The US Department of Veterans Affairs (VA) has been integral in resident training. Resident surgical training requires a balance of supervision and autonomy, along with procedure repetition and appropriate feedback.^1-3 Non-VA research has found that resident participation across various otolaryngology procedures, including thyroidectomy, neck dissection, and laryngectomy, does not increase patient morbidity.^4-7 However, resident involvement in private and academic settings that included nonhead and neck procedures was linked to increased operative time and reduced productivity, as determined by work relative value units (wRVUs).^7-13 This has also been identified in other specialties, including general surgery, orthopedics, and ophthalmology.^14-16

Unlike the private sector, surgeon compensation at the VA is not as closely linked to operative productivity, offering a unique setting for resident training. While VA integration in otolaryngology residency programs increases resident case numbers, particularly in head and neck cases, the impact on VA patient outcomes and productivity is unknown.¹⁷ The use of larynxpreserving treatment modalities for laryngeal cancer has led to a decline in the number of total laryngectomies performed, which could potentially impact resident operative training for laryngectomies.^18-20

This study sought to determine the impact of resident participation on operative time, wRVUs, and patient outcomes in veterans who underwent a total laryngectomy. This study was reviewed and approved by the MedStar Georgetown University Hospital Institutional Review Board and Research and Development Committee (#1595672).

Methods

A retrospective cohort of veterans nationwide who underwent total laryngectomy between 2001 and 2021, with or without neck dissection, was identified from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Data were extracted via the VA Informatics and Computing Infrastructure and patients were included based on Current Procedural Terminology codes for total laryngectomy, with or without neck dissection (31320, 31360, 31365). Laryngopharyngectomies, partial laryngectomies, and minimally invasive laryngectomies were excluded. VASQIP nurse data managers reviewed patient data for operative data, postoperative outcomes (including 30- day morbidity and mortality), and preoperative risk factors (Appendix).²¹

The VASQIP data provide the highest resident or postgraduate year (PGY) per surgery. PGY 1, 2, and 3 were considered junior residents and PGY ≥4, surgical fellows, and individuals who took research years during residency were considered senior residents. Cases performed by attending physicians alone were compared with those involving junior or senior residents.

Patient demographic data included age, body mass index, smoking and alcohol use, weight loss, and functional status. Consumption of any tobacco products within 12 months of surgery was considered tobacco use. Drinking on average ≥2 alcoholic beverages daily was considered alcohol use. Weight loss was defined as a 10% reduction in body weight within the 6 months before surgery, excluding patients enrolled in a weight loss program. Functional status was categorized as independent, partially dependent, totally dependent, and unknown.

Primary outcomes included operative time, wRVUs generated, and wRVUs generated per hour of operative time. Postoperative complications were recorded both as a continuous variable and as a binary variable for presence or absence of a complication. Additional outcome variables included length of postoperative hospital stay, return to the operating room (OR), and death within 30 days of surgery.

Statistical Analysis

Data were summarized using frequency and percentage for categorical variables and median with IQR for continuous variables. Data were also summarized based on resident involvement in the surgery and the PGY level of the residents involved. The occurrence of total laryngectomy, rate of complications, and patient return to the OR were summarized by year.

Univariate associations between resident involvement and surgical outcomes were analyzed using the Kruskal-Wallis test for continuous variables and the ÷2 test for categorical variables. A Fisher exact test was used when the cell count in the contingency table was < 5. The univariate associations between surgical outcomes and demographic/preoperative variables were examined using 2-sided Wilcoxon ranksum tests or Kruskal-Wallis tests between continuous variables and categorical variables, X² or Fisher exact test between 2 categorical variables, and 2-sided Spearman correlation test between 2 continuous variables. A false-discovery rate approach was used for simultaneous posthoc tests to determine the adjusted P values for wRVUs generated/operative time for attending physicians alone vs with junior residents and for attending physicians alone vs with senior residents. Models were used to evaluate the effects of resident involvement on surgical outcomes, adjusting for variables that showed significant univariate associations. Linear regression models were used for operative time, wRVUs generated, wRVUs generated/operative time, and length of postoperative stay. A logistic regression model was used for death within 30 days. Models were not built for postoperative complications or patient return to the OR, as these were only statistically significantly associated with the patient’s preoperative functional status. A finding was considered significant if P < .05. All analyses were performed using statistical software RStudio Version 2023.03.0.

Results

Between 2001 and 2021, 1857 patients who underwent total laryngectomy were identified from the VASQIP database nationwide. Most of the total laryngectomies were staffed by an attending physician with a senior resident (n = 1190, 64%), 446 (24%) were conducted by the attending physician alone, and 221 (12%) by an attending physician with a junior resident (Table 1). The mean operating time for an attending physician alone was 378 minutes, 384 minutes for an attending physician with a senior resident, and 432 minutes for an attending physician with a junior resident (Table 2). There was a statistically significant increase in operating time for laryngectomies with resident participation compared to attending physicians operating alone (P < .001).

When the wRVUs generated/operative time was analyzed, there was a statistically significant difference between comparison groups. Total laryngectomies performed by attending physicians alone had the highest wRVUs generated/operative time (5.5), followed by laryngectomies performed by attending physicians with senior residents and laryngectomies performed by attending physicians with junior residents (5.2 and 4.8, respectively; P = .002). Table 3 describes adjusted P values for wRVUs generated/ operative time for total laryngectomies performed by attending physicians alone vs with junior residents (P = .003) and for attending physicians alone vs with senior residents (P = .02). Resident participation in total laryngectomies did not significantly impact the development or number of postoperative complications or the rate of return to the OR.

