it comes to using the drugs: fear of “missing an infection,” coupled with patient expectations that they will leave the office with a prescription and combined with an overemphasis on the potential benefit to the individual at the expense of the risk to society of antibiotic resistance.

Antibiotics are the only drugs that lose their efficacy for all patients over time the more they are used. “For example, if I give a beta blocker to a patient, it’s not going to affect other patients down the road,” Dr. Cutrell said. “It’s not going to lose its efficacy.”

“What we need in medicine is a new culture around antibiotic use,” Dr. Cutrell added. “We need more respect for the dangers of antibiotic misuse and to have confidence in [their] benefits and when they can be used wisely.”
 

Rampant misuse

Outpatient prescriptions account for at least 60% of antibiotic use in the United States. The rate is even higher in other countries, Dr. Cutrell said during a presentation at the 2022 annual Internal Medicine Meeting of the American College of Physicians.

“About 10% of adult visits and 20% of pediatric visits will result in an antibiotic prescription,” said Dr. Cutrell, noting that prescribing patterns vary widely across the country, with as much as a three-fold difference in some locations. But at least 30% of outpatient antibiotic prescriptions are inappropriately ordered, he said.

“When we look at acute respiratory infections, upwards of 50% are not indicated at all,” he said. Imagine, he added, if the same error rate applied to other medical practices: “What if surgeons were only right 50% of the time, or if the oncologist was only giving the right treatment 50% of the time?”

The most recent Antibiotic Threats Report from the U.S. Centers for Disease Control and Prevention estimated that antibiotic-resistant bacteria and fungi cause more than 2.8 million infections and about 36,000 deaths annually in the United States alone.
 

How to be a better steward

The core elements for antimicrobial stewardship in the outpatient setting, according to Dr. Cutrell, include making a commitment to optimize prescribing, implementing at least one policy or practice to improve prescribing, monitoring prescribing practices and offering feedback to clinicians, and educating both patients and clinicians.

All that is similar to in-patient stewardship, he said, but outpatient clinicians face a few unique challenges. “Patients are lower acuity, and there is less diagnostic data, and program resources and time are more limited,” he said. Patient satisfaction is also a major driver, and it is also more difficult to measure and track ambulatory antibiotic use.

Interventions have been identified, however, that can help improve stewardship. One is auditing and feedback with peers. “Another [is] commitment posters, which can be placed around the clinic, and that helps set the culture,” he said. “Clinical education and practice guidelines are also important.”

Clinicians should also:

• Observe antibiotic best practices
• Optimize antibiotic selection and dosing
• Practice effective diagnostic stewardship
• Use the shortest duration of therapy necessary
• Avoid antibiotics for inappropriate indications
• Educate patients on when antibiotics are needed
• Follow and become good antibiotic stewardship mentors

“Multiple antibiotic stewardship interventions are effective, particularly those focused on behavioral interventions,” Dr. Cutrell said. “Every provider should follow antibiotic ‘best practices’ and other simple steps to prescribe antibiotics more wisely and to improve patient care.”

Dr. Cutrell reported financial relationships with Gilead Sciences and Regeneron Pharmaceuticals.

A version of this article first appeared on Medscape.com.

Is fear of missing an infection – call it “FOMI” – leading you to overprescribe antibiotics to your patients?   

Inappropriate use of antibiotics can result in adverse events and toxicity, superinfections such as Clostridioides difficile and Methicillin-resistant Staphylococcus aureus, excess mortality and costs, and resistance to the drugs.   

All that has been well-known for years, and antibiotic resistance has become a leading public health concern. So why are physicians continuing to overprescribe the drugs?

Speaking at the 2022 annual Internal Medicine Meeting of the American College of Physicians, James “Brad” Cutrell, MD, medical director of antimicrobial stewardship, University of Texas Southwestern Medical Center, Dallas, said clinicians in the United States and elsewhere appear to be falling into a three-part fallacy when it comes to using the drugs: fear of “missing an infection,” coupled with patient expectations that they will leave the office with a prescription and combined with an overemphasis on the potential benefit to the individual at the expense of the risk to society of antibiotic resistance.

Antibiotics are the only drugs that lose their efficacy for all patients over time the more they are used. “For example, if I give a beta blocker to a patient, it’s not going to affect other patients down the road,” Dr. Cutrell said. “It’s not going to lose its efficacy.”

“What we need in medicine is a new culture around antibiotic use,” Dr. Cutrell added. “We need more respect for the dangers of antibiotic misuse and to have confidence in [their] benefits and when they can be used wisely.”
 

Rampant misuse

Outpatient prescriptions account for at least 60% of antibiotic use in the United States. The rate is even higher in other countries, Dr. Cutrell said during a presentation at the 2022 annual Internal Medicine Meeting of the American College of Physicians.

“About 10% of adult visits and 20% of pediatric visits will result in an antibiotic prescription,” said Dr. Cutrell, noting that prescribing patterns vary widely across the country, with as much as a three-fold difference in some locations. But at least 30% of outpatient antibiotic prescriptions are inappropriately ordered, he said.

“When we look at acute respiratory infections, upwards of 50% are not indicated at all,” he said. Imagine, he added, if the same error rate applied to other medical practices: “What if surgeons were only right 50% of the time, or if the oncologist was only giving the right treatment 50% of the time?”

The most recent Antibiotic Threats Report from the U.S. Centers for Disease Control and Prevention estimated that antibiotic-resistant bacteria and fungi cause more than 2.8 million infections and about 36,000 deaths annually in the United States alone.
 

How to be a better steward

The core elements for antimicrobial stewardship in the outpatient setting, according to Dr. Cutrell, include making a commitment to optimize prescribing, implementing at least one policy or practice to improve prescribing, monitoring prescribing practices and offering feedback to clinicians, and educating both patients and clinicians.

All that is similar to in-patient stewardship, he said, but outpatient clinicians face a few unique challenges. “Patients are lower acuity, and there is less diagnostic data, and program resources and time are more limited,” he said. Patient satisfaction is also a major driver, and it is also more difficult to measure and track ambulatory antibiotic use.

Interventions have been identified, however, that can help improve stewardship. One is auditing and feedback with peers. “Another [is] commitment posters, which can be placed around the clinic, and that helps set the culture,” he said. “Clinical education and practice guidelines are also important.”

Clinicians should also:

• Observe antibiotic best practices
• Optimize antibiotic selection and dosing
• Practice effective diagnostic stewardship
• Use the shortest duration of therapy necessary
• Avoid antibiotics for inappropriate indications
• Educate patients on when antibiotics are needed
• Follow and become good antibiotic stewardship mentors

“Multiple antibiotic stewardship interventions are effective, particularly those focused on behavioral interventions,” Dr. Cutrell said. “Every provider should follow antibiotic ‘best practices’ and other simple steps to prescribe antibiotics more wisely and to improve patient care.”

Dr. Cutrell reported financial relationships with Gilead Sciences and Regeneron Pharmaceuticals.

A version of this article first appeared on Medscape.com.

Is fear of missing an infection – call it “FOMI” – leading you to overprescribe antibiotics to your patients?   

Inappropriate use of antibiotics can result in adverse events and toxicity, superinfections such as Clostridioides difficile and Methicillin-resistant Staphylococcus aureus, excess mortality and costs, and resistance to the drugs.   

All that has been well-known for years, and antibiotic resistance has become a leading public health concern. So why are physicians continuing to overprescribe the drugs?

Speaking at the 2022 annual Internal Medicine Meeting of the American College of Physicians, James “Brad” Cutrell, MD, medical director of antimicrobial stewardship, University of Texas Southwestern Medical Center, Dallas, said clinicians in the United States and elsewhere appear to be falling into a three-part fallacy when it comes to using the drugs: fear of “missing an infection,” coupled with patient expectations that they will leave the office with a prescription and combined with an overemphasis on the potential benefit to the individual at the expense of the risk to society of antibiotic resistance.

Antibiotics are the only drugs that lose their efficacy for all patients over time the more they are used. “For example, if I give a beta blocker to a patient, it’s not going to affect other patients down the road,” Dr. Cutrell said. “It’s not going to lose its efficacy.”

“What we need in medicine is a new culture around antibiotic use,” Dr. Cutrell added. “We need more respect for the dangers of antibiotic misuse and to have confidence in [their] benefits and when they can be used wisely.”
 

Rampant misuse

Outpatient prescriptions account for at least 60% of antibiotic use in the United States. The rate is even higher in other countries, Dr. Cutrell said during a presentation at the 2022 annual Internal Medicine Meeting of the American College of Physicians.

“About 10% of adult visits and 20% of pediatric visits will result in an antibiotic prescription,” said Dr. Cutrell, noting that prescribing patterns vary widely across the country, with as much as a three-fold difference in some locations. But at least 30% of outpatient antibiotic prescriptions are inappropriately ordered, he said.

“When we look at acute respiratory infections, upwards of 50% are not indicated at all,” he said. Imagine, he added, if the same error rate applied to other medical practices: “What if surgeons were only right 50% of the time, or if the oncologist was only giving the right treatment 50% of the time?”

The most recent Antibiotic Threats Report from the U.S. Centers for Disease Control and Prevention estimated that antibiotic-resistant bacteria and fungi cause more than 2.8 million infections and about 36,000 deaths annually in the United States alone.
 

How to be a better steward

The core elements for antimicrobial stewardship in the outpatient setting, according to Dr. Cutrell, include making a commitment to optimize prescribing, implementing at least one policy or practice to improve prescribing, monitoring prescribing practices and offering feedback to clinicians, and educating both patients and clinicians.

All that is similar to in-patient stewardship, he said, but outpatient clinicians face a few unique challenges. “Patients are lower acuity, and there is less diagnostic data, and program resources and time are more limited,” he said. Patient satisfaction is also a major driver, and it is also more difficult to measure and track ambulatory antibiotic use.

Interventions have been identified, however, that can help improve stewardship. One is auditing and feedback with peers. “Another [is] commitment posters, which can be placed around the clinic, and that helps set the culture,” he said. “Clinical education and practice guidelines are also important.”

Clinicians should also:

• Observe antibiotic best practices
• Optimize antibiotic selection and dosing
• Practice effective diagnostic stewardship
• Use the shortest duration of therapy necessary
• Avoid antibiotics for inappropriate indications
• Educate patients on when antibiotics are needed
• Follow and become good antibiotic stewardship mentors

“Multiple antibiotic stewardship interventions are effective, particularly those focused on behavioral interventions,” Dr. Cutrell said. “Every provider should follow antibiotic ‘best practices’ and other simple steps to prescribe antibiotics more wisely and to improve patient care.”

Dr. Cutrell reported financial relationships with Gilead Sciences and Regeneron Pharmaceuticals.

A version of this article first appeared on Medscape.com.

Multiple biomarkers of depression involved in several brain circuits are altered in patients with unipolar depression.

The first comprehensive meta-analysis of all biomarkers quantified to date in cerebrospinal fluid (CSF) of individuals with unipolar depression showed that several could be “clinically meaningful” because they suggest neuroimmunological alterations, disturbances in the blood-brain-barrier, hyperactivity in the hypothalamic-pituitary-adrenal (HPA) axis, and impaired neuroplasticity as factors in depression pathophysiology.

However, said study investigator Michael E. Benros, MD, PhD, professor and head of research at Mental Health Centre Copenhagen and University of Copenhagen, this is on a group level. “So in order to be relevant in a clinical context, the results need to be validated by further high-quality studies identifying subgroups with different biological underpinnings,” he told this news organization.

Identification of potential subgroups of depression with different biomarkers might help explain the diverse symptomatology and variability in treatment response observed in patients with depression, he noted.

The study was published online in JAMA Psychiatry.
 

Multiple pathways to depression

The systematic review and meta-analysis included 97 studies investigating 165 CSF biomarkers. 

Of the 42 biomarkers investigated in at least two studies, patients with unipolar depression had higher CSF levels of interleukin 6, a marker of chronic inflammation; total protein, which signals blood-brain barrier dysfunction and increased permeability; and cortisol, which is linked to psychological stress, compared with healthy controls.

Depression was also associated with:

• Lower CSF levels of homovanillic acid, the major terminal metabolite of dopamine.
• Gamma-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the CNS thought to play a vital role in the control of stress and depression.
• Somatostatin, a neuropeptide often coexpressed with GABA.
• Brain-derived neurotrophic factor (BDNF), a protein involved in neurogenesis, synaptic plasticity, and neurotransmission.
• Amyloid-β 40, implicated in Alzheimer’s disease.
• Transthyretin, involved in transport of thyroxine across the blood-brain barrier.

Collectively, the findings point toward a “dysregulated dopaminergic system, a compromised inhibitory system, HPA axis hyperactivity, increased neuroinflammation and blood-brain barrier permeability, and impaired neuroplasticity as important factors in depression pathophysiology,” the investigators wrote.

“It is notable that we did not find significant difference in the metabolite levels of serotonin and noradrenalin, which are the most targeted neurotransmitters in modern antidepressant treatment,” said Dr. Benros.

However, this could be explained by substantial heterogeneity between studies and the fact that quantification of total CSF biomarker concentrations does not reflect local alteration within the brain, he explained.

Many of the studies had small cohorts and most quantified only a few biomarkers, making it hard to examine potential interactions between biomarkers or identify specific phenotypes of depression.

“Novel high-quality studies including larger cohorts with an integrative approach and extensive numbers of biomarkers are needed to validate these potential biomarkers of depression and set the stage for the development of more effective and precise treatments,” the researchers noted. 
 

Which ones hold water?

Reached for comment, Dean MacKinnon, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, noted that this analysis “extracts the vast amount of knowledge” gained from different studies on biomarkers in the CSF for depression.

“They were able to identify 97 papers that have enough information in them that they could sort of lump them together and see which ones still hold water. It’s always useful to be able to look at patterns in the research and see if you can find some consistent trends,” he told this news organization.

Dr. MacKinnon, who was not part of the research team, also noted that “nonreplicability” is a problem in psychiatry and psychology research, “so being able to show that at least some studies were sufficiently well done, to get a good result, and that they could be replicated in at least one other good study is useful information.”

When it comes to depression, Dr. MacKinnon said, “We just don’t know enough to really pin down a physiologic pathway to explain it. The fact that some people seem to have high cortisol and some people seem to have high permeability of blood-brain barrier, and others have abnormalities in dopamine, is interesting and suggests that depression is likely not a unitary disease with a single cause.”

He cautioned, however, that the findings don’t have immediate clinical implications for individual patients with depression. 

“Theoretically, down the road, if you extrapolate from what they found, and if it’s truly the case that this research maps to something that could suggest a different clinical approach, you might be able to determine whether one patient might respond better to an SSRI or an SNRI or something like that,” Dr. MacKinnon said.

Dr. Benros reported grants from Lundbeck Foundation during the conduct of the study. Dr. MacKinnon has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Multiple biomarkers of depression involved in several brain circuits are altered in patients with unipolar depression.