The number of laryngectomies performed in a single fiscal year peaked in 2010 at 170 cases (Figure 1). Between 2001 and 2021, the mean rates of postoperative complications (21.3%) and patient return to the OR (14.6%) did not significantly change. Resident participation in total laryngectomies also peaked in 2010 at 89.0% but has significantly declined, falling to a low of 43.6% in 2021 (Figure 2). From 2001 to 2011, the mean resident participation rate in total laryngectomies was 80.6%, compared with 68.3% from 2012 to 2021 (P < .001).

The effect of various demographic and preoperative characteristics on surgical outcomes was also analyzed. A linear regression model accounted for each variable significantly associated with operative time. On multivariable analysis, when all other variables were held constant, Table 4 shows the estimated change in operative time based on certain criteria. For instance, the operative time for attendings with junior residents surgeries was 40 minutes longer (95% CI, 16 to 64) than that of attending alone surgeries (P = .001). Furthermore, operative time decreased by 1.1 minutes (95% CI, 0.30 to 2.04) for each 1-year increase in patient age (P = .009).

A multivariable logistic regression model evaluated the effect of resident involvement on 30-day mortality rates. Senior resident involvement (P = .02), partially dependent functional status (P = .01), totally dependent functional status (P < .001), and advanced age (P = .02) all were significantly associated with 30-day mortality (Table 5). When other variables remained constant, the odds of death for totally dependent patients were 10.4 times higher than that of patients with independent functional status. Thus, totally dependent functional status appeared to have a greater impact on this outcome than resident participation. The linear regression model for postoperative length of stay demonstrated that senior resident involvement (P = .04), functional status (partially dependent vs independent P < .001), and age (P = .03) were significantly associated with prolonged length of stay.

Discussion

Otolaryngology residency training is designed to educate future otolaryngologists through hands-on learning, adequate feedback, and supervision.¹ Although this exposure is paramount for resident education, balancing appropriate supervision and autonomy while mitigating patient risk has been difficult. Numerous non-VA studies have reviewed the impact of resident participation on patient outcomes in various specialties, ranging from a single institution to the National Surgical Quality Improvement Program (NSQIP).^4,5,7,22 This study is the first to describe the nationwide impact of resident participation on outcomes in veterans undergoing total laryngectomy.

This study found that resident participation increases operative time and decreases wRVUs generated/operative time without impacting complication rates or patient return to the OR. This reinforces the notion that under close supervision, resident participation does not negatively impact patient outcomes. Resident operative training requires time and dedication by the attending physician and surgical team, thereby increasing operative time. Because VA physician compensation is not linked with productivity as closely as it is in other private and academic settings, surgeons can dedicate more time to operative teaching. This study found that a total laryngectomy involving a junior resident took about 45 minutes longer than an attending physician working alone.

As expected, with longer operative times, the wRVUs generated/operative time ratio was lower in cases with resident participation. Even though resident participation leads to lower OR efficiency, their participation may not significantly impact ancillary costs.²³ However, a recent study from NSQIP found an opportunity cost of $60.44 per hour for surgeons operating with a resident in head and neck cases.¹³

Postoperative complications and mortality are key measures of surgical outcomes in addition to operative time and efficiency. This study found that neither junior nor senior resident participation significantly increased complication rates or patient return to the OR. Despite declining resident involvement and the number of total laryngectomy surgeries in the VA, the complication rate has remained steady. The 30-day mortality rate was significantly higher in cases involving senior residents compared to cases with attending physicians alone. This could be a result of senior resident participation in more challenging cases, such as laryngectomies performed as salvage surgery following radiation. Residents are more often involved in cases with greater complexity at teaching institutions.^24-26 Therefore, the higher mortality seen among laryngectomies with senior resident involvement is likely due to the higher complexity of those cases.

The proportion of resident involvement in laryngectomies at VA medical centers has been decreasing over time. Due to the single payer nature of the VA health care system and the number of complex and comorbid patients, the VA offers an invaluable space for resident education in the OR. The fact that less than half of laryngectomies in 2021 involved resident participation is noteworthy for residency training programs. As wRVU compensation models evolve, VA attending surgeons may face less pressure to move the case along, leading to a high potential for operative teaching. Therefore, complex cases, such as laryngectomies, are often ideal for resident participation in the VA.

The steady decline in total laryngectomies at the VA parallels the recent decrease seen in non-VA settings.²⁰ This is due in part to the use of larynx-preserving treatment modalities for laryngeal cancer as well as decreases in the incidence of laryngeal cancer due to population level changes in smoking behaviors. ^18,19 Although a laryngectomy is not a key indicator case as determined by the Accreditation Council for Graduate Medical Education, it is important for otolaryngology residents to be exposed to these cases and have a thorough understanding of the operative technique.²⁷ Total laryngectomy was selected for this study because it is a complex and time-consuming surgery with somewhat standardized surgical steps. Unlike microvascular surgery that is very rarely performed by an attending physician alone, laryngectomies can be performed by attending physicians alone or with a resident.²⁸

Limitations

Since this was a retrospective study, it was susceptible to errors in data entry and data extraction from the VASQIP database. Another limitation is the lack of preoperative treatment data on tumor stage and prior nonoperative treatment. For example, a salvage laryngectomy after treatment with radiation and/or chemoradiation is a higher risk procedure than an upfront laryngectomy. Senior resident involvement may be more common in patients undergoing salvage laryngectomy due to the high risk of postoperative fistula and other complications. This may have contributed to the association identified between senior resident participation and 30-day mortality.

Since we could not account for residents who took research years or were fellows, a senior resident may have been mislabeled as a junior resident or vice versa. However, because most research years occur following the third year of residency. We are confident that PGY-1, PGY-2, and PGY-3 is likely to capture junior residents. Other factors, such as coattending surgeon cases, medical student assistance, and fellow involvement may have also impacted the results of this study.

Conclusions

This study is the first to investigate the impact of resident participation on operative time, wRVUs generated, and complication rates in head and neck surgery at VA medical centers. It found that resident participation in total laryngectomies among veterans increased operative time and reduced wRVUs generated per hour but did not impact complication rate or patient return to the OR. The VA offers a unique and invaluable space for resident education and operative training, and the recent decline in resident participation among laryngectomies is important for residency programs to acknowledge and potentially address moving forward.

In contrast to oral cavity resections which can vary from partial glossectomies to composite resections, laryngectomy represents a homogenous procedure from which to draw meaningful conclusions about complication rates, operative time, and outcome. Future directions should include studying other types of head and neck surgery in the VA to determine whether the impact of resident participation mirrors the findings of this study.

The US Department of Veterans Affairs (VA) has been integral in resident training. Resident surgical training requires a balance of supervision and autonomy, along with procedure repetition and appropriate feedback.^1-3 Non-VA research has found that resident participation across various otolaryngology procedures, including thyroidectomy, neck dissection, and laryngectomy, does not increase patient morbidity.^4-7 However, resident involvement in private and academic settings that included nonhead and neck procedures was linked to increased operative time and reduced productivity, as determined by work relative value units (wRVUs).^7-13 This has also been identified in other specialties, including general surgery, orthopedics, and ophthalmology.^14-16

Unlike the private sector, surgeon compensation at the VA is not as closely linked to operative productivity, offering a unique setting for resident training. While VA integration in otolaryngology residency programs increases resident case numbers, particularly in head and neck cases, the impact on VA patient outcomes and productivity is unknown.¹⁷ The use of larynxpreserving treatment modalities for laryngeal cancer has led to a decline in the number of total laryngectomies performed, which could potentially impact resident operative training for laryngectomies.^18-20

This study sought to determine the impact of resident participation on operative time, wRVUs, and patient outcomes in veterans who underwent a total laryngectomy. This study was reviewed and approved by the MedStar Georgetown University Hospital Institutional Review Board and Research and Development Committee (#1595672).

Methods

A retrospective cohort of veterans nationwide who underwent total laryngectomy between 2001 and 2021, with or without neck dissection, was identified from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Data were extracted via the VA Informatics and Computing Infrastructure and patients were included based on Current Procedural Terminology codes for total laryngectomy, with or without neck dissection (31320, 31360, 31365). Laryngopharyngectomies, partial laryngectomies, and minimally invasive laryngectomies were excluded. VASQIP nurse data managers reviewed patient data for operative data, postoperative outcomes (including 30- day morbidity and mortality), and preoperative risk factors (Appendix).²¹

The VASQIP data provide the highest resident or postgraduate year (PGY) per surgery. PGY 1, 2, and 3 were considered junior residents and PGY ≥4, surgical fellows, and individuals who took research years during residency were considered senior residents. Cases performed by attending physicians alone were compared with those involving junior or senior residents.

Patient demographic data included age, body mass index, smoking and alcohol use, weight loss, and functional status. Consumption of any tobacco products within 12 months of surgery was considered tobacco use. Drinking on average ≥2 alcoholic beverages daily was considered alcohol use. Weight loss was defined as a 10% reduction in body weight within the 6 months before surgery, excluding patients enrolled in a weight loss program. Functional status was categorized as independent, partially dependent, totally dependent, and unknown.

Primary outcomes included operative time, wRVUs generated, and wRVUs generated per hour of operative time. Postoperative complications were recorded both as a continuous variable and as a binary variable for presence or absence of a complication. Additional outcome variables included length of postoperative hospital stay, return to the operating room (OR), and death within 30 days of surgery.

Statistical Analysis

Data were summarized using frequency and percentage for categorical variables and median with IQR for continuous variables. Data were also summarized based on resident involvement in the surgery and the PGY level of the residents involved. The occurrence of total laryngectomy, rate of complications, and patient return to the OR were summarized by year.

Univariate associations between resident involvement and surgical outcomes were analyzed using the Kruskal-Wallis test for continuous variables and the ÷2 test for categorical variables. A Fisher exact test was used when the cell count in the contingency table was < 5. The univariate associations between surgical outcomes and demographic/preoperative variables were examined using 2-sided Wilcoxon ranksum tests or Kruskal-Wallis tests between continuous variables and categorical variables, X² or Fisher exact test between 2 categorical variables, and 2-sided Spearman correlation test between 2 continuous variables. A false-discovery rate approach was used for simultaneous posthoc tests to determine the adjusted P values for wRVUs generated/operative time for attending physicians alone vs with junior residents and for attending physicians alone vs with senior residents. Models were used to evaluate the effects of resident involvement on surgical outcomes, adjusting for variables that showed significant univariate associations. Linear regression models were used for operative time, wRVUs generated, wRVUs generated/operative time, and length of postoperative stay. A logistic regression model was used for death within 30 days. Models were not built for postoperative complications or patient return to the OR, as these were only statistically significantly associated with the patient’s preoperative functional status. A finding was considered significant if P < .05. All analyses were performed using statistical software RStudio Version 2023.03.0.