The first comprehensive meta-analysis of all biomarkers quantified to date in cerebrospinal fluid (CSF) of individuals with unipolar depression showed that several could be “clinically meaningful” because they suggest neuroimmunological alterations, disturbances in the blood-brain-barrier, hyperactivity in the hypothalamic-pituitary-adrenal (HPA) axis, and impaired neuroplasticity as factors in depression pathophysiology.

However, said study investigator Michael E. Benros, MD, PhD, professor and head of research at Mental Health Centre Copenhagen and University of Copenhagen, this is on a group level. “So in order to be relevant in a clinical context, the results need to be validated by further high-quality studies identifying subgroups with different biological underpinnings,” he told this news organization.

Identification of potential subgroups of depression with different biomarkers might help explain the diverse symptomatology and variability in treatment response observed in patients with depression, he noted.

The study was published online in JAMA Psychiatry.
 

Multiple pathways to depression

The systematic review and meta-analysis included 97 studies investigating 165 CSF biomarkers. 

Of the 42 biomarkers investigated in at least two studies, patients with unipolar depression had higher CSF levels of interleukin 6, a marker of chronic inflammation; total protein, which signals blood-brain barrier dysfunction and increased permeability; and cortisol, which is linked to psychological stress, compared with healthy controls.

Depression was also associated with:

• Lower CSF levels of homovanillic acid, the major terminal metabolite of dopamine.
• Gamma-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the CNS thought to play a vital role in the control of stress and depression.
• Somatostatin, a neuropeptide often coexpressed with GABA.
• Brain-derived neurotrophic factor (BDNF), a protein involved in neurogenesis, synaptic plasticity, and neurotransmission.
• Amyloid-β 40, implicated in Alzheimer’s disease.
• Transthyretin, involved in transport of thyroxine across the blood-brain barrier.

Collectively, the findings point toward a “dysregulated dopaminergic system, a compromised inhibitory system, HPA axis hyperactivity, increased neuroinflammation and blood-brain barrier permeability, and impaired neuroplasticity as important factors in depression pathophysiology,” the investigators wrote.

“It is notable that we did not find significant difference in the metabolite levels of serotonin and noradrenalin, which are the most targeted neurotransmitters in modern antidepressant treatment,” said Dr. Benros.

However, this could be explained by substantial heterogeneity between studies and the fact that quantification of total CSF biomarker concentrations does not reflect local alteration within the brain, he explained.

Many of the studies had small cohorts and most quantified only a few biomarkers, making it hard to examine potential interactions between biomarkers or identify specific phenotypes of depression.

“Novel high-quality studies including larger cohorts with an integrative approach and extensive numbers of biomarkers are needed to validate these potential biomarkers of depression and set the stage for the development of more effective and precise treatments,” the researchers noted. 
 

Which ones hold water?

Reached for comment, Dean MacKinnon, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, noted that this analysis “extracts the vast amount of knowledge” gained from different studies on biomarkers in the CSF for depression.

“They were able to identify 97 papers that have enough information in them that they could sort of lump them together and see which ones still hold water. It’s always useful to be able to look at patterns in the research and see if you can find some consistent trends,” he told this news organization.

Dr. MacKinnon, who was not part of the research team, also noted that “nonreplicability” is a problem in psychiatry and psychology research, “so being able to show that at least some studies were sufficiently well done, to get a good result, and that they could be replicated in at least one other good study is useful information.”

When it comes to depression, Dr. MacKinnon said, “We just don’t know enough to really pin down a physiologic pathway to explain it. The fact that some people seem to have high cortisol and some people seem to have high permeability of blood-brain barrier, and others have abnormalities in dopamine, is interesting and suggests that depression is likely not a unitary disease with a single cause.”

He cautioned, however, that the findings don’t have immediate clinical implications for individual patients with depression. 

“Theoretically, down the road, if you extrapolate from what they found, and if it’s truly the case that this research maps to something that could suggest a different clinical approach, you might be able to determine whether one patient might respond better to an SSRI or an SNRI or something like that,” Dr. MacKinnon said.

Dr. Benros reported grants from Lundbeck Foundation during the conduct of the study. Dr. MacKinnon has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Multiple biomarkers of depression involved in several brain circuits are altered in patients with unipolar depression.

The first comprehensive meta-analysis of all biomarkers quantified to date in cerebrospinal fluid (CSF) of individuals with unipolar depression showed that several could be “clinically meaningful” because they suggest neuroimmunological alterations, disturbances in the blood-brain-barrier, hyperactivity in the hypothalamic-pituitary-adrenal (HPA) axis, and impaired neuroplasticity as factors in depression pathophysiology.

However, said study investigator Michael E. Benros, MD, PhD, professor and head of research at Mental Health Centre Copenhagen and University of Copenhagen, this is on a group level. “So in order to be relevant in a clinical context, the results need to be validated by further high-quality studies identifying subgroups with different biological underpinnings,” he told this news organization.

Identification of potential subgroups of depression with different biomarkers might help explain the diverse symptomatology and variability in treatment response observed in patients with depression, he noted.

The study was published online in JAMA Psychiatry.
 

Multiple pathways to depression

The systematic review and meta-analysis included 97 studies investigating 165 CSF biomarkers. 

Of the 42 biomarkers investigated in at least two studies, patients with unipolar depression had higher CSF levels of interleukin 6, a marker of chronic inflammation; total protein, which signals blood-brain barrier dysfunction and increased permeability; and cortisol, which is linked to psychological stress, compared with healthy controls.

Depression was also associated with:

• Lower CSF levels of homovanillic acid, the major terminal metabolite of dopamine.
• Gamma-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the CNS thought to play a vital role in the control of stress and depression.
• Somatostatin, a neuropeptide often coexpressed with GABA.
• Brain-derived neurotrophic factor (BDNF), a protein involved in neurogenesis, synaptic plasticity, and neurotransmission.
• Amyloid-β 40, implicated in Alzheimer’s disease.
• Transthyretin, involved in transport of thyroxine across the blood-brain barrier.

Collectively, the findings point toward a “dysregulated dopaminergic system, a compromised inhibitory system, HPA axis hyperactivity, increased neuroinflammation and blood-brain barrier permeability, and impaired neuroplasticity as important factors in depression pathophysiology,” the investigators wrote.

“It is notable that we did not find significant difference in the metabolite levels of serotonin and noradrenalin, which are the most targeted neurotransmitters in modern antidepressant treatment,” said Dr. Benros.

However, this could be explained by substantial heterogeneity between studies and the fact that quantification of total CSF biomarker concentrations does not reflect local alteration within the brain, he explained.

Many of the studies had small cohorts and most quantified only a few biomarkers, making it hard to examine potential interactions between biomarkers or identify specific phenotypes of depression.

“Novel high-quality studies including larger cohorts with an integrative approach and extensive numbers of biomarkers are needed to validate these potential biomarkers of depression and set the stage for the development of more effective and precise treatments,” the researchers noted. 
 

Which ones hold water?

Reached for comment, Dean MacKinnon, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, noted that this analysis “extracts the vast amount of knowledge” gained from different studies on biomarkers in the CSF for depression.

“They were able to identify 97 papers that have enough information in them that they could sort of lump them together and see which ones still hold water. It’s always useful to be able to look at patterns in the research and see if you can find some consistent trends,” he told this news organization.

Dr. MacKinnon, who was not part of the research team, also noted that “nonreplicability” is a problem in psychiatry and psychology research, “so being able to show that at least some studies were sufficiently well done, to get a good result, and that they could be replicated in at least one other good study is useful information.”

When it comes to depression, Dr. MacKinnon said, “We just don’t know enough to really pin down a physiologic pathway to explain it. The fact that some people seem to have high cortisol and some people seem to have high permeability of blood-brain barrier, and others have abnormalities in dopamine, is interesting and suggests that depression is likely not a unitary disease with a single cause.”

He cautioned, however, that the findings don’t have immediate clinical implications for individual patients with depression. 

“Theoretically, down the road, if you extrapolate from what they found, and if it’s truly the case that this research maps to something that could suggest a different clinical approach, you might be able to determine whether one patient might respond better to an SSRI or an SNRI or something like that,” Dr. MacKinnon said.

Dr. Benros reported grants from Lundbeck Foundation during the conduct of the study. Dr. MacKinnon has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Burnout in psychiatrists is “highly prevalent” across the globe, new research shows.

In a review and meta-analysis of 36 studies and more than 5,000 psychiatrists in European countries, as well as the United States, Australia, New Zealand, India, Turkey, and Thailand, results showed that 25% of respondents met criteria for burnout, as measured by the Maslach Burnout Inventory (MBI) – and more than 50% qualified on the basis of the Copenhagen Burnout Inventory (CBI).

“Our review showed that regardless of the identification method of burnout, its prevalence among psychiatrists is high and ranges from 25% to 50%,” lead author Kirill Bykov, MD, a PhD candidate at the Peoples’ Friendship University of Russia (RUDN University), Moscow, Russian Federation, told this news organization.

There was a “high heterogeneity of studies in terms of statistics, screening methods, burnout definitions, and cutoff points in the included studies, which necessitates the unification of future research methodology, but not to the detriment of the development of the theoretical background,” Dr. Bykov said.

The findings were published online in the Journal of Affective Disorders.
 

‘Unresolved problem’

Although burnout is a serious and prevalent problem among health care workers, little research has focused on burnout in mental health workers compared with other professionals, the investigators noted.

A previous systematic review and meta-analysis that focused specifically on burnout in psychiatrists was limited by methodologic concerns, including that the only burnout screening instrument used in the included studies was the full-length (22-item) MBI.

The current researchers surmised that “the integration of different empirical studies of psychiatrists’ burnout prevalence [remained] an unresolved problem.”

Dr. Bykov noted the current review was “investigator-initiated” and was a part of his PhD dissertation.

“Studying the works devoted to the burnout of psychiatrists, I drew attention to the varying prevalence rates of this phenomenon among them. This prompted me to conduct a systematic review of the literature and summarize the available data,” he said.

Unlike the previous review, the current one “does not contain restrictions regarding the place of research, publication language, covered burnout concepts, definitions, and screening instruments. Thus, its results will be helpful for practitioners and scientists around the world,” Dr. Bykov added.

Among the inclusion criteria was that a study should be empirical and quantitative, contain at least 20 practicing psychiatrists as participants, use a valid and reliable burnout screening instrument, have at least one burnout metric extractable specifically with regard to psychiatrists, and have a national survey or a response rate among psychiatrists of 20% or greater.

Qualitative or review articles or studies consisting of psychiatric trainees (such as medical students or residents) or nonpracticing psychiatrists were excluded.
 

Pooled prevalence

The researchers included 36 studies that comprised 5,481 participants (51.3% were women; mean age, 46.7 years). All studies had from 20 to 1,157 participants. They were employed in an array of settings in 19 countries.

In 22 studies, survey years ranged from 1996 to 2018; 14 studies did not report the year of data collection.

Most studies (75%) used some version of the MBI, and 19 studies used the full-length 22-item MBI Human Service Survey (MBI-HSS) . The survey rates emotional exhaustion (EE), depersonalization (DP), and low personal achievement (PA) on a 7-point Likert scale from 0 (“never”) to 6 (“almost every day”).

Other instruments included the CBI, the 16-item Oldenburg Burnout Inventory, the 21-item Tedium Measure, the 30-item Professional Quality of Life measure, the Rohland et al. Single-Item Measure of Self-Perceived Burnout, and the 21-item Brief Burnout Questionnaire.

Only three studies were free of methodologic limitations. The remaining 33 studies had some problems, such as not reporting the response rate or comparability between responders and nonresponders.

Results showed that the overall prevalence of burnout, as measured by the MBI and the CBI, was 25.9% (range, 11.1%-40.75%) and 50.3% (range, 30.9%-69.8%), respectively.

The pooled prevalence for burnout components is shown in the table.

‘Carry the hope’

In a comment, Christine Crawford, MD, associate medical director of the National Alliance on Mental Illness (NAMI), said she was surprised the burnout numbers weren’t higher.

Many colleagues she interacts with “have been experiencing pretty significant burnout that has only been exacerbated by the pandemic and ever-growing demand for mental health providers, and there aren’t enough to meet that demand,” said Dr. Crawford, a psychiatrist at Boston Medical Center’s Outpatient Child and Adolescent Psychiatry Clinic and at Codman Square Health Center. She was not involved with the current research.

Courtesy Boston Medical Center

Dr. Crawford noted that much of the data was from Europeans. Speaking to the experience of U.S.-based psychiatrists, she said there is a “greater appreciation for what we do as mental health providers, due to the growing conversations around mental health and normalizing mental health conditions.”

On the other hand, there is “a lack of parity in reimbursement rates. Although the general public values mental health, the medical system doesn’t value mental health providers in the same way as physicians in other specialties,” Dr. Crawford said. Feeling devalued can contribute to burnout, she added.

One way to counter burnout is to remember “that our role is to carry the hope. We can be hopeful for the patient that the treatment will work or the medications can provide some relief,” Dr. Crawford noted.

Psychiatrists “may need to hold on tightly to that hope because we may not receive that instant gratification from the patient or receive praise or see the change from the patient during that time, which can be challenging,” she said.

“But it’s important for us to keep in mind that, even in that moment when the patient can’t see it, we can work alongside the patient to create the vision of hope and what it will look like in the future,” said Dr. Crawford.

In the 2022 Medscape Psychiatrist Lifestyle, Happiness & Burnout Report, an annual online survey of Medscape member physicians, 47% of respondents reported burnout – which was up from 42% the previous year.

The investigators received no funding for this work. They and Dr. Crawford report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Burnout in psychiatrists is “highly prevalent” across the globe, new research shows.

In a review and meta-analysis of 36 studies and more than 5,000 psychiatrists in European countries, as well as the United States, Australia, New Zealand, India, Turkey, and Thailand, results showed that 25% of respondents met criteria for burnout, as measured by the Maslach Burnout Inventory (MBI) – and more than 50% qualified on the basis of the Copenhagen Burnout Inventory (CBI).

“Our review showed that regardless of the identification method of burnout, its prevalence among psychiatrists is high and ranges from 25% to 50%,” lead author Kirill Bykov, MD, a PhD candidate at the Peoples’ Friendship University of Russia (RUDN University), Moscow, Russian Federation, told this news organization.

There was a “high heterogeneity of studies in terms of statistics, screening methods, burnout definitions, and cutoff points in the included studies, which necessitates the unification of future research methodology, but not to the detriment of the development of the theoretical background,” Dr. Bykov said.

The findings were published online in the Journal of Affective Disorders.
 

‘Unresolved problem’

Although burnout is a serious and prevalent problem among health care workers, little research has focused on burnout in mental health workers compared with other professionals, the investigators noted.

A previous systematic review and meta-analysis that focused specifically on burnout in psychiatrists was limited by methodologic concerns, including that the only burnout screening instrument used in the included studies was the full-length (22-item) MBI.

The current researchers surmised that “the integration of different empirical studies of psychiatrists’ burnout prevalence [remained] an unresolved problem.”

Dr. Bykov noted the current review was “investigator-initiated” and was a part of his PhD dissertation.

“Studying the works devoted to the burnout of psychiatrists, I drew attention to the varying prevalence rates of this phenomenon among them. This prompted me to conduct a systematic review of the literature and summarize the available data,” he said.

Unlike the previous review, the current one “does not contain restrictions regarding the place of research, publication language, covered burnout concepts, definitions, and screening instruments. Thus, its results will be helpful for practitioners and scientists around the world,” Dr. Bykov added.

Among the inclusion criteria was that a study should be empirical and quantitative, contain at least 20 practicing psychiatrists as participants, use a valid and reliable burnout screening instrument, have at least one burnout metric extractable specifically with regard to psychiatrists, and have a national survey or a response rate among psychiatrists of 20% or greater.

Qualitative or review articles or studies consisting of psychiatric trainees (such as medical students or residents) or nonpracticing psychiatrists were excluded.
 

Pooled prevalence

The researchers included 36 studies that comprised 5,481 participants (51.3% were women; mean age, 46.7 years). All studies had from 20 to 1,157 participants. They were employed in an array of settings in 19 countries.

In 22 studies, survey years ranged from 1996 to 2018; 14 studies did not report the year of data collection.

Most studies (75%) used some version of the MBI, and 19 studies used the full-length 22-item MBI Human Service Survey (MBI-HSS) . The survey rates emotional exhaustion (EE), depersonalization (DP), and low personal achievement (PA) on a 7-point Likert scale from 0 (“never”) to 6 (“almost every day”).

Other instruments included the CBI, the 16-item Oldenburg Burnout Inventory, the 21-item Tedium Measure, the 30-item Professional Quality of Life measure, the Rohland et al. Single-Item Measure of Self-Perceived Burnout, and the 21-item Brief Burnout Questionnaire.

Only three studies were free of methodologic limitations. The remaining 33 studies had some problems, such as not reporting the response rate or comparability between responders and nonresponders.

Results showed that the overall prevalence of burnout, as measured by the MBI and the CBI, was 25.9% (range, 11.1%-40.75%) and 50.3% (range, 30.9%-69.8%), respectively.

The pooled prevalence for burnout components is shown in the table.

‘Carry the hope’

In a comment, Christine Crawford, MD, associate medical director of the National Alliance on Mental Illness (NAMI), said she was surprised the burnout numbers weren’t higher.

Many colleagues she interacts with “have been experiencing pretty significant burnout that has only been exacerbated by the pandemic and ever-growing demand for mental health providers, and there aren’t enough to meet that demand,” said Dr. Crawford, a psychiatrist at Boston Medical Center’s Outpatient Child and Adolescent Psychiatry Clinic and at Codman Square Health Center. She was not involved with the current research.

Courtesy Boston Medical Center

Dr. Crawford noted that much of the data was from Europeans. Speaking to the experience of U.S.-based psychiatrists, she said there is a “greater appreciation for what we do as mental health providers, due to the growing conversations around mental health and normalizing mental health conditions.”

On the other hand, there is “a lack of parity in reimbursement rates. Although the general public values mental health, the medical system doesn’t value mental health providers in the same way as physicians in other specialties,” Dr. Crawford said. Feeling devalued can contribute to burnout, she added.

One way to counter burnout is to remember “that our role is to carry the hope. We can be hopeful for the patient that the treatment will work or the medications can provide some relief,” Dr. Crawford noted.

Psychiatrists “may need to hold on tightly to that hope because we may not receive that instant gratification from the patient or receive praise or see the change from the patient during that time, which can be challenging,” she said.

“But it’s important for us to keep in mind that, even in that moment when the patient can’t see it, we can work alongside the patient to create the vision of hope and what it will look like in the future,” said Dr. Crawford.

In the 2022 Medscape Psychiatrist Lifestyle, Happiness & Burnout Report, an annual online survey of Medscape member physicians, 47% of respondents reported burnout – which was up from 42% the previous year.

The investigators received no funding for this work. They and Dr. Crawford report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Burnout in psychiatrists is “highly prevalent” across the globe, new research shows.

In a review and meta-analysis of 36 studies and more than 5,000 psychiatrists in European countries, as well as the United States, Australia, New Zealand, India, Turkey, and Thailand, results showed that 25% of respondents met criteria for burnout, as measured by the Maslach Burnout Inventory (MBI) – and more than 50% qualified on the basis of the Copenhagen Burnout Inventory (CBI).

“Our review showed that regardless of the identification method of burnout, its prevalence among psychiatrists is high and ranges from 25% to 50%,” lead author Kirill Bykov, MD, a PhD candidate at the Peoples’ Friendship University of Russia (RUDN University), Moscow, Russian Federation, told this news organization.

There was a “high heterogeneity of studies in terms of statistics, screening methods, burnout definitions, and cutoff points in the included studies, which necessitates the unification of future research methodology, but not to the detriment of the development of the theoretical background,” Dr. Bykov said.

The findings were published online in the Journal of Affective Disorders.
 

‘Unresolved problem’

Although burnout is a serious and prevalent problem among health care workers, little research has focused on burnout in mental health workers compared with other professionals, the investigators noted.

A previous systematic review and meta-analysis that focused specifically on burnout in psychiatrists was limited by methodologic concerns, including that the only burnout screening instrument used in the included studies was the full-length (22-item) MBI.

The current researchers surmised that “the integration of different empirical studies of psychiatrists’ burnout prevalence [remained] an unresolved problem.”

Dr. Bykov noted the current review was “investigator-initiated” and was a part of his PhD dissertation.

“Studying the works devoted to the burnout of psychiatrists, I drew attention to the varying prevalence rates of this phenomenon among them. This prompted me to conduct a systematic review of the literature and summarize the available data,” he said.

Unlike the previous review, the current one “does not contain restrictions regarding the place of research, publication language, covered burnout concepts, definitions, and screening instruments. Thus, its results will be helpful for practitioners and scientists around the world,” Dr. Bykov added.

Among the inclusion criteria was that a study should be empirical and quantitative, contain at least 20 practicing psychiatrists as participants, use a valid and reliable burnout screening instrument, have at least one burnout metric extractable specifically with regard to psychiatrists, and have a national survey or a response rate among psychiatrists of 20% or greater.

Qualitative or review articles or studies consisting of psychiatric trainees (such as medical students or residents) or nonpracticing psychiatrists were excluded.
 

Pooled prevalence

The researchers included 36 studies that comprised 5,481 participants (51.3% were women; mean age, 46.7 years). All studies had from 20 to 1,157 participants. They were employed in an array of settings in 19 countries.

In 22 studies, survey years ranged from 1996 to 2018; 14 studies did not report the year of data collection.

Most studies (75%) used some version of the MBI, and 19 studies used the full-length 22-item MBI Human Service Survey (MBI-HSS) . The survey rates emotional exhaustion (EE), depersonalization (DP), and low personal achievement (PA) on a 7-point Likert scale from 0 (“never”) to 6 (“almost every day”).

Other instruments included the CBI, the 16-item Oldenburg Burnout Inventory, the 21-item Tedium Measure, the 30-item Professional Quality of Life measure, the Rohland et al. Single-Item Measure of Self-Perceived Burnout, and the 21-item Brief Burnout Questionnaire.

Only three studies were free of methodologic limitations. The remaining 33 studies had some problems, such as not reporting the response rate or comparability between responders and nonresponders.

Results showed that the overall prevalence of burnout, as measured by the MBI and the CBI, was 25.9% (range, 11.1%-40.75%) and 50.3% (range, 30.9%-69.8%), respectively.

The pooled prevalence for burnout components is shown in the table.

‘Carry the hope’

In a comment, Christine Crawford, MD, associate medical director of the National Alliance on Mental Illness (NAMI), said she was surprised the burnout numbers weren’t higher.

Many colleagues she interacts with “have been experiencing pretty significant burnout that has only been exacerbated by the pandemic and ever-growing demand for mental health providers, and there aren’t enough to meet that demand,” said Dr. Crawford, a psychiatrist at Boston Medical Center’s Outpatient Child and Adolescent Psychiatry Clinic and at Codman Square Health Center. She was not involved with the current research.

Courtesy Boston Medical Center

Dr. Crawford noted that much of the data was from Europeans. Speaking to the experience of U.S.-based psychiatrists, she said there is a “greater appreciation for what we do as mental health providers, due to the growing conversations around mental health and normalizing mental health conditions.”

On the other hand, there is “a lack of parity in reimbursement rates. Although the general public values mental health, the medical system doesn’t value mental health providers in the same way as physicians in other specialties,” Dr. Crawford said. Feeling devalued can contribute to burnout, she added.

One way to counter burnout is to remember “that our role is to carry the hope. We can be hopeful for the patient that the treatment will work or the medications can provide some relief,” Dr. Crawford noted.

Psychiatrists “may need to hold on tightly to that hope because we may not receive that instant gratification from the patient or receive praise or see the change from the patient during that time, which can be challenging,” she said.

“But it’s important for us to keep in mind that, even in that moment when the patient can’t see it, we can work alongside the patient to create the vision of hope and what it will look like in the future,” said Dr. Crawford.

In the 2022 Medscape Psychiatrist Lifestyle, Happiness & Burnout Report, an annual online survey of Medscape member physicians, 47% of respondents reported burnout – which was up from 42% the previous year.

The investigators received no funding for this work. They and Dr. Crawford report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Transcriptomic profiling of phagocytes in the lamina propria of patients with inflammatory bowel disease (IBD) may guide future treatment selection, according to investigators.

Mucosal gut biopsies revealed that phagocytic gene expression correlated with inflammatory states, types of IBD, and responses to therapy, lead author Gillian E. Jacobsen a MD/PhD candidate at the University of Miami and colleagues reported.

In an article in Gastro Hep Advances, the investigators wrote that “lamina propria phagocytes along with epithelial cells represent a first line of defense and play a balancing act between tolerance toward commensal microbes and generation of immune responses toward pathogenic microorganisms. ... Inappropriate responses by lamina propria phagocytes have been linked to IBD.”

To better understand these responses, the researchers collected 111 gut mucosal biopsies from 54 patients with IBD, among whom 59% were taking biologics, 72% had inflammation in at least one biopsy site, and 41% had previously used at least one other biologic. Samples were analyzed to determine cell phenotypes, gene expression, and cytokine responses to in vitro Janus kinase (JAK) inhibitor exposure.

Ms. Jacobsen and colleagues noted that most reports that address the function of phagocytes focus on circulating dendritic cells, monocytes, or monocyte-derived macrophages, rather than on resident phagocyte populations located in the lamina propria. However, these circulating cells “do not reflect intestinal inflammation, or whole tissue biopsies.”

Phagocytes based on CD11b expression and phenotyped CD11b+-enriched cells using flow cytometry were identified. In samples with active inflammation, cells were most often granulocytes (45.5%), followed by macrophages (22.6%) and monocytes (9.4%). Uninflamed samples had a slightly lower proportion of granulocytes (33.6%), about the same proportion of macrophages (22.7%), and a higher rate of B cells (15.6% vs. 9.0%).

Ms. Jacobsen and colleagues highlighted the absolute uptick in granulocytes, including neutrophils.

“Neutrophilic infiltration is a major indicator of IBD activity and may be critically linked to ongoing inflammation,” they wrote. “These data demonstrate that CD11b+ enrichment reflects the inflammatory state of the biopsies.”

The investigators also showed that transcriptional profiles of lamina propria CD11b+ cells differed “greatly” between colon and ileum, which suggested that “the location or cellular environment plays a marked role in determining the gene expression of phagocytes.”

CD11b+ cell gene expression profiles also correlated with ulcerative colitis versus Crohn’s disease, although the researchers noted that these patterns were less pronounced than correlations with inflammatory states

“There are pathways common to inflammation regardless of the IBD type that could be used as markers of inflammation or targets for therapy.”

Comparing colon samples from patients who responded to anti–tumor necrosis factor therapy with those who were refractory to anti-TNF therapy revealed significant associations between response type and 52 differentially expressed genes.

“These genes were mostly immunoglobulin genes up-regulated in the anti–TNF-treated inflamed colon, suggesting that CD11b+ B cells may play a role in medication refractoriness.”

Evaluating inflamed colon and anti-TNF refractory ileum revealed differential expression of OSM, a known marker of TNF-resistant disease, as well as TREM1, a proinflammatory marker. In contrast, NTS genes showed high expression in uninflamed samples on anti-TNF therapy. The researchers noted that these findings “may be used to build precision medicine approaches in IBD.”

Further experiments showed that in vitro exposure of anti-TNF refractory samples to JAK inhibitors resulted in significantly reduced secretion of interleukin-8 and TNF-alpha.

“Our study provides functional data that JAK inhibition with tofacitinib (JAK1/JAK3) or ruxolitinib (JAK1/JAK2) inhibits lipopolysaccharide-induced cytokine production even in TNF-refractory samples,” the researchers wrote. “These data inform the response of patients to JAK inhibitors, including those refractory to other treatments.”

The study was supported by Pfizer, the National Institute of Diabetes and Digestive and Kidney Diseases, the Micky & Madeleine Arison Family Foundation Crohn’s & Colitis Discovery Laboratory, and Martin Kalser Chair in Gastroenterology at the University of Miami. The investigators disclosed additional relationships with Takeda, Abbvie, Eli Lilly, and others.

Transcriptomic profiling of phagocytes in the lamina propria of patients with inflammatory bowel disease (IBD) may guide future treatment selection, according to investigators.

Mucosal gut biopsies revealed that phagocytic gene expression correlated with inflammatory states, types of IBD, and responses to therapy, lead author Gillian E. Jacobsen a MD/PhD candidate at the University of Miami and colleagues reported.

In an article in Gastro Hep Advances, the investigators wrote that “lamina propria phagocytes along with epithelial cells represent a first line of defense and play a balancing act between tolerance toward commensal microbes and generation of immune responses toward pathogenic microorganisms. ... Inappropriate responses by lamina propria phagocytes have been linked to IBD.”

To better understand these responses, the researchers collected 111 gut mucosal biopsies from 54 patients with IBD, among whom 59% were taking biologics, 72% had inflammation in at least one biopsy site, and 41% had previously used at least one other biologic. Samples were analyzed to determine cell phenotypes, gene expression, and cytokine responses to in vitro Janus kinase (JAK) inhibitor exposure.

Ms. Jacobsen and colleagues noted that most reports that address the function of phagocytes focus on circulating dendritic cells, monocytes, or monocyte-derived macrophages, rather than on resident phagocyte populations located in the lamina propria. However, these circulating cells “do not reflect intestinal inflammation, or whole tissue biopsies.”