Results

Between 2001 and 2021, 1857 patients who underwent total laryngectomy were identified from the VASQIP database nationwide. Most of the total laryngectomies were staffed by an attending physician with a senior resident (n = 1190, 64%), 446 (24%) were conducted by the attending physician alone, and 221 (12%) by an attending physician with a junior resident (Table 1). The mean operating time for an attending physician alone was 378 minutes, 384 minutes for an attending physician with a senior resident, and 432 minutes for an attending physician with a junior resident (Table 2). There was a statistically significant increase in operating time for laryngectomies with resident participation compared to attending physicians operating alone (P < .001).

When the wRVUs generated/operative time was analyzed, there was a statistically significant difference between comparison groups. Total laryngectomies performed by attending physicians alone had the highest wRVUs generated/operative time (5.5), followed by laryngectomies performed by attending physicians with senior residents and laryngectomies performed by attending physicians with junior residents (5.2 and 4.8, respectively; P = .002). Table 3 describes adjusted P values for wRVUs generated/ operative time for total laryngectomies performed by attending physicians alone vs with junior residents (P = .003) and for attending physicians alone vs with senior residents (P = .02). Resident participation in total laryngectomies did not significantly impact the development or number of postoperative complications or the rate of return to the OR.

The number of laryngectomies performed in a single fiscal year peaked in 2010 at 170 cases (Figure 1). Between 2001 and 2021, the mean rates of postoperative complications (21.3%) and patient return to the OR (14.6%) did not significantly change. Resident participation in total laryngectomies also peaked in 2010 at 89.0% but has significantly declined, falling to a low of 43.6% in 2021 (Figure 2). From 2001 to 2011, the mean resident participation rate in total laryngectomies was 80.6%, compared with 68.3% from 2012 to 2021 (P < .001).

The effect of various demographic and preoperative characteristics on surgical outcomes was also analyzed. A linear regression model accounted for each variable significantly associated with operative time. On multivariable analysis, when all other variables were held constant, Table 4 shows the estimated change in operative time based on certain criteria. For instance, the operative time for attendings with junior residents surgeries was 40 minutes longer (95% CI, 16 to 64) than that of attending alone surgeries (P = .001). Furthermore, operative time decreased by 1.1 minutes (95% CI, 0.30 to 2.04) for each 1-year increase in patient age (P = .009).

A multivariable logistic regression model evaluated the effect of resident involvement on 30-day mortality rates. Senior resident involvement (P = .02), partially dependent functional status (P = .01), totally dependent functional status (P < .001), and advanced age (P = .02) all were significantly associated with 30-day mortality (Table 5). When other variables remained constant, the odds of death for totally dependent patients were 10.4 times higher than that of patients with independent functional status. Thus, totally dependent functional status appeared to have a greater impact on this outcome than resident participation. The linear regression model for postoperative length of stay demonstrated that senior resident involvement (P = .04), functional status (partially dependent vs independent P < .001), and age (P = .03) were significantly associated with prolonged length of stay.

Discussion

Otolaryngology residency training is designed to educate future otolaryngologists through hands-on learning, adequate feedback, and supervision.¹ Although this exposure is paramount for resident education, balancing appropriate supervision and autonomy while mitigating patient risk has been difficult. Numerous non-VA studies have reviewed the impact of resident participation on patient outcomes in various specialties, ranging from a single institution to the National Surgical Quality Improvement Program (NSQIP).^4,5,7,22 This study is the first to describe the nationwide impact of resident participation on outcomes in veterans undergoing total laryngectomy.

This study found that resident participation increases operative time and decreases wRVUs generated/operative time without impacting complication rates or patient return to the OR. This reinforces the notion that under close supervision, resident participation does not negatively impact patient outcomes. Resident operative training requires time and dedication by the attending physician and surgical team, thereby increasing operative time. Because VA physician compensation is not linked with productivity as closely as it is in other private and academic settings, surgeons can dedicate more time to operative teaching. This study found that a total laryngectomy involving a junior resident took about 45 minutes longer than an attending physician working alone.

As expected, with longer operative times, the wRVUs generated/operative time ratio was lower in cases with resident participation. Even though resident participation leads to lower OR efficiency, their participation may not significantly impact ancillary costs.²³ However, a recent study from NSQIP found an opportunity cost of $60.44 per hour for surgeons operating with a resident in head and neck cases.¹³

Postoperative complications and mortality are key measures of surgical outcomes in addition to operative time and efficiency. This study found that neither junior nor senior resident participation significantly increased complication rates or patient return to the OR. Despite declining resident involvement and the number of total laryngectomy surgeries in the VA, the complication rate has remained steady. The 30-day mortality rate was significantly higher in cases involving senior residents compared to cases with attending physicians alone. This could be a result of senior resident participation in more challenging cases, such as laryngectomies performed as salvage surgery following radiation. Residents are more often involved in cases with greater complexity at teaching institutions.^24-26 Therefore, the higher mortality seen among laryngectomies with senior resident involvement is likely due to the higher complexity of those cases.