Phagocytes based on CD11b expression and phenotyped CD11b+-enriched cells using flow cytometry were identified. In samples with active inflammation, cells were most often granulocytes (45.5%), followed by macrophages (22.6%) and monocytes (9.4%). Uninflamed samples had a slightly lower proportion of granulocytes (33.6%), about the same proportion of macrophages (22.7%), and a higher rate of B cells (15.6% vs. 9.0%).

Ms. Jacobsen and colleagues highlighted the absolute uptick in granulocytes, including neutrophils.

“Neutrophilic infiltration is a major indicator of IBD activity and may be critically linked to ongoing inflammation,” they wrote. “These data demonstrate that CD11b+ enrichment reflects the inflammatory state of the biopsies.”

The investigators also showed that transcriptional profiles of lamina propria CD11b+ cells differed “greatly” between colon and ileum, which suggested that “the location or cellular environment plays a marked role in determining the gene expression of phagocytes.”

CD11b+ cell gene expression profiles also correlated with ulcerative colitis versus Crohn’s disease, although the researchers noted that these patterns were less pronounced than correlations with inflammatory states

“There are pathways common to inflammation regardless of the IBD type that could be used as markers of inflammation or targets for therapy.”

Comparing colon samples from patients who responded to anti–tumor necrosis factor therapy with those who were refractory to anti-TNF therapy revealed significant associations between response type and 52 differentially expressed genes.

“These genes were mostly immunoglobulin genes up-regulated in the anti–TNF-treated inflamed colon, suggesting that CD11b+ B cells may play a role in medication refractoriness.”

Evaluating inflamed colon and anti-TNF refractory ileum revealed differential expression of OSM, a known marker of TNF-resistant disease, as well as TREM1, a proinflammatory marker. In contrast, NTS genes showed high expression in uninflamed samples on anti-TNF therapy. The researchers noted that these findings “may be used to build precision medicine approaches in IBD.”

Further experiments showed that in vitro exposure of anti-TNF refractory samples to JAK inhibitors resulted in significantly reduced secretion of interleukin-8 and TNF-alpha.

“Our study provides functional data that JAK inhibition with tofacitinib (JAK1/JAK3) or ruxolitinib (JAK1/JAK2) inhibits lipopolysaccharide-induced cytokine production even in TNF-refractory samples,” the researchers wrote. “These data inform the response of patients to JAK inhibitors, including those refractory to other treatments.”

The study was supported by Pfizer, the National Institute of Diabetes and Digestive and Kidney Diseases, the Micky & Madeleine Arison Family Foundation Crohn’s & Colitis Discovery Laboratory, and Martin Kalser Chair in Gastroenterology at the University of Miami. The investigators disclosed additional relationships with Takeda, Abbvie, Eli Lilly, and others.

Transcriptomic profiling of phagocytes in the lamina propria of patients with inflammatory bowel disease (IBD) may guide future treatment selection, according to investigators.

Mucosal gut biopsies revealed that phagocytic gene expression correlated with inflammatory states, types of IBD, and responses to therapy, lead author Gillian E. Jacobsen a MD/PhD candidate at the University of Miami and colleagues reported.

In an article in Gastro Hep Advances, the investigators wrote that “lamina propria phagocytes along with epithelial cells represent a first line of defense and play a balancing act between tolerance toward commensal microbes and generation of immune responses toward pathogenic microorganisms. ... Inappropriate responses by lamina propria phagocytes have been linked to IBD.”

To better understand these responses, the researchers collected 111 gut mucosal biopsies from 54 patients with IBD, among whom 59% were taking biologics, 72% had inflammation in at least one biopsy site, and 41% had previously used at least one other biologic. Samples were analyzed to determine cell phenotypes, gene expression, and cytokine responses to in vitro Janus kinase (JAK) inhibitor exposure.

Ms. Jacobsen and colleagues noted that most reports that address the function of phagocytes focus on circulating dendritic cells, monocytes, or monocyte-derived macrophages, rather than on resident phagocyte populations located in the lamina propria. However, these circulating cells “do not reflect intestinal inflammation, or whole tissue biopsies.”

Phagocytes based on CD11b expression and phenotyped CD11b+-enriched cells using flow cytometry were identified. In samples with active inflammation, cells were most often granulocytes (45.5%), followed by macrophages (22.6%) and monocytes (9.4%). Uninflamed samples had a slightly lower proportion of granulocytes (33.6%), about the same proportion of macrophages (22.7%), and a higher rate of B cells (15.6% vs. 9.0%).

Ms. Jacobsen and colleagues highlighted the absolute uptick in granulocytes, including neutrophils.

“Neutrophilic infiltration is a major indicator of IBD activity and may be critically linked to ongoing inflammation,” they wrote. “These data demonstrate that CD11b+ enrichment reflects the inflammatory state of the biopsies.”

The investigators also showed that transcriptional profiles of lamina propria CD11b+ cells differed “greatly” between colon and ileum, which suggested that “the location or cellular environment plays a marked role in determining the gene expression of phagocytes.”

CD11b+ cell gene expression profiles also correlated with ulcerative colitis versus Crohn’s disease, although the researchers noted that these patterns were less pronounced than correlations with inflammatory states

“There are pathways common to inflammation regardless of the IBD type that could be used as markers of inflammation or targets for therapy.”

Comparing colon samples from patients who responded to anti–tumor necrosis factor therapy with those who were refractory to anti-TNF therapy revealed significant associations between response type and 52 differentially expressed genes.

“These genes were mostly immunoglobulin genes up-regulated in the anti–TNF-treated inflamed colon, suggesting that CD11b+ B cells may play a role in medication refractoriness.”

Evaluating inflamed colon and anti-TNF refractory ileum revealed differential expression of OSM, a known marker of TNF-resistant disease, as well as TREM1, a proinflammatory marker. In contrast, NTS genes showed high expression in uninflamed samples on anti-TNF therapy. The researchers noted that these findings “may be used to build precision medicine approaches in IBD.”

Further experiments showed that in vitro exposure of anti-TNF refractory samples to JAK inhibitors resulted in significantly reduced secretion of interleukin-8 and TNF-alpha.

“Our study provides functional data that JAK inhibition with tofacitinib (JAK1/JAK3) or ruxolitinib (JAK1/JAK2) inhibits lipopolysaccharide-induced cytokine production even in TNF-refractory samples,” the researchers wrote. “These data inform the response of patients to JAK inhibitors, including those refractory to other treatments.”

The study was supported by Pfizer, the National Institute of Diabetes and Digestive and Kidney Diseases, the Micky & Madeleine Arison Family Foundation Crohn’s & Colitis Discovery Laboratory, and Martin Kalser Chair in Gastroenterology at the University of Miami. The investigators disclosed additional relationships with Takeda, Abbvie, Eli Lilly, and others.

Burnout and other forms of psychosocial distress are common among health care professionals necessitating measures to promote well-being and reduce burnout.¹ Studies have shown that nonmedical reading is associated with low burnout and that small group study sections can promote wellness.^2,3 Narrative medicine, which proposes a model for humane and effective medical practice, advocates for the necessity of narrative competence.

Short Story Club

Narrative competence is the ability to acknowledge, interpret, and act on the stories of others. The narrative skill of close reading also encourages reflective practice, equipping practitioners to better weather the tides of illness.⁴ In our case, we formed a short story club intervention to closely read, or read and reflect, on literary fiction. We explored how reading and reflecting would result in profound changes in thinking and feeling and noted different ways by which they can cause such well-being. We describe here the 7 ways in which stories led us to increase bonding, improve empathy, and promote meaning in medicine.

Slowing Down

The short story club helped to bond us together and increase our sense of meaning in medicine by slowing us down. One member of the group likened the experience to increasing the pixels in a painting, thereby improving the resolution and seeing more clearly. Another member mentioned the experience as a form of meditation in slowing down the brain, breathing in the story, and breathing out impressions. One story by Anatole Broyard emphasized the importance of slowing down and “brooding” over a patient.⁵ The author describes his experience as a prostate cancer patient, in which his body was treated but his story was ignored. He begged his doctors to pay more attention to his story to listen and to brood over him. This story was enlightening to us; we saw how desperate our patients are to tell their stories, and for us to hear their stories.

Mirrors and Windows

Another way reading and reflecting on short stories helped was by reflecting our practices to ourselves, as though looking into a mirror to see ourselves and out of a window to see others. We found that stories mirrored our own world and allowed us to discuss issues close to us without the embarrassment or stigma of owning the story. In one session we read “The Doctor’s Visit” by Anton Chekhov.⁶ Some of the members resonated with the doctor of this story who awkwardly attended to his lady patient whose son was dying of a brain tumor. The doctor was nervous, insecure, and unable to express any empathy. He was also the father of the child who was dying and refused to admit any responsibility. One member of the group stated that he could relate to the doctor’s insecurities and mentioned that he too felt insecure and even sometimes felt like an imposter. This led to a discussion of insecurities, ways to bolster self-confidence, and ways to accept and respect limitations. This was a conversation that may not have taken place without the story as anchor to discuss insecurities that we individually may not have been willing to admit to the group.

In a different session, we discussed the story “Interpreter of Maladies” by Jhumpa Lahiri in which a settled Indian American family returns to India to tour and learn about their heritage from a guide (the interpreter of maladies) who interpreted the culture for them.⁷ The family professed to be interested in knowing about the culture but could not concentrate: the wife stayed busy flirting with the guide and revealing outrageous secrets to him, the children were engrossed in their squabbles, and the father was essentially absent taking photographs as souvenirs instead of seeing the sites firsthand. Some of the members of the group were Indian American and could relate to the alienation from their home and nostalgia for their country, while others could relate to the same alienation, albeit from other cultures and countries. This allowed us to talk about deeply personal topics, without having to own the topic or reveal personal issues. The discussion led to a deep understanding and empathy for us and our colleagues knowing the pain of alienation that some of them felt but could not discuss.

The stories also served as windows into the world of others which enabled us to see and become the other. For example, in one session we reflected on “Babylon Revisited” by F. Scott Fitzgerald.⁸ In this story, an American man returns to Paris after the Great Depression and recalls his life as a young artist in the American artist expatriate community of Paris in the 1920s and 1930s. During that time, he partied, drank in excess, lost his wife to pneumonia (for which he was at least partially responsible), lost custody of his daughter, and lost his fortune. As he returned to Paris to try to reclaim his daughter, we feel his pain as he tries but fails to overcome chronic alcoholism, sexual indiscretions, and losses. This gave rise to discussion of losses in general as we became one with the main character. This increased our empathy for others in a way that could not have been possible without this short story as anchor.

In another session we reflected on “Hills Like White Elephants” by Ernest Hemingway, in which a man is waiting for a train while proposing his girlfriend get an abortion.⁹ She agonizes over her choices and makes no decision in this story. Yet, we the reader could “become” the woman in the story faced with hard choices of having a baby but losing the man she loves, or having an abortion and maybe losing him anyway. In becoming this woman, we could experience the complex emotions and feel an experience of the other.

Exploring the Taboo

A third aspect of the club was enabling discussion of controversial topics. There were topics that arose in the group which never would have arisen in clinical practice discussions. These had to do with the taboo topics such as romantic attachments to patients. We read “The Caves of Lascaux” and reflected on the story of a young doctor who becomes enamored and obsessed with his beautiful but dying patient.¹⁰ He becomes so obsessed with her that he almost abandons his wife, family, and stable livelihood to descend with her into the caves. This story gave rise to discussions about romantic attachment to patients and how to handle and extricate one from the situation. The senior doctors explained some of their relevant experiences and how they either transferred care or sought counseling to extricate themselves from a potentially dangerous situation, especially when they too fell under the spell of forbidden romance.

Moral Grounding

These sessions also served to define the moral basis of our own practice. Much of health care psychosocial distress is related to moral injury in which health care professionals do the wrong thing or fail to do the right thing at the right time, due to external pressures related to financial or other gains. Reading and reflecting put us face-to-face with moral dilemmas and let us find our moral grounding. In reading “The Haircut” by Ring Lardner, we explored the disruptive town scoundrel who harassed and tortured his friends and neighbors but in such outrageous ways that he was considered a comedian rather than an abuser.¹¹ Despite his hurtful acts, the townspeople (including the narrator) considered him a clown and laughed at his racist and sexist statements as well as his tricks.He faced no consequences such as confrontation, until the end when fate caught up. This story gave rise to a discussion of how we handle unkind, racist, sexist, or other comments which are disguised as humor, and to what extent we tolerate such controversial behavior. Do we go along with the scoundrel and laugh, or do we confront such people and insist that they respect and honor other people? The story sensitized the group to the ways in which prejudice and racism or sexism can be masked as humor, and to consider our moral responsibilities in society.

In another session we read and reflected on “Three Questions” by Leo Tolstoy.¹² In this story, a king travels to another territory but gets distracted by helping a neighbor in need, and thereby inadvertently and fortunately avoids the trap that had been devised to kill him. The author gives us his moral basis by asking and answering 3 questions: Who is the most important person? What is the most important thing to do? What is the most important thing to do now? His answers provided his moral grounding. We discussed our answers and the basis of our moral grounding, whether it be the injunction do no harm, the more complex religious backgrounds of our childhood, or otherwise.

Symbols and Metaphors

The practice of reading and reflecting also taught us symbols and metaphors. Symbols and metaphors are the essence of storytelling, and they provide keys to understanding people. We sought out and studied the metaphors and symbols in each of the stories we read. In “I Stood There Ironing”, a woman is ironing as she is being questioned by a social worker on the upbringing of her first daughter, and its impact on her psychosocial distress.¹³ The woman remembers the hardships in raising her daughter and her neglect and abuse of the child due to circumstances beyond her control. She keeps ironing back and forth as she recounts the ways in which she neglected her child. The ironing provides a metaphor for attempting to straighten out her life and for recognizing finally at the end of the story that the daughter should not be the dress, under which her iron is pressing. This gave rise to a discussion of metaphors in our lives and the meanings they carry.

Problem-solving Guide

A sixth way the reflections helped was by serving as a guide to solving our problems. Some of the stories we read resonated deeply with members of the group and provided guides to solving problems. In one meeting we discussed “Those Are as Brothers” by Nancy Hale, a story in which a Nazi concentration camp survivor finds refuge in a country home and develops a friendship with a survivor of an abusive marriage.¹⁴ Reading and reflecting on this story enabled us to see the impact of trauma on ourselves, our life choices, professions, ways of being, philosophies, and even on our next generation. The story was personal for several members of the group, some of whom were second-generation Holocaust survivors, and for one who admitted to severe trauma as a child. Discussing our backgrounds together, we empathized with each other and helped each other heal. The story also provided a guide to healing from trauma, as its title indicates: sharing stories together can be a way to heal. The solidarity of standing together, as brothers, heals. The concentration camp survivor was mistreated in his job, but the abuse trauma victim rushes to his defense and vows her friendship and support. This soothed his soul and healed his mind. The guidance is clear: we can do the same, find friends, treat them like brothers, support each other and heal.