The proportion of resident involvement in laryngectomies at VA medical centers has been decreasing over time. Due to the single payer nature of the VA health care system and the number of complex and comorbid patients, the VA offers an invaluable space for resident education in the OR. The fact that less than half of laryngectomies in 2021 involved resident participation is noteworthy for residency training programs. As wRVU compensation models evolve, VA attending surgeons may face less pressure to move the case along, leading to a high potential for operative teaching. Therefore, complex cases, such as laryngectomies, are often ideal for resident participation in the VA.

The steady decline in total laryngectomies at the VA parallels the recent decrease seen in non-VA settings.²⁰ This is due in part to the use of larynx-preserving treatment modalities for laryngeal cancer as well as decreases in the incidence of laryngeal cancer due to population level changes in smoking behaviors. ^18,19 Although a laryngectomy is not a key indicator case as determined by the Accreditation Council for Graduate Medical Education, it is important for otolaryngology residents to be exposed to these cases and have a thorough understanding of the operative technique.²⁷ Total laryngectomy was selected for this study because it is a complex and time-consuming surgery with somewhat standardized surgical steps. Unlike microvascular surgery that is very rarely performed by an attending physician alone, laryngectomies can be performed by attending physicians alone or with a resident.²⁸

Limitations

Since this was a retrospective study, it was susceptible to errors in data entry and data extraction from the VASQIP database. Another limitation is the lack of preoperative treatment data on tumor stage and prior nonoperative treatment. For example, a salvage laryngectomy after treatment with radiation and/or chemoradiation is a higher risk procedure than an upfront laryngectomy. Senior resident involvement may be more common in patients undergoing salvage laryngectomy due to the high risk of postoperative fistula and other complications. This may have contributed to the association identified between senior resident participation and 30-day mortality.

Since we could not account for residents who took research years or were fellows, a senior resident may have been mislabeled as a junior resident or vice versa. However, because most research years occur following the third year of residency. We are confident that PGY-1, PGY-2, and PGY-3 is likely to capture junior residents. Other factors, such as coattending surgeon cases, medical student assistance, and fellow involvement may have also impacted the results of this study.

Conclusions

This study is the first to investigate the impact of resident participation on operative time, wRVUs generated, and complication rates in head and neck surgery at VA medical centers. It found that resident participation in total laryngectomies among veterans increased operative time and reduced wRVUs generated per hour but did not impact complication rate or patient return to the OR. The VA offers a unique and invaluable space for resident education and operative training, and the recent decline in resident participation among laryngectomies is important for residency programs to acknowledge and potentially address moving forward.

In contrast to oral cavity resections which can vary from partial glossectomies to composite resections, laryngectomy represents a homogenous procedure from which to draw meaningful conclusions about complication rates, operative time, and outcome. Future directions should include studying other types of head and neck surgery in the VA to determine whether the impact of resident participation mirrors the findings of this study.

The US Department of Veterans Affairs (VA) has been integral in resident training. Resident surgical training requires a balance of supervision and autonomy, along with procedure repetition and appropriate feedback.^1-3 Non-VA research has found that resident participation across various otolaryngology procedures, including thyroidectomy, neck dissection, and laryngectomy, does not increase patient morbidity.^4-7 However, resident involvement in private and academic settings that included nonhead and neck procedures was linked to increased operative time and reduced productivity, as determined by work relative value units (wRVUs).^7-13 This has also been identified in other specialties, including general surgery, orthopedics, and ophthalmology.^14-16

Unlike the private sector, surgeon compensation at the VA is not as closely linked to operative productivity, offering a unique setting for resident training. While VA integration in otolaryngology residency programs increases resident case numbers, particularly in head and neck cases, the impact on VA patient outcomes and productivity is unknown.¹⁷ The use of larynxpreserving treatment modalities for laryngeal cancer has led to a decline in the number of total laryngectomies performed, which could potentially impact resident operative training for laryngectomies.^18-20

This study sought to determine the impact of resident participation on operative time, wRVUs, and patient outcomes in veterans who underwent a total laryngectomy. This study was reviewed and approved by the MedStar Georgetown University Hospital Institutional Review Board and Research and Development Committee (#1595672).

Methods

A retrospective cohort of veterans nationwide who underwent total laryngectomy between 2001 and 2021, with or without neck dissection, was identified from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Data were extracted via the VA Informatics and Computing Infrastructure and patients were included based on Current Procedural Terminology codes for total laryngectomy, with or without neck dissection (31320, 31360, 31365). Laryngopharyngectomies, partial laryngectomies, and minimally invasive laryngectomies were excluded. VASQIP nurse data managers reviewed patient data for operative data, postoperative outcomes (including 30- day morbidity and mortality), and preoperative risk factors (Appendix).²¹

The VASQIP data provide the highest resident or postgraduate year (PGY) per surgery. PGY 1, 2, and 3 were considered junior residents and PGY ≥4, surgical fellows, and individuals who took research years during residency were considered senior residents. Cases performed by attending physicians alone were compared with those involving junior or senior residents.

Patient demographic data included age, body mass index, smoking and alcohol use, weight loss, and functional status. Consumption of any tobacco products within 12 months of surgery was considered tobacco use. Drinking on average ≥2 alcoholic beverages daily was considered alcohol use. Weight loss was defined as a 10% reduction in body weight within the 6 months before surgery, excluding patients enrolled in a weight loss program. Functional status was categorized as independent, partially dependent, totally dependent, and unknown.

Primary outcomes included operative time, wRVUs generated, and wRVUs generated per hour of operative time. Postoperative complications were recorded both as a continuous variable and as a binary variable for presence or absence of a complication. Additional outcome variables included length of postoperative hospital stay, return to the operating room (OR), and death within 30 days of surgery.

Statistical Analysis

Data were summarized using frequency and percentage for categorical variables and median with IQR for continuous variables. Data were also summarized based on resident involvement in the surgery and the PGY level of the residents involved. The occurrence of total laryngectomy, rate of complications, and patient return to the OR were summarized by year.

Univariate associations between resident involvement and surgical outcomes were analyzed using the Kruskal-Wallis test for continuous variables and the ÷2 test for categorical variables. A Fisher exact test was used when the cell count in the contingency table was < 5. The univariate associations between surgical outcomes and demographic/preoperative variables were examined using 2-sided Wilcoxon ranksum tests or Kruskal-Wallis tests between continuous variables and categorical variables, X² or Fisher exact test between 2 categorical variables, and 2-sided Spearman correlation test between 2 continuous variables. A false-discovery rate approach was used for simultaneous posthoc tests to determine the adjusted P values for wRVUs generated/operative time for attending physicians alone vs with junior residents and for attending physicians alone vs with senior residents. Models were used to evaluate the effects of resident involvement on surgical outcomes, adjusting for variables that showed significant univariate associations. Linear regression models were used for operative time, wRVUs generated, wRVUs generated/operative time, and length of postoperative stay. A logistic regression model was used for death within 30 days. Models were not built for postoperative complications or patient return to the OR, as these were only statistically significantly associated with the patient’s preoperative functional status. A finding was considered significant if P < .05. All analyses were performed using statistical software RStudio Version 2023.03.0.

Results

Between 2001 and 2021, 1857 patients who underwent total laryngectomy were identified from the VASQIP database nationwide. Most of the total laryngectomies were staffed by an attending physician with a senior resident (n = 1190, 64%), 446 (24%) were conducted by the attending physician alone, and 221 (12%) by an attending physician with a junior resident (Table 1). The mean operating time for an attending physician alone was 378 minutes, 384 minutes for an attending physician with a senior resident, and 432 minutes for an attending physician with a junior resident (Table 2). There was a statistically significant increase in operating time for laryngectomies with resident participation compared to attending physicians operating alone (P < .001).

When the wRVUs generated/operative time was analyzed, there was a statistically significant difference between comparison groups. Total laryngectomies performed by attending physicians alone had the highest wRVUs generated/operative time (5.5), followed by laryngectomies performed by attending physicians with senior residents and laryngectomies performed by attending physicians with junior residents (5.2 and 4.8, respectively; P = .002). Table 3 describes adjusted P values for wRVUs generated/ operative time for total laryngectomies performed by attending physicians alone vs with junior residents (P = .003) and for attending physicians alone vs with senior residents (P = .02). Resident participation in total laryngectomies did not significantly impact the development or number of postoperative complications or the rate of return to the OR.

The number of laryngectomies performed in a single fiscal year peaked in 2010 at 170 cases (Figure 1). Between 2001 and 2021, the mean rates of postoperative complications (21.3%) and patient return to the OR (14.6%) did not significantly change. Resident participation in total laryngectomies also peaked in 2010 at 89.0% but has significantly declined, falling to a low of 43.6% in 2021 (Figure 2). From 2001 to 2011, the mean resident participation rate in total laryngectomies was 80.6%, compared with 68.3% from 2012 to 2021 (P < .001).

The effect of various demographic and preoperative characteristics on surgical outcomes was also analyzed. A linear regression model accounted for each variable significantly associated with operative time. On multivariable analysis, when all other variables were held constant, Table 4 shows the estimated change in operative time based on certain criteria. For instance, the operative time for attendings with junior residents surgeries was 40 minutes longer (95% CI, 16 to 64) than that of attending alone surgeries (P = .001). Furthermore, operative time decreased by 1.1 minutes (95% CI, 0.30 to 2.04) for each 1-year increase in patient age (P = .009).

A multivariable logistic regression model evaluated the effect of resident involvement on 30-day mortality rates. Senior resident involvement (P = .02), partially dependent functional status (P = .01), totally dependent functional status (P < .001), and advanced age (P = .02) all were significantly associated with 30-day mortality (Table 5). When other variables remained constant, the odds of death for totally dependent patients were 10.4 times higher than that of patients with independent functional status. Thus, totally dependent functional status appeared to have a greater impact on this outcome than resident participation. The linear regression model for postoperative length of stay demonstrated that senior resident involvement (P = .04), functional status (partially dependent vs independent P < .001), and age (P = .03) were significantly associated with prolonged length of stay.