Bonding Through Shared Experience

The final and possibly most important way in which the club helped was by serving as an adventure to bond group members together through shared experience. We believe that literature can capture imagination in extraordinary ways and provide an opportunity to undertake remarkable journeys. As such, together we traveled to the ends of the earth from the beginning to the end of time and beyond. We traveled through the hills of Africa, meandered in the streets of Russia and Poland, watched the racetracks in Italy, toured the Taj Mahal in India, and descended into the caves of Lascaux, all while working in Little Rock, Arkansas. We shared a wide array of experiences together, which allowed us to know ourselves and others better, to share stories, and to develop a common vision, common ground, and common culture.

Conclusions

Through reading and reflecting on stories, we bonded as a group, increased our empathy for each other and others, and found meaning in medicine. Other studies have shown that participation in small study groups promote physician well-being, improve job satisfaction, and decrease burnout.³ We synergized this effort by reading nonmedical stories on a consistent basis, hoping to gain resilience to psychosocial distress.³ We chose short stories rather than novels to minimize any stress from excess reading. Combining these interventions, small group studies and nonmedical reading, into a single intervention as is typical in the practice of narrative medicine may provide a way to improve team functioning.

This pilot study showed that it is possible to form short story clubs even in a busy oncology program and that such programs benefit participants in a variety of ways with no apparent adverse effects. Further research is needed to study the impact of reading and reflecting on medical work in small study groups in larger numbers of subjects and to evaluate their impact on burnout. Further study is also needed to develop narrative medicine curricula that best address the needs of particular subspecialties and to determine the optimal conditions for implementation.

Acknowledgments

The authors acknowledge Dr. Erick Messias for inspiring and encouraging this project at the University of Arkansas for Medical Sciences where he was Associate Dean for Faculty Affairs. He is presently Chair of Psychiatry and Behavioral Neuroscience at the St. Louis University School of Medicine, St. Louis, Missouri.

Burnout and other forms of psychosocial distress are common among health care professionals necessitating measures to promote well-being and reduce burnout.¹ Studies have shown that nonmedical reading is associated with low burnout and that small group study sections can promote wellness.^2,3 Narrative medicine, which proposes a model for humane and effective medical practice, advocates for the necessity of narrative competence.

Short Story Club

Narrative competence is the ability to acknowledge, interpret, and act on the stories of others. The narrative skill of close reading also encourages reflective practice, equipping practitioners to better weather the tides of illness.⁴ In our case, we formed a short story club intervention to closely read, or read and reflect, on literary fiction. We explored how reading and reflecting would result in profound changes in thinking and feeling and noted different ways by which they can cause such well-being. We describe here the 7 ways in which stories led us to increase bonding, improve empathy, and promote meaning in medicine.

Slowing Down

The short story club helped to bond us together and increase our sense of meaning in medicine by slowing us down. One member of the group likened the experience to increasing the pixels in a painting, thereby improving the resolution and seeing more clearly. Another member mentioned the experience as a form of meditation in slowing down the brain, breathing in the story, and breathing out impressions. One story by Anatole Broyard emphasized the importance of slowing down and “brooding” over a patient.⁵ The author describes his experience as a prostate cancer patient, in which his body was treated but his story was ignored. He begged his doctors to pay more attention to his story to listen and to brood over him. This story was enlightening to us; we saw how desperate our patients are to tell their stories, and for us to hear their stories.

Mirrors and Windows

Another way reading and reflecting on short stories helped was by reflecting our practices to ourselves, as though looking into a mirror to see ourselves and out of a window to see others. We found that stories mirrored our own world and allowed us to discuss issues close to us without the embarrassment or stigma of owning the story. In one session we read “The Doctor’s Visit” by Anton Chekhov.⁶ Some of the members resonated with the doctor of this story who awkwardly attended to his lady patient whose son was dying of a brain tumor. The doctor was nervous, insecure, and unable to express any empathy. He was also the father of the child who was dying and refused to admit any responsibility. One member of the group stated that he could relate to the doctor’s insecurities and mentioned that he too felt insecure and even sometimes felt like an imposter. This led to a discussion of insecurities, ways to bolster self-confidence, and ways to accept and respect limitations. This was a conversation that may not have taken place without the story as anchor to discuss insecurities that we individually may not have been willing to admit to the group.

In a different session, we discussed the story “Interpreter of Maladies” by Jhumpa Lahiri in which a settled Indian American family returns to India to tour and learn about their heritage from a guide (the interpreter of maladies) who interpreted the culture for them.⁷ The family professed to be interested in knowing about the culture but could not concentrate: the wife stayed busy flirting with the guide and revealing outrageous secrets to him, the children were engrossed in their squabbles, and the father was essentially absent taking photographs as souvenirs instead of seeing the sites firsthand. Some of the members of the group were Indian American and could relate to the alienation from their home and nostalgia for their country, while others could relate to the same alienation, albeit from other cultures and countries. This allowed us to talk about deeply personal topics, without having to own the topic or reveal personal issues. The discussion led to a deep understanding and empathy for us and our colleagues knowing the pain of alienation that some of them felt but could not discuss.

The stories also served as windows into the world of others which enabled us to see and become the other. For example, in one session we reflected on “Babylon Revisited” by F. Scott Fitzgerald.⁸ In this story, an American man returns to Paris after the Great Depression and recalls his life as a young artist in the American artist expatriate community of Paris in the 1920s and 1930s. During that time, he partied, drank in excess, lost his wife to pneumonia (for which he was at least partially responsible), lost custody of his daughter, and lost his fortune. As he returned to Paris to try to reclaim his daughter, we feel his pain as he tries but fails to overcome chronic alcoholism, sexual indiscretions, and losses. This gave rise to discussion of losses in general as we became one with the main character. This increased our empathy for others in a way that could not have been possible without this short story as anchor.

In another session we reflected on “Hills Like White Elephants” by Ernest Hemingway, in which a man is waiting for a train while proposing his girlfriend get an abortion.⁹ She agonizes over her choices and makes no decision in this story. Yet, we the reader could “become” the woman in the story faced with hard choices of having a baby but losing the man she loves, or having an abortion and maybe losing him anyway. In becoming this woman, we could experience the complex emotions and feel an experience of the other.

Exploring the Taboo

A third aspect of the club was enabling discussion of controversial topics. There were topics that arose in the group which never would have arisen in clinical practice discussions. These had to do with the taboo topics such as romantic attachments to patients. We read “The Caves of Lascaux” and reflected on the story of a young doctor who becomes enamored and obsessed with his beautiful but dying patient.¹⁰ He becomes so obsessed with her that he almost abandons his wife, family, and stable livelihood to descend with her into the caves. This story gave rise to discussions about romantic attachment to patients and how to handle and extricate one from the situation. The senior doctors explained some of their relevant experiences and how they either transferred care or sought counseling to extricate themselves from a potentially dangerous situation, especially when they too fell under the spell of forbidden romance.

Moral Grounding

These sessions also served to define the moral basis of our own practice. Much of health care psychosocial distress is related to moral injury in which health care professionals do the wrong thing or fail to do the right thing at the right time, due to external pressures related to financial or other gains. Reading and reflecting put us face-to-face with moral dilemmas and let us find our moral grounding. In reading “The Haircut” by Ring Lardner, we explored the disruptive town scoundrel who harassed and tortured his friends and neighbors but in such outrageous ways that he was considered a comedian rather than an abuser.¹¹ Despite his hurtful acts, the townspeople (including the narrator) considered him a clown and laughed at his racist and sexist statements as well as his tricks.He faced no consequences such as confrontation, until the end when fate caught up. This story gave rise to a discussion of how we handle unkind, racist, sexist, or other comments which are disguised as humor, and to what extent we tolerate such controversial behavior. Do we go along with the scoundrel and laugh, or do we confront such people and insist that they respect and honor other people? The story sensitized the group to the ways in which prejudice and racism or sexism can be masked as humor, and to consider our moral responsibilities in society.

In another session we read and reflected on “Three Questions” by Leo Tolstoy.¹² In this story, a king travels to another territory but gets distracted by helping a neighbor in need, and thereby inadvertently and fortunately avoids the trap that had been devised to kill him. The author gives us his moral basis by asking and answering 3 questions: Who is the most important person? What is the most important thing to do? What is the most important thing to do now? His answers provided his moral grounding. We discussed our answers and the basis of our moral grounding, whether it be the injunction do no harm, the more complex religious backgrounds of our childhood, or otherwise.

Symbols and Metaphors

The practice of reading and reflecting also taught us symbols and metaphors. Symbols and metaphors are the essence of storytelling, and they provide keys to understanding people. We sought out and studied the metaphors and symbols in each of the stories we read. In “I Stood There Ironing”, a woman is ironing as she is being questioned by a social worker on the upbringing of her first daughter, and its impact on her psychosocial distress.¹³ The woman remembers the hardships in raising her daughter and her neglect and abuse of the child due to circumstances beyond her control. She keeps ironing back and forth as she recounts the ways in which she neglected her child. The ironing provides a metaphor for attempting to straighten out her life and for recognizing finally at the end of the story that the daughter should not be the dress, under which her iron is pressing. This gave rise to a discussion of metaphors in our lives and the meanings they carry.

Problem-solving Guide

A sixth way the reflections helped was by serving as a guide to solving our problems. Some of the stories we read resonated deeply with members of the group and provided guides to solving problems. In one meeting we discussed “Those Are as Brothers” by Nancy Hale, a story in which a Nazi concentration camp survivor finds refuge in a country home and develops a friendship with a survivor of an abusive marriage.¹⁴ Reading and reflecting on this story enabled us to see the impact of trauma on ourselves, our life choices, professions, ways of being, philosophies, and even on our next generation. The story was personal for several members of the group, some of whom were second-generation Holocaust survivors, and for one who admitted to severe trauma as a child. Discussing our backgrounds together, we empathized with each other and helped each other heal. The story also provided a guide to healing from trauma, as its title indicates: sharing stories together can be a way to heal. The solidarity of standing together, as brothers, heals. The concentration camp survivor was mistreated in his job, but the abuse trauma victim rushes to his defense and vows her friendship and support. This soothed his soul and healed his mind. The guidance is clear: we can do the same, find friends, treat them like brothers, support each other and heal.

Bonding Through Shared Experience

The final and possibly most important way in which the club helped was by serving as an adventure to bond group members together through shared experience. We believe that literature can capture imagination in extraordinary ways and provide an opportunity to undertake remarkable journeys. As such, together we traveled to the ends of the earth from the beginning to the end of time and beyond. We traveled through the hills of Africa, meandered in the streets of Russia and Poland, watched the racetracks in Italy, toured the Taj Mahal in India, and descended into the caves of Lascaux, all while working in Little Rock, Arkansas. We shared a wide array of experiences together, which allowed us to know ourselves and others better, to share stories, and to develop a common vision, common ground, and common culture.

Conclusions

Through reading and reflecting on stories, we bonded as a group, increased our empathy for each other and others, and found meaning in medicine. Other studies have shown that participation in small study groups promote physician well-being, improve job satisfaction, and decrease burnout.³ We synergized this effort by reading nonmedical stories on a consistent basis, hoping to gain resilience to psychosocial distress.³ We chose short stories rather than novels to minimize any stress from excess reading. Combining these interventions, small group studies and nonmedical reading, into a single intervention as is typical in the practice of narrative medicine may provide a way to improve team functioning.

This pilot study showed that it is possible to form short story clubs even in a busy oncology program and that such programs benefit participants in a variety of ways with no apparent adverse effects. Further research is needed to study the impact of reading and reflecting on medical work in small study groups in larger numbers of subjects and to evaluate their impact on burnout. Further study is also needed to develop narrative medicine curricula that best address the needs of particular subspecialties and to determine the optimal conditions for implementation.

Acknowledgments

The authors acknowledge Dr. Erick Messias for inspiring and encouraging this project at the University of Arkansas for Medical Sciences where he was Associate Dean for Faculty Affairs. He is presently Chair of Psychiatry and Behavioral Neuroscience at the St. Louis University School of Medicine, St. Louis, Missouri.

Burnout and other forms of psychosocial distress are common among health care professionals necessitating measures to promote well-being and reduce burnout.¹ Studies have shown that nonmedical reading is associated with low burnout and that small group study sections can promote wellness.^2,3 Narrative medicine, which proposes a model for humane and effective medical practice, advocates for the necessity of narrative competence.

Short Story Club

Narrative competence is the ability to acknowledge, interpret, and act on the stories of others. The narrative skill of close reading also encourages reflective practice, equipping practitioners to better weather the tides of illness.⁴ In our case, we formed a short story club intervention to closely read, or read and reflect, on literary fiction. We explored how reading and reflecting would result in profound changes in thinking and feeling and noted different ways by which they can cause such well-being. We describe here the 7 ways in which stories led us to increase bonding, improve empathy, and promote meaning in medicine.

Slowing Down

The short story club helped to bond us together and increase our sense of meaning in medicine by slowing us down. One member of the group likened the experience to increasing the pixels in a painting, thereby improving the resolution and seeing more clearly. Another member mentioned the experience as a form of meditation in slowing down the brain, breathing in the story, and breathing out impressions. One story by Anatole Broyard emphasized the importance of slowing down and “brooding” over a patient.⁵ The author describes his experience as a prostate cancer patient, in which his body was treated but his story was ignored. He begged his doctors to pay more attention to his story to listen and to brood over him. This story was enlightening to us; we saw how desperate our patients are to tell their stories, and for us to hear their stories.

Mirrors and Windows

Another way reading and reflecting on short stories helped was by reflecting our practices to ourselves, as though looking into a mirror to see ourselves and out of a window to see others. We found that stories mirrored our own world and allowed us to discuss issues close to us without the embarrassment or stigma of owning the story. In one session we read “The Doctor’s Visit” by Anton Chekhov.⁶ Some of the members resonated with the doctor of this story who awkwardly attended to his lady patient whose son was dying of a brain tumor. The doctor was nervous, insecure, and unable to express any empathy. He was also the father of the child who was dying and refused to admit any responsibility. One member of the group stated that he could relate to the doctor’s insecurities and mentioned that he too felt insecure and even sometimes felt like an imposter. This led to a discussion of insecurities, ways to bolster self-confidence, and ways to accept and respect limitations. This was a conversation that may not have taken place without the story as anchor to discuss insecurities that we individually may not have been willing to admit to the group.

In a different session, we discussed the story “Interpreter of Maladies” by Jhumpa Lahiri in which a settled Indian American family returns to India to tour and learn about their heritage from a guide (the interpreter of maladies) who interpreted the culture for them.⁷ The family professed to be interested in knowing about the culture but could not concentrate: the wife stayed busy flirting with the guide and revealing outrageous secrets to him, the children were engrossed in their squabbles, and the father was essentially absent taking photographs as souvenirs instead of seeing the sites firsthand. Some of the members of the group were Indian American and could relate to the alienation from their home and nostalgia for their country, while others could relate to the same alienation, albeit from other cultures and countries. This allowed us to talk about deeply personal topics, without having to own the topic or reveal personal issues. The discussion led to a deep understanding and empathy for us and our colleagues knowing the pain of alienation that some of them felt but could not discuss.

The stories also served as windows into the world of others which enabled us to see and become the other. For example, in one session we reflected on “Babylon Revisited” by F. Scott Fitzgerald.⁸ In this story, an American man returns to Paris after the Great Depression and recalls his life as a young artist in the American artist expatriate community of Paris in the 1920s and 1930s. During that time, he partied, drank in excess, lost his wife to pneumonia (for which he was at least partially responsible), lost custody of his daughter, and lost his fortune. As he returned to Paris to try to reclaim his daughter, we feel his pain as he tries but fails to overcome chronic alcoholism, sexual indiscretions, and losses. This gave rise to discussion of losses in general as we became one with the main character. This increased our empathy for others in a way that could not have been possible without this short story as anchor.

In another session we reflected on “Hills Like White Elephants” by Ernest Hemingway, in which a man is waiting for a train while proposing his girlfriend get an abortion.⁹ She agonizes over her choices and makes no decision in this story. Yet, we the reader could “become” the woman in the story faced with hard choices of having a baby but losing the man she loves, or having an abortion and maybe losing him anyway. In becoming this woman, we could experience the complex emotions and feel an experience of the other.

Exploring the Taboo

A third aspect of the club was enabling discussion of controversial topics. There were topics that arose in the group which never would have arisen in clinical practice discussions. These had to do with the taboo topics such as romantic attachments to patients. We read “The Caves of Lascaux” and reflected on the story of a young doctor who becomes enamored and obsessed with his beautiful but dying patient.¹⁰ He becomes so obsessed with her that he almost abandons his wife, family, and stable livelihood to descend with her into the caves. This story gave rise to discussions about romantic attachment to patients and how to handle and extricate one from the situation. The senior doctors explained some of their relevant experiences and how they either transferred care or sought counseling to extricate themselves from a potentially dangerous situation, especially when they too fell under the spell of forbidden romance.

Moral Grounding

These sessions also served to define the moral basis of our own practice. Much of health care psychosocial distress is related to moral injury in which health care professionals do the wrong thing or fail to do the right thing at the right time, due to external pressures related to financial or other gains. Reading and reflecting put us face-to-face with moral dilemmas and let us find our moral grounding. In reading “The Haircut” by Ring Lardner, we explored the disruptive town scoundrel who harassed and tortured his friends and neighbors but in such outrageous ways that he was considered a comedian rather than an abuser.¹¹ Despite his hurtful acts, the townspeople (including the narrator) considered him a clown and laughed at his racist and sexist statements as well as his tricks.He faced no consequences such as confrontation, until the end when fate caught up. This story gave rise to a discussion of how we handle unkind, racist, sexist, or other comments which are disguised as humor, and to what extent we tolerate such controversial behavior. Do we go along with the scoundrel and laugh, or do we confront such people and insist that they respect and honor other people? The story sensitized the group to the ways in which prejudice and racism or sexism can be masked as humor, and to consider our moral responsibilities in society.

In another session we read and reflected on “Three Questions” by Leo Tolstoy.¹² In this story, a king travels to another territory but gets distracted by helping a neighbor in need, and thereby inadvertently and fortunately avoids the trap that had been devised to kill him. The author gives us his moral basis by asking and answering 3 questions: Who is the most important person? What is the most important thing to do? What is the most important thing to do now? His answers provided his moral grounding. We discussed our answers and the basis of our moral grounding, whether it be the injunction do no harm, the more complex religious backgrounds of our childhood, or otherwise.

Symbols and Metaphors

The practice of reading and reflecting also taught us symbols and metaphors. Symbols and metaphors are the essence of storytelling, and they provide keys to understanding people. We sought out and studied the metaphors and symbols in each of the stories we read. In “I Stood There Ironing”, a woman is ironing as she is being questioned by a social worker on the upbringing of her first daughter, and its impact on her psychosocial distress.¹³ The woman remembers the hardships in raising her daughter and her neglect and abuse of the child due to circumstances beyond her control. She keeps ironing back and forth as she recounts the ways in which she neglected her child. The ironing provides a metaphor for attempting to straighten out her life and for recognizing finally at the end of the story that the daughter should not be the dress, under which her iron is pressing. This gave rise to a discussion of metaphors in our lives and the meanings they carry.

Problem-solving Guide

A sixth way the reflections helped was by serving as a guide to solving our problems. Some of the stories we read resonated deeply with members of the group and provided guides to solving problems. In one meeting we discussed “Those Are as Brothers” by Nancy Hale, a story in which a Nazi concentration camp survivor finds refuge in a country home and develops a friendship with a survivor of an abusive marriage.¹⁴ Reading and reflecting on this story enabled us to see the impact of trauma on ourselves, our life choices, professions, ways of being, philosophies, and even on our next generation. The story was personal for several members of the group, some of whom were second-generation Holocaust survivors, and for one who admitted to severe trauma as a child. Discussing our backgrounds together, we empathized with each other and helped each other heal. The story also provided a guide to healing from trauma, as its title indicates: sharing stories together can be a way to heal. The solidarity of standing together, as brothers, heals. The concentration camp survivor was mistreated in his job, but the abuse trauma victim rushes to his defense and vows her friendship and support. This soothed his soul and healed his mind. The guidance is clear: we can do the same, find friends, treat them like brothers, support each other and heal.

Bonding Through Shared Experience

The final and possibly most important way in which the club helped was by serving as an adventure to bond group members together through shared experience. We believe that literature can capture imagination in extraordinary ways and provide an opportunity to undertake remarkable journeys. As such, together we traveled to the ends of the earth from the beginning to the end of time and beyond. We traveled through the hills of Africa, meandered in the streets of Russia and Poland, watched the racetracks in Italy, toured the Taj Mahal in India, and descended into the caves of Lascaux, all while working in Little Rock, Arkansas. We shared a wide array of experiences together, which allowed us to know ourselves and others better, to share stories, and to develop a common vision, common ground, and common culture.

Conclusions

Through reading and reflecting on stories, we bonded as a group, increased our empathy for each other and others, and found meaning in medicine. Other studies have shown that participation in small study groups promote physician well-being, improve job satisfaction, and decrease burnout.³ We synergized this effort by reading nonmedical stories on a consistent basis, hoping to gain resilience to psychosocial distress.³ We chose short stories rather than novels to minimize any stress from excess reading. Combining these interventions, small group studies and nonmedical reading, into a single intervention as is typical in the practice of narrative medicine may provide a way to improve team functioning.

This pilot study showed that it is possible to form short story clubs even in a busy oncology program and that such programs benefit participants in a variety of ways with no apparent adverse effects. Further research is needed to study the impact of reading and reflecting on medical work in small study groups in larger numbers of subjects and to evaluate their impact on burnout. Further study is also needed to develop narrative medicine curricula that best address the needs of particular subspecialties and to determine the optimal conditions for implementation.

Acknowledgments

The authors acknowledge Dr. Erick Messias for inspiring and encouraging this project at the University of Arkansas for Medical Sciences where he was Associate Dean for Faculty Affairs. He is presently Chair of Psychiatry and Behavioral Neuroscience at the St. Louis University School of Medicine, St. Louis, Missouri.

Exposure to per- and polyfluoroalkyl substances (PFAS) - a class of widely used synthetic chemicals dubbed “forever chemicals” - can lead to liver damage and may be a culprit in rising rates of nonalcoholic fatty liver disease (NAFLD), say the authors of a comprehensive evidence review.

They found “consistent” evidence for PFAS hepatotoxicity from rodent studies. In addition, exposure to PFAS was found to be associated with markers of liver function in observational studies in people.

The review, published online in Environmental Health Perspectives, may be the first systematic analysis of PFAS exposure and liver damage.

Possible contributor to growing NAFLD epidemic

In their analysis, the authors included 85 rodent studies and 24 epidemiologic studies, primarily involving people from the United States and largely focusing on four “legacy” PFAS: perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), perfluorononanoic acid (PFNA), and perfluorohexanesulfonic acid (PFHxS).

Meta-analyses of human studies found that higher levels of alanine aminotransferase were significantly associated with exposure to three of the older chemicals – PFOA, PFOS, and PFNA.

The “positive” and “convincing” associations between exposure to these synthetic chemicals and higher ALT levels suggest that exposure may contribute to the growing NAFLD epidemic, the researchers write.

Exposure to one of the chemicals, PFOA, was also associated with higher aspartate aminotransferase and gamma-glutamyl transferase levels in people.

In rodents, exposure to these synthetic chemicals consistently resulted in higher ALT levels and steatosis.

“The mechanism is not well understood yet, but there are a few proposed theories,” first author Elizabeth Costello, MPH, PhD student, department of population and public health sciences, University of Southern California, Los Angeles, told this news organization.

“PFAS are similar to fatty acids in chemical structure, so it’s possible that they activate some of the same receptors or otherwise interfere with fat metabolism. This might lead to inflammation or fat accumulation in the liver,” Ms. Costello explained.

People widely exposed

PFAS are ubiquitous in the environment. They have been detected in the blood of most people and have been linked to a variety of health concerns. Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and even drinking water.

“We are exposed to PFAS in so many ways – through water, food, and products we use. It can be very difficult for individuals to control their own exposure,” Ms. Costello commented.

“At this point, it’s important to look for ways to remove PFAS from the environment and phase them out of our products and carefully consider the safety of any replacement chemicals,” she said.

Although most of the research to date has been limited to the four older PFAS (PFOA, PFOS, PFNA, and PFHxS), there are thousands of different PFAS chemicals.

“We don’t know very much about the effects of exposure to multiple PFAS at the same time or how newer replacement PFAS might affect liver disease or other health conditions,” Ms. Costello said.

Reached for comment, Lisa B. VanWagner, MD, with Northwestern University, Chicago, said this analysis is “very interesting,” but she is also “left wondering how we could do anything since it seems from my reading that these chemicals are ubiquitous and used regularly in the environment.”

Dr. VanWagner, who was not involved in the study, said the major limitation is the small number of human studies and the high heterogeneity between studies, “meaning it is hard to come to a firm conclusion about whether what has been observed in the animal studies does truly apply to humans.

“Overall, this study provides important proof of concept for future work to look more specifically at PFAS exposure, and more specific markers of fatty liver disease and liver damage, like liver biopsy, are needed in humans,” Dr. VanWagner said.

“If data accumulate showing that these chemicals do in fact contribute to fatty liver and worsening inflammation or liver damage as a result of exposure, then public health interventions to remove or reduce use of these chemicals could have wide-ranging public health effects,” Dr. VanWagner added.

Further research needed

The authors of an invited perspective published with the study say it underscores the “urgent need for further research and for immediate and reasonable public health action.”

“This work firmly puts PFAS exposure on the list of persistent pollutants, such as polychlorinated biphenyls, that cause hepatotoxicity and whose mechanism is linked to steatosis,” write Alan Ducatman, MD. MSc, with West Virginia University School of Public Health, Morgantown, and Suzanne Fenton, PhD, MS, with the National Institute of Environmental Health Sciences, Research Triangle Park, N.C.

They say other important questions raised by this review include whether individuals who are overweight or obese and those with diabetes are more susceptible to PFAS hepatoxicity, which “replacement” or emerging PFAS can cause liver damage, and whether high doses cause different kinds of liver toxicity than low doses.

“GenX, a current replacement [chemical] for PFOA, has shown significant hepatotoxicity in several recent experimental studies, suggesting it may not be a safe replacement,” they point out.

“A significant challenge will be deciding which of the multiple metabolic pathways altered by PFAS are most important and predictive for induction of liver damage and for progression of liver disease, so that emerging PFAS may be screened for hepatotoxicity prior to entering the market,” Dr. Ducatman and Dr. Fenton conclude.

Support for this research was provided by the National Institute of Environmental Health Science, part of the National Institutes of Health, and the U.S. Department of Agriculture National Institute of Food and Agriculture. Dr. Costello, Dr. VanWagner, Dr. Ducatman, and Dr. Fenton report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Exposure to per- and polyfluoroalkyl substances (PFAS) - a class of widely used synthetic chemicals dubbed “forever chemicals” - can lead to liver damage and may be a culprit in rising rates of nonalcoholic fatty liver disease (NAFLD), say the authors of a comprehensive evidence review.

They found “consistent” evidence for PFAS hepatotoxicity from rodent studies. In addition, exposure to PFAS was found to be associated with markers of liver function in observational studies in people.

The review, published online in Environmental Health Perspectives, may be the first systematic analysis of PFAS exposure and liver damage.

Possible contributor to growing NAFLD epidemic

In their analysis, the authors included 85 rodent studies and 24 epidemiologic studies, primarily involving people from the United States and largely focusing on four “legacy” PFAS: perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), perfluorononanoic acid (PFNA), and perfluorohexanesulfonic acid (PFHxS).

Meta-analyses of human studies found that higher levels of alanine aminotransferase were significantly associated with exposure to three of the older chemicals – PFOA, PFOS, and PFNA.

The “positive” and “convincing” associations between exposure to these synthetic chemicals and higher ALT levels suggest that exposure may contribute to the growing NAFLD epidemic, the researchers write.

Exposure to one of the chemicals, PFOA, was also associated with higher aspartate aminotransferase and gamma-glutamyl transferase levels in people.

In rodents, exposure to these synthetic chemicals consistently resulted in higher ALT levels and steatosis.

“The mechanism is not well understood yet, but there are a few proposed theories,” first author Elizabeth Costello, MPH, PhD student, department of population and public health sciences, University of Southern California, Los Angeles, told this news organization.

“PFAS are similar to fatty acids in chemical structure, so it’s possible that they activate some of the same receptors or otherwise interfere with fat metabolism. This might lead to inflammation or fat accumulation in the liver,” Ms. Costello explained.

People widely exposed

PFAS are ubiquitous in the environment. They have been detected in the blood of most people and have been linked to a variety of health concerns. Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and even drinking water.

“We are exposed to PFAS in so many ways – through water, food, and products we use. It can be very difficult for individuals to control their own exposure,” Ms. Costello commented.

“At this point, it’s important to look for ways to remove PFAS from the environment and phase them out of our products and carefully consider the safety of any replacement chemicals,” she said.

Although most of the research to date has been limited to the four older PFAS (PFOA, PFOS, PFNA, and PFHxS), there are thousands of different PFAS chemicals.

“We don’t know very much about the effects of exposure to multiple PFAS at the same time or how newer replacement PFAS might affect liver disease or other health conditions,” Ms. Costello said.

Reached for comment, Lisa B. VanWagner, MD, with Northwestern University, Chicago, said this analysis is “very interesting,” but she is also “left wondering how we could do anything since it seems from my reading that these chemicals are ubiquitous and used regularly in the environment.”