Discussion

Otolaryngology residency training is designed to educate future otolaryngologists through hands-on learning, adequate feedback, and supervision.¹ Although this exposure is paramount for resident education, balancing appropriate supervision and autonomy while mitigating patient risk has been difficult. Numerous non-VA studies have reviewed the impact of resident participation on patient outcomes in various specialties, ranging from a single institution to the National Surgical Quality Improvement Program (NSQIP).^4,5,7,22 This study is the first to describe the nationwide impact of resident participation on outcomes in veterans undergoing total laryngectomy.

This study found that resident participation increases operative time and decreases wRVUs generated/operative time without impacting complication rates or patient return to the OR. This reinforces the notion that under close supervision, resident participation does not negatively impact patient outcomes. Resident operative training requires time and dedication by the attending physician and surgical team, thereby increasing operative time. Because VA physician compensation is not linked with productivity as closely as it is in other private and academic settings, surgeons can dedicate more time to operative teaching. This study found that a total laryngectomy involving a junior resident took about 45 minutes longer than an attending physician working alone.

As expected, with longer operative times, the wRVUs generated/operative time ratio was lower in cases with resident participation. Even though resident participation leads to lower OR efficiency, their participation may not significantly impact ancillary costs.²³ However, a recent study from NSQIP found an opportunity cost of $60.44 per hour for surgeons operating with a resident in head and neck cases.¹³

Postoperative complications and mortality are key measures of surgical outcomes in addition to operative time and efficiency. This study found that neither junior nor senior resident participation significantly increased complication rates or patient return to the OR. Despite declining resident involvement and the number of total laryngectomy surgeries in the VA, the complication rate has remained steady. The 30-day mortality rate was significantly higher in cases involving senior residents compared to cases with attending physicians alone. This could be a result of senior resident participation in more challenging cases, such as laryngectomies performed as salvage surgery following radiation. Residents are more often involved in cases with greater complexity at teaching institutions.^24-26 Therefore, the higher mortality seen among laryngectomies with senior resident involvement is likely due to the higher complexity of those cases.

The proportion of resident involvement in laryngectomies at VA medical centers has been decreasing over time. Due to the single payer nature of the VA health care system and the number of complex and comorbid patients, the VA offers an invaluable space for resident education in the OR. The fact that less than half of laryngectomies in 2021 involved resident participation is noteworthy for residency training programs. As wRVU compensation models evolve, VA attending surgeons may face less pressure to move the case along, leading to a high potential for operative teaching. Therefore, complex cases, such as laryngectomies, are often ideal for resident participation in the VA.

The steady decline in total laryngectomies at the VA parallels the recent decrease seen in non-VA settings.²⁰ This is due in part to the use of larynx-preserving treatment modalities for laryngeal cancer as well as decreases in the incidence of laryngeal cancer due to population level changes in smoking behaviors. ^18,19 Although a laryngectomy is not a key indicator case as determined by the Accreditation Council for Graduate Medical Education, it is important for otolaryngology residents to be exposed to these cases and have a thorough understanding of the operative technique.²⁷ Total laryngectomy was selected for this study because it is a complex and time-consuming surgery with somewhat standardized surgical steps. Unlike microvascular surgery that is very rarely performed by an attending physician alone, laryngectomies can be performed by attending physicians alone or with a resident.²⁸

Limitations

Since this was a retrospective study, it was susceptible to errors in data entry and data extraction from the VASQIP database. Another limitation is the lack of preoperative treatment data on tumor stage and prior nonoperative treatment. For example, a salvage laryngectomy after treatment with radiation and/or chemoradiation is a higher risk procedure than an upfront laryngectomy. Senior resident involvement may be more common in patients undergoing salvage laryngectomy due to the high risk of postoperative fistula and other complications. This may have contributed to the association identified between senior resident participation and 30-day mortality.

Since we could not account for residents who took research years or were fellows, a senior resident may have been mislabeled as a junior resident or vice versa. However, because most research years occur following the third year of residency. We are confident that PGY-1, PGY-2, and PGY-3 is likely to capture junior residents. Other factors, such as coattending surgeon cases, medical student assistance, and fellow involvement may have also impacted the results of this study.

Conclusions

This study is the first to investigate the impact of resident participation on operative time, wRVUs generated, and complication rates in head and neck surgery at VA medical centers. It found that resident participation in total laryngectomies among veterans increased operative time and reduced wRVUs generated per hour but did not impact complication rate or patient return to the OR. The VA offers a unique and invaluable space for resident education and operative training, and the recent decline in resident participation among laryngectomies is important for residency programs to acknowledge and potentially address moving forward.

In contrast to oral cavity resections which can vary from partial glossectomies to composite resections, laryngectomy represents a homogenous procedure from which to draw meaningful conclusions about complication rates, operative time, and outcome. Future directions should include studying other types of head and neck surgery in the VA to determine whether the impact of resident participation mirrors the findings of this study.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

Random biopsy during colonoscopy improves dysplasia detection among patients with inflammatory bowel disease (IBD), but level of benefit depends on equipment and disease characteristics, according to a recent review and meta-analysis.

Random biopsies collected in studies after 2011 provided limited additional yield, suggesting that high-definition equipment alone may be sufficient to achieve a high detection rate, lead author Li Gao, MD, of Air Force Medical University, Xi’an, China, and colleagues reported. In contrast, patients with primary sclerosing cholangitis (PSC) consistently benefited from random biopsy, offering clearer support for use in this subgroup.