Dr. VanWagner, who was not involved in the study, said the major limitation is the small number of human studies and the high heterogeneity between studies, “meaning it is hard to come to a firm conclusion about whether what has been observed in the animal studies does truly apply to humans.

“Overall, this study provides important proof of concept for future work to look more specifically at PFAS exposure, and more specific markers of fatty liver disease and liver damage, like liver biopsy, are needed in humans,” Dr. VanWagner said.

“If data accumulate showing that these chemicals do in fact contribute to fatty liver and worsening inflammation or liver damage as a result of exposure, then public health interventions to remove or reduce use of these chemicals could have wide-ranging public health effects,” Dr. VanWagner added.

Further research needed

The authors of an invited perspective published with the study say it underscores the “urgent need for further research and for immediate and reasonable public health action.”

“This work firmly puts PFAS exposure on the list of persistent pollutants, such as polychlorinated biphenyls, that cause hepatotoxicity and whose mechanism is linked to steatosis,” write Alan Ducatman, MD. MSc, with West Virginia University School of Public Health, Morgantown, and Suzanne Fenton, PhD, MS, with the National Institute of Environmental Health Sciences, Research Triangle Park, N.C.

They say other important questions raised by this review include whether individuals who are overweight or obese and those with diabetes are more susceptible to PFAS hepatoxicity, which “replacement” or emerging PFAS can cause liver damage, and whether high doses cause different kinds of liver toxicity than low doses.

“GenX, a current replacement [chemical] for PFOA, has shown significant hepatotoxicity in several recent experimental studies, suggesting it may not be a safe replacement,” they point out.

“A significant challenge will be deciding which of the multiple metabolic pathways altered by PFAS are most important and predictive for induction of liver damage and for progression of liver disease, so that emerging PFAS may be screened for hepatotoxicity prior to entering the market,” Dr. Ducatman and Dr. Fenton conclude.

Support for this research was provided by the National Institute of Environmental Health Science, part of the National Institutes of Health, and the U.S. Department of Agriculture National Institute of Food and Agriculture. Dr. Costello, Dr. VanWagner, Dr. Ducatman, and Dr. Fenton report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Exposure to per- and polyfluoroalkyl substances (PFAS) - a class of widely used synthetic chemicals dubbed “forever chemicals” - can lead to liver damage and may be a culprit in rising rates of nonalcoholic fatty liver disease (NAFLD), say the authors of a comprehensive evidence review.

They found “consistent” evidence for PFAS hepatotoxicity from rodent studies. In addition, exposure to PFAS was found to be associated with markers of liver function in observational studies in people.

The review, published online in Environmental Health Perspectives, may be the first systematic analysis of PFAS exposure and liver damage.

Possible contributor to growing NAFLD epidemic

In their analysis, the authors included 85 rodent studies and 24 epidemiologic studies, primarily involving people from the United States and largely focusing on four “legacy” PFAS: perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), perfluorononanoic acid (PFNA), and perfluorohexanesulfonic acid (PFHxS).

Meta-analyses of human studies found that higher levels of alanine aminotransferase were significantly associated with exposure to three of the older chemicals – PFOA, PFOS, and PFNA.

The “positive” and “convincing” associations between exposure to these synthetic chemicals and higher ALT levels suggest that exposure may contribute to the growing NAFLD epidemic, the researchers write.

Exposure to one of the chemicals, PFOA, was also associated with higher aspartate aminotransferase and gamma-glutamyl transferase levels in people.

In rodents, exposure to these synthetic chemicals consistently resulted in higher ALT levels and steatosis.

“The mechanism is not well understood yet, but there are a few proposed theories,” first author Elizabeth Costello, MPH, PhD student, department of population and public health sciences, University of Southern California, Los Angeles, told this news organization.

“PFAS are similar to fatty acids in chemical structure, so it’s possible that they activate some of the same receptors or otherwise interfere with fat metabolism. This might lead to inflammation or fat accumulation in the liver,” Ms. Costello explained.

People widely exposed

PFAS are ubiquitous in the environment. They have been detected in the blood of most people and have been linked to a variety of health concerns. Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and even drinking water.

“We are exposed to PFAS in so many ways – through water, food, and products we use. It can be very difficult for individuals to control their own exposure,” Ms. Costello commented.

“At this point, it’s important to look for ways to remove PFAS from the environment and phase them out of our products and carefully consider the safety of any replacement chemicals,” she said.

Although most of the research to date has been limited to the four older PFAS (PFOA, PFOS, PFNA, and PFHxS), there are thousands of different PFAS chemicals.

“We don’t know very much about the effects of exposure to multiple PFAS at the same time or how newer replacement PFAS might affect liver disease or other health conditions,” Ms. Costello said.

Reached for comment, Lisa B. VanWagner, MD, with Northwestern University, Chicago, said this analysis is “very interesting,” but she is also “left wondering how we could do anything since it seems from my reading that these chemicals are ubiquitous and used regularly in the environment.”

Dr. VanWagner, who was not involved in the study, said the major limitation is the small number of human studies and the high heterogeneity between studies, “meaning it is hard to come to a firm conclusion about whether what has been observed in the animal studies does truly apply to humans.

“Overall, this study provides important proof of concept for future work to look more specifically at PFAS exposure, and more specific markers of fatty liver disease and liver damage, like liver biopsy, are needed in humans,” Dr. VanWagner said.

“If data accumulate showing that these chemicals do in fact contribute to fatty liver and worsening inflammation or liver damage as a result of exposure, then public health interventions to remove or reduce use of these chemicals could have wide-ranging public health effects,” Dr. VanWagner added.

Further research needed

The authors of an invited perspective published with the study say it underscores the “urgent need for further research and for immediate and reasonable public health action.”

“This work firmly puts PFAS exposure on the list of persistent pollutants, such as polychlorinated biphenyls, that cause hepatotoxicity and whose mechanism is linked to steatosis,” write Alan Ducatman, MD. MSc, with West Virginia University School of Public Health, Morgantown, and Suzanne Fenton, PhD, MS, with the National Institute of Environmental Health Sciences, Research Triangle Park, N.C.

They say other important questions raised by this review include whether individuals who are overweight or obese and those with diabetes are more susceptible to PFAS hepatoxicity, which “replacement” or emerging PFAS can cause liver damage, and whether high doses cause different kinds of liver toxicity than low doses.

“GenX, a current replacement [chemical] for PFOA, has shown significant hepatotoxicity in several recent experimental studies, suggesting it may not be a safe replacement,” they point out.

“A significant challenge will be deciding which of the multiple metabolic pathways altered by PFAS are most important and predictive for induction of liver damage and for progression of liver disease, so that emerging PFAS may be screened for hepatotoxicity prior to entering the market,” Dr. Ducatman and Dr. Fenton conclude.

Support for this research was provided by the National Institute of Environmental Health Science, part of the National Institutes of Health, and the U.S. Department of Agriculture National Institute of Food and Agriculture. Dr. Costello, Dr. VanWagner, Dr. Ducatman, and Dr. Fenton report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new deep learning system can classify hepatocellular nodular lesions (HNLs) via whole-slide images, improving risk stratification of patients and diagnostic rate of hepatocellular carcinoma (HCC), according to investigators.

While the model requires further validation, it could eventually be used to optimize accuracy and efficiency of histologic diagnoses, potentially decreasing reliance on pathologists, particularly in areas with limited access to subspecialists.

In an article published in Gastroenterology, Na Cheng, MD, of Sun Yat-sen University, Guangzhou, China, and colleagues wrote that the “diagnostic process [for HNLs] is laborious, time-consuming, and subject to the experience of the pathologists, often with significant interobserver and intraobserver variability. ... Therefore, [an] automated analysis system is highly demanded in the pathology field, which could considerably ease the workload, speed up the diagnosis, and facilitate the in-time treatment.”

To this end, Dr. Cheng and colleagues developed the hepatocellular-nodular artificial intelligence model (HnAIM) that can scan whole-image slides to identify seven types of tissue: well-differentiated HCC, high-grade dysplastic nodules, low-grade dysplastic nodules, hepatocellular adenoma, focal nodular hyperplasia, and background tissue.

Developing and testing HnAIM was a multistep process that began with three subspecialist pathologists, who independently reviewed and classified liver slides from surgical resection. Unanimous agreement was achieved in 649 slides from 462 patients. These slides were then scanned to create whole-slide images, which were divided into sets for training (70%), validation (15%), and internal testing (15%). Accuracy, measured by area under the curve (AUC), was over 99.9% for the internal testing set. The accuracy of HnAIM was independently, externally validated.

First, HnAIM evaluated liver biopsy slides from 30 patients at one center. Results were compared with diagnoses made by nine pathologists classified as either senior, intermediate, or junior. While HnAIM correctly diagnosed 100% of the cases, senior pathologists correctly diagnosed 94.4% of the cases, followed in accuracy by intermediate (86.7%) and junior (73.3%) pathologists.

The researchers noted that the “rate of agreement with subspecialists was higher for HnAIM than for all 9 pathologists at distinguishing 7 liver tissues, with important diagnostic implications for fragmentary or scarce biopsy specimens.”

Next, HnAIM evaluated 234 samples from three hospitals. Accuracy was slightly lower, with an AUC of 93.5%. The researchers highlighted how HnAIM consistently differentiated precancerous lesions and well-defined HCC from benign lesions and background tissues.

A final experiment showed how HnAIM reacted to the most challenging cases. The investigators selected 12 cases without definitive diagnoses and found that, similar to the findings of three subspecialist pathologists, HnAIM did not reach a single diagnostic conclusion.

The researchers reported that “This may be due to a number of potential reasons, such as inherent uncertainty in the 2-dimensional interpretation of a 3-dimensional specimen, the limited number of tissue samples, and cognitive factors such as anchoring.”

However, HnAIM contributed to the diagnostic process by generating multiple diagnostic possibilities with weighted likelihood. After reviewing these results, the expert pathologists reached consensus in 5 out of 12 cases. Moreover, two out of three expert pathologists agreed on all 12 cases, improving agreement rate from 25% to 100%.

The researchers concluded that the model holds the promise to facilitate human HNL diagnoses and improve efficiency and quality. It can also reduce the workload of pathologists, especially where subspecialists are unavailable.

The study was supported by the National Natural Science Foundation of China, the Guangdong Basic and Applied Basic Research Foundation, the Natural Science Foundation of Guangdong Province, and others. The investigators reported no conflicts of interest.

A new deep learning system can classify hepatocellular nodular lesions (HNLs) via whole-slide images, improving risk stratification of patients and diagnostic rate of hepatocellular carcinoma (HCC), according to investigators.

While the model requires further validation, it could eventually be used to optimize accuracy and efficiency of histologic diagnoses, potentially decreasing reliance on pathologists, particularly in areas with limited access to subspecialists.

In an article published in Gastroenterology, Na Cheng, MD, of Sun Yat-sen University, Guangzhou, China, and colleagues wrote that the “diagnostic process [for HNLs] is laborious, time-consuming, and subject to the experience of the pathologists, often with significant interobserver and intraobserver variability. ... Therefore, [an] automated analysis system is highly demanded in the pathology field, which could considerably ease the workload, speed up the diagnosis, and facilitate the in-time treatment.”

To this end, Dr. Cheng and colleagues developed the hepatocellular-nodular artificial intelligence model (HnAIM) that can scan whole-image slides to identify seven types of tissue: well-differentiated HCC, high-grade dysplastic nodules, low-grade dysplastic nodules, hepatocellular adenoma, focal nodular hyperplasia, and background tissue.

Developing and testing HnAIM was a multistep process that began with three subspecialist pathologists, who independently reviewed and classified liver slides from surgical resection. Unanimous agreement was achieved in 649 slides from 462 patients. These slides were then scanned to create whole-slide images, which were divided into sets for training (70%), validation (15%), and internal testing (15%). Accuracy, measured by area under the curve (AUC), was over 99.9% for the internal testing set. The accuracy of HnAIM was independently, externally validated.

First, HnAIM evaluated liver biopsy slides from 30 patients at one center. Results were compared with diagnoses made by nine pathologists classified as either senior, intermediate, or junior. While HnAIM correctly diagnosed 100% of the cases, senior pathologists correctly diagnosed 94.4% of the cases, followed in accuracy by intermediate (86.7%) and junior (73.3%) pathologists.

The researchers noted that the “rate of agreement with subspecialists was higher for HnAIM than for all 9 pathologists at distinguishing 7 liver tissues, with important diagnostic implications for fragmentary or scarce biopsy specimens.”

Next, HnAIM evaluated 234 samples from three hospitals. Accuracy was slightly lower, with an AUC of 93.5%. The researchers highlighted how HnAIM consistently differentiated precancerous lesions and well-defined HCC from benign lesions and background tissues.

A final experiment showed how HnAIM reacted to the most challenging cases. The investigators selected 12 cases without definitive diagnoses and found that, similar to the findings of three subspecialist pathologists, HnAIM did not reach a single diagnostic conclusion.

The researchers reported that “This may be due to a number of potential reasons, such as inherent uncertainty in the 2-dimensional interpretation of a 3-dimensional specimen, the limited number of tissue samples, and cognitive factors such as anchoring.”

However, HnAIM contributed to the diagnostic process by generating multiple diagnostic possibilities with weighted likelihood. After reviewing these results, the expert pathologists reached consensus in 5 out of 12 cases. Moreover, two out of three expert pathologists agreed on all 12 cases, improving agreement rate from 25% to 100%.

The researchers concluded that the model holds the promise to facilitate human HNL diagnoses and improve efficiency and quality. It can also reduce the workload of pathologists, especially where subspecialists are unavailable.

The study was supported by the National Natural Science Foundation of China, the Guangdong Basic and Applied Basic Research Foundation, the Natural Science Foundation of Guangdong Province, and others. The investigators reported no conflicts of interest.

A new deep learning system can classify hepatocellular nodular lesions (HNLs) via whole-slide images, improving risk stratification of patients and diagnostic rate of hepatocellular carcinoma (HCC), according to investigators.

While the model requires further validation, it could eventually be used to optimize accuracy and efficiency of histologic diagnoses, potentially decreasing reliance on pathologists, particularly in areas with limited access to subspecialists.

In an article published in Gastroenterology, Na Cheng, MD, of Sun Yat-sen University, Guangzhou, China, and colleagues wrote that the “diagnostic process [for HNLs] is laborious, time-consuming, and subject to the experience of the pathologists, often with significant interobserver and intraobserver variability. ... Therefore, [an] automated analysis system is highly demanded in the pathology field, which could considerably ease the workload, speed up the diagnosis, and facilitate the in-time treatment.”

To this end, Dr. Cheng and colleagues developed the hepatocellular-nodular artificial intelligence model (HnAIM) that can scan whole-image slides to identify seven types of tissue: well-differentiated HCC, high-grade dysplastic nodules, low-grade dysplastic nodules, hepatocellular adenoma, focal nodular hyperplasia, and background tissue.

Developing and testing HnAIM was a multistep process that began with three subspecialist pathologists, who independently reviewed and classified liver slides from surgical resection. Unanimous agreement was achieved in 649 slides from 462 patients. These slides were then scanned to create whole-slide images, which were divided into sets for training (70%), validation (15%), and internal testing (15%). Accuracy, measured by area under the curve (AUC), was over 99.9% for the internal testing set. The accuracy of HnAIM was independently, externally validated.

First, HnAIM evaluated liver biopsy slides from 30 patients at one center. Results were compared with diagnoses made by nine pathologists classified as either senior, intermediate, or junior. While HnAIM correctly diagnosed 100% of the cases, senior pathologists correctly diagnosed 94.4% of the cases, followed in accuracy by intermediate (86.7%) and junior (73.3%) pathologists.

The researchers noted that the “rate of agreement with subspecialists was higher for HnAIM than for all 9 pathologists at distinguishing 7 liver tissues, with important diagnostic implications for fragmentary or scarce biopsy specimens.”

Next, HnAIM evaluated 234 samples from three hospitals. Accuracy was slightly lower, with an AUC of 93.5%. The researchers highlighted how HnAIM consistently differentiated precancerous lesions and well-defined HCC from benign lesions and background tissues.

A final experiment showed how HnAIM reacted to the most challenging cases. The investigators selected 12 cases without definitive diagnoses and found that, similar to the findings of three subspecialist pathologists, HnAIM did not reach a single diagnostic conclusion.

The researchers reported that “This may be due to a number of potential reasons, such as inherent uncertainty in the 2-dimensional interpretation of a 3-dimensional specimen, the limited number of tissue samples, and cognitive factors such as anchoring.”

However, HnAIM contributed to the diagnostic process by generating multiple diagnostic possibilities with weighted likelihood. After reviewing these results, the expert pathologists reached consensus in 5 out of 12 cases. Moreover, two out of three expert pathologists agreed on all 12 cases, improving agreement rate from 25% to 100%.

The researchers concluded that the model holds the promise to facilitate human HNL diagnoses and improve efficiency and quality. It can also reduce the workload of pathologists, especially where subspecialists are unavailable.

The study was supported by the National Natural Science Foundation of China, the Guangdong Basic and Applied Basic Research Foundation, the Natural Science Foundation of Guangdong Province, and others. The investigators reported no conflicts of interest.

Hypertensive disorders in pregnancy affect nearly 16% of women who give birth in U.S. hospitals and appear to be increasing, according to an April 29 report from the Centers for Disease Control and Prevention.

Older patients and Black women are substantially more likely to experience hypertension in pregnancy, the analysis found.

“Addressing hypertensive disorders in pregnancy is a key strategy in reducing inequities in pregnancy-related mortality,” study coauthor Wanda Barfield, MD, MPH, director of CDC’s Division of Reproductive Health, said in a statement.
 

Age, obesity, diabetes

The overall prevalence of hypertensive disorders in pregnancy increased from 13.3% in 2017 to 15.9% in 2019, the researchers reported in the CDC’s Morbidity and Mortality Weekly Report.

The uptick in hypertension coincides with trends toward older maternal age and higher rates of obesity and diabetes, which may explain the increase, they said.

For the study, Dr. Barfield and her colleagues analyzed nationally representative data from the National Inpatient Sample. They identified patients with a diagnosis of chronic hypertension, pregnancy-associated hypertension, or unspecified maternal hypertension during their hospitalization.

Among women aged 45-55 years, the prevalence of hypertension was 31%. Among those aged 35-44 years, it was 18%.

Hypertension diagnoses were more common in women who were Black (20.9%) or American Indian or Alaska Native (16.4%), than in other groups.

Of patients who died during delivery hospitalization, 31.6% had a hypertensive disorder.

The study shows a marked increase in hypertensive disorders over a relatively short time, according to Jane van Dis, MD, of the department of obstetrics and gynecology at the University of Rochester (N.Y.), who was not involved in the research. The phenomenon is consistent with her own experience, she said.

“When I am admitting patients, I’m oftentimes surprised when someone does not have a hypertensive disorder because I feel like the majority of patients these days do,” Dr. van Dis told this news organization.

Dr. Van Dis speculated that factors related to the environment, including air pollution and endocrine disrupters, could contribute to elevated rates of hypertensive disorders.

Natalie Bello, MD, MPH, director of hypertension research at Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, said rates of hypertension today could be even higher than in the study.

The CDC report relied on pre-COVID data, and the pandemic “increased disparities in health outcomes,” Dr. Bello said in an interview. “I’m worried that in actuality these numbers are an underestimation of the current state of hypertension in pregnancy.”

Dr. Bello, who has studied the need for better training in cardio-obstetrics, applauded Vice President Kamala Harris’ efforts to improve maternal health.

“The racial and geographic disparities that we continue to see in the field are disheartening but should be a call to action to redouble our work to improve maternal outcomes,” Dr. Bello told this news organization. “The good news is that a lot of morbidity related to hypertension can be avoided with timely diagnosis and treatment of blood pressure. However, we need to act to provide all pregnant persons with optimal care.”

Janet Wright, MD, director of CDC’s Division for Heart Disease and Stroke Prevention, said blood pressure home monitoring is a “great example” of a strategy clinicians can use to identify and manage patients with hypertension.

But one approach – self-monitoring blood pressure from home during pregnancy – did not significantly improve the health of pregnant women, according to new results from randomized trials in the United Kingdom.

Trial results published in JAMA show that blood pressure home-monitoring coupled to telemonitoring, as compared with usual care, did not significantly improve blood pressure control among patients with chronic or gestational hypertension.

A second trial published in JAMA that included patients at risk for preeclampsia found that self-monitoring with telemonitoring did not lead to significantly earlier diagnoses of hypertension.

“Individuals at risk for a hypertensive disorder of pregnancy, or with gestational or chronic hypertension, cannot be treated with a single approach,” Malavika Prabhu, MD, with Weill Cornell Medicine, New York, and coauthors write in an editorial accompanying the JAMA studies. Although the data suggest that self-monitoring of blood pressure is practical and tolerated, “More research is needed to determine optimal, high-value, equitable approaches to averting adverse perinatal outcomes associated with hypertensive disorders of pregnancy,” they write.

The CDC study authors and Dr. van Dis have disclosed no relevant financial relationships. Dr. Bello is funded by the National Institutes of Health to study blood pressure monitoring in pregnancy. The JAMA editorial authors disclosed university, government, and corporate grants and work with publishing companies.

A version of this article first appeared on Medscape.com.

Hypertensive disorders in pregnancy affect nearly 16% of women who give birth in U.S. hospitals and appear to be increasing, according to an April 29 report from the Centers for Disease Control and Prevention.

Older patients and Black women are substantially more likely to experience hypertension in pregnancy, the analysis found.

“Addressing hypertensive disorders in pregnancy is a key strategy in reducing inequities in pregnancy-related mortality,” study coauthor Wanda Barfield, MD, MPH, director of CDC’s Division of Reproductive Health, said in a statement.
 

Age, obesity, diabetes

The overall prevalence of hypertensive disorders in pregnancy increased from 13.3% in 2017 to 15.9% in 2019, the researchers reported in the CDC’s Morbidity and Mortality Weekly Report.

The uptick in hypertension coincides with trends toward older maternal age and higher rates of obesity and diabetes, which may explain the increase, they said.

For the study, Dr. Barfield and her colleagues analyzed nationally representative data from the National Inpatient Sample. They identified patients with a diagnosis of chronic hypertension, pregnancy-associated hypertension, or unspecified maternal hypertension during their hospitalization.

Among women aged 45-55 years, the prevalence of hypertension was 31%. Among those aged 35-44 years, it was 18%.

Hypertension diagnoses were more common in women who were Black (20.9%) or American Indian or Alaska Native (16.4%), than in other groups.

Of patients who died during delivery hospitalization, 31.6% had a hypertensive disorder.

The study shows a marked increase in hypertensive disorders over a relatively short time, according to Jane van Dis, MD, of the department of obstetrics and gynecology at the University of Rochester (N.Y.), who was not involved in the research. The phenomenon is consistent with her own experience, she said.

“When I am admitting patients, I’m oftentimes surprised when someone does not have a hypertensive disorder because I feel like the majority of patients these days do,” Dr. van Dis told this news organization.

Dr. Van Dis speculated that factors related to the environment, including air pollution and endocrine disrupters, could contribute to elevated rates of hypertensive disorders.

Natalie Bello, MD, MPH, director of hypertension research at Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, said rates of hypertension today could be even higher than in the study.

The CDC report relied on pre-COVID data, and the pandemic “increased disparities in health outcomes,” Dr. Bello said in an interview. “I’m worried that in actuality these numbers are an underestimation of the current state of hypertension in pregnancy.”

Dr. Bello, who has studied the need for better training in cardio-obstetrics, applauded Vice President Kamala Harris’ efforts to improve maternal health.

“The racial and geographic disparities that we continue to see in the field are disheartening but should be a call to action to redouble our work to improve maternal outcomes,” Dr. Bello told this news organization. “The good news is that a lot of morbidity related to hypertension can be avoided with timely diagnosis and treatment of blood pressure. However, we need to act to provide all pregnant persons with optimal care.”

Janet Wright, MD, director of CDC’s Division for Heart Disease and Stroke Prevention, said blood pressure home monitoring is a “great example” of a strategy clinicians can use to identify and manage patients with hypertension.

But one approach – self-monitoring blood pressure from home during pregnancy – did not significantly improve the health of pregnant women, according to new results from randomized trials in the United Kingdom.

Trial results published in JAMA show that blood pressure home-monitoring coupled to telemonitoring, as compared with usual care, did not significantly improve blood pressure control among patients with chronic or gestational hypertension.

A second trial published in JAMA that included patients at risk for preeclampsia found that self-monitoring with telemonitoring did not lead to significantly earlier diagnoses of hypertension.

“Individuals at risk for a hypertensive disorder of pregnancy, or with gestational or chronic hypertension, cannot be treated with a single approach,” Malavika Prabhu, MD, with Weill Cornell Medicine, New York, and coauthors write in an editorial accompanying the JAMA studies. Although the data suggest that self-monitoring of blood pressure is practical and tolerated, “More research is needed to determine optimal, high-value, equitable approaches to averting adverse perinatal outcomes associated with hypertensive disorders of pregnancy,” they write.

The CDC study authors and Dr. van Dis have disclosed no relevant financial relationships. Dr. Bello is funded by the National Institutes of Health to study blood pressure monitoring in pregnancy. The JAMA editorial authors disclosed university, government, and corporate grants and work with publishing companies.

A version of this article first appeared on Medscape.com.

Hypertensive disorders in pregnancy affect nearly 16% of women who give birth in U.S. hospitals and appear to be increasing, according to an April 29 report from the Centers for Disease Control and Prevention.

Older patients and Black women are substantially more likely to experience hypertension in pregnancy, the analysis found.

“Addressing hypertensive disorders in pregnancy is a key strategy in reducing inequities in pregnancy-related mortality,” study coauthor Wanda Barfield, MD, MPH, director of CDC’s Division of Reproductive Health, said in a statement.
 

Age, obesity, diabetes

The overall prevalence of hypertensive disorders in pregnancy increased from 13.3% in 2017 to 15.9% in 2019, the researchers reported in the CDC’s Morbidity and Mortality Weekly Report.

The uptick in hypertension coincides with trends toward older maternal age and higher rates of obesity and diabetes, which may explain the increase, they said.

For the study, Dr. Barfield and her colleagues analyzed nationally representative data from the National Inpatient Sample. They identified patients with a diagnosis of chronic hypertension, pregnancy-associated hypertension, or unspecified maternal hypertension during their hospitalization.

Among women aged 45-55 years, the prevalence of hypertension was 31%. Among those aged 35-44 years, it was 18%.

Hypertension diagnoses were more common in women who were Black (20.9%) or American Indian or Alaska Native (16.4%), than in other groups.

Of patients who died during delivery hospitalization, 31.6% had a hypertensive disorder.

The study shows a marked increase in hypertensive disorders over a relatively short time, according to Jane van Dis, MD, of the department of obstetrics and gynecology at the University of Rochester (N.Y.), who was not involved in the research. The phenomenon is consistent with her own experience, she said.

“When I am admitting patients, I’m oftentimes surprised when someone does not have a hypertensive disorder because I feel like the majority of patients these days do,” Dr. van Dis told this news organization.

Dr. Van Dis speculated that factors related to the environment, including air pollution and endocrine disrupters, could contribute to elevated rates of hypertensive disorders.

Natalie Bello, MD, MPH, director of hypertension research at Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, said rates of hypertension today could be even higher than in the study.

The CDC report relied on pre-COVID data, and the pandemic “increased disparities in health outcomes,” Dr. Bello said in an interview. “I’m worried that in actuality these numbers are an underestimation of the current state of hypertension in pregnancy.”

Dr. Bello, who has studied the need for better training in cardio-obstetrics, applauded Vice President Kamala Harris’ efforts to improve maternal health.

“The racial and geographic disparities that we continue to see in the field are disheartening but should be a call to action to redouble our work to improve maternal outcomes,” Dr. Bello told this news organization. “The good news is that a lot of morbidity related to hypertension can be avoided with timely diagnosis and treatment of blood pressure. However, we need to act to provide all pregnant persons with optimal care.”

Janet Wright, MD, director of CDC’s Division for Heart Disease and Stroke Prevention, said blood pressure home monitoring is a “great example” of a strategy clinicians can use to identify and manage patients with hypertension.

But one approach – self-monitoring blood pressure from home during pregnancy – did not significantly improve the health of pregnant women, according to new results from randomized trials in the United Kingdom.

Trial results published in JAMA show that blood pressure home-monitoring coupled to telemonitoring, as compared with usual care, did not significantly improve blood pressure control among patients with chronic or gestational hypertension.

A second trial published in JAMA that included patients at risk for preeclampsia found that self-monitoring with telemonitoring did not lead to significantly earlier diagnoses of hypertension.

“Individuals at risk for a hypertensive disorder of pregnancy, or with gestational or chronic hypertension, cannot be treated with a single approach,” Malavika Prabhu, MD, with Weill Cornell Medicine, New York, and coauthors write in an editorial accompanying the JAMA studies. Although the data suggest that self-monitoring of blood pressure is practical and tolerated, “More research is needed to determine optimal, high-value, equitable approaches to averting adverse perinatal outcomes associated with hypertensive disorders of pregnancy,” they write.

The CDC study authors and Dr. van Dis have disclosed no relevant financial relationships. Dr. Bello is funded by the National Institutes of Health to study blood pressure monitoring in pregnancy. The JAMA editorial authors disclosed university, government, and corporate grants and work with publishing companies.

A version of this article first appeared on Medscape.com.