“Random biopsy has been proposed as a strategy that may detect dysplastic lesions that cannot be identified endoscopically, thus minimizing the occurrence of missed colitis-associated dysplasia during colonoscopy,” the investigators wrote in Clinical Gastroenterology and Hepatology. However, the role of random biopsies in colonoscopic surveillance for patients with IBD remains a topic of ongoing debate.”

The SCENIC guidelines remain inconclusive on the role of random biopsy in IBD surveillance, the investigators noted, while other guidelines recommend random biopsy with high-definition white light endoscopy, but not chromoendoscopy. 

The present meta-analysis aimed to characterize the impact of random biopsy on dysplasia detection. The investigators aggregated prospective and retrospective studies published in English through September 2023, all of which compared random biopsy with other surveillance techniques and reported the proportion of dysplasia detected exclusively through random biopsy. 

“To the best of our knowledge, this systematic review and meta-analysis was the first comprehensive summary of the additional yield of random biopsy during colorectal cancer surveillance in patients with IBD,” Dr. Gao and colleagues noted.

The final dataset comprised 37 studies with 9,051 patients undergoing colorectal cancer surveillance for IBD. Patients had diverse baseline characteristics, including different proportions of ulcerative colitis and Crohn’s disease, as well as varying prevalence of PSC, a known risk factor for colorectal neoplasia.

The pooled additional yield of random biopsy was 10.34% in per-patient analysis and 16.20% in per-lesion analysis, meaning that approximately 1 in 10 patients and 1 in 6 lesions were detected exclusively through random biopsy. Despite these benefits, detection rates were relatively low: 1.31% per patient and 2.82% per lesion.

Subgroup analyses showed a decline in random biopsy additional yield over time. Studies conducted before 2011 reported an additional yield of 14.43% in per-patient analysis, compared to just 0.42% in studies conducted after 2011. This decline coincided with the widespread adoption of high-definition endoscopy.

PSC status strongly influenced detection rates throughout the study period. In patients without PSC (0%-10% PSC prevalence), the additional yield of random biopsy was 4.83% in per-patient analysis and 11.23% in per-lesion analysis. In studies where all patients had PSC, the additional yield increased dramatically to 56.05% and 45.22%, respectively.

“These findings highlight the incremental benefits of random biopsy and provide valuable insights into the management of endoscopic surveillance in patients with IBD,” the investigators wrote. “Considering the decreased additional yields in studies initiated after 2011, and the influence of PSC, endoscopy centers lacking full high-definition equipment should consider incorporating random biopsy in the standard colonoscopy surveillance for IBD patients, especially in those with PSC.”This study was supported by the National Key R&D Program of China, the Key Research and Development Program of Shaanxi Province, and the Nanchang High-Level Scientific and Technological Innovation Talents “Double Hundred Plan” project. The investigators disclosed no conflicts of interest.

Random biopsy during colonoscopy improves dysplasia detection among patients with inflammatory bowel disease (IBD), but level of benefit depends on equipment and disease characteristics, according to a recent review and meta-analysis.

Random biopsies collected in studies after 2011 provided limited additional yield, suggesting that high-definition equipment alone may be sufficient to achieve a high detection rate, lead author Li Gao, MD, of Air Force Medical University, Xi’an, China, and colleagues reported. In contrast, patients with primary sclerosing cholangitis (PSC) consistently benefited from random biopsy, offering clearer support for use in this subgroup.

“Random biopsy has been proposed as a strategy that may detect dysplastic lesions that cannot be identified endoscopically, thus minimizing the occurrence of missed colitis-associated dysplasia during colonoscopy,” the investigators wrote in Clinical Gastroenterology and Hepatology. However, the role of random biopsies in colonoscopic surveillance for patients with IBD remains a topic of ongoing debate.”

The SCENIC guidelines remain inconclusive on the role of random biopsy in IBD surveillance, the investigators noted, while other guidelines recommend random biopsy with high-definition white light endoscopy, but not chromoendoscopy. 

The present meta-analysis aimed to characterize the impact of random biopsy on dysplasia detection. The investigators aggregated prospective and retrospective studies published in English through September 2023, all of which compared random biopsy with other surveillance techniques and reported the proportion of dysplasia detected exclusively through random biopsy. 

“To the best of our knowledge, this systematic review and meta-analysis was the first comprehensive summary of the additional yield of random biopsy during colorectal cancer surveillance in patients with IBD,” Dr. Gao and colleagues noted.

The final dataset comprised 37 studies with 9,051 patients undergoing colorectal cancer surveillance for IBD. Patients had diverse baseline characteristics, including different proportions of ulcerative colitis and Crohn’s disease, as well as varying prevalence of PSC, a known risk factor for colorectal neoplasia.

The pooled additional yield of random biopsy was 10.34% in per-patient analysis and 16.20% in per-lesion analysis, meaning that approximately 1 in 10 patients and 1 in 6 lesions were detected exclusively through random biopsy. Despite these benefits, detection rates were relatively low: 1.31% per patient and 2.82% per lesion.

Subgroup analyses showed a decline in random biopsy additional yield over time. Studies conducted before 2011 reported an additional yield of 14.43% in per-patient analysis, compared to just 0.42% in studies conducted after 2011. This decline coincided with the widespread adoption of high-definition endoscopy.

PSC status strongly influenced detection rates throughout the study period. In patients without PSC (0%-10% PSC prevalence), the additional yield of random biopsy was 4.83% in per-patient analysis and 11.23% in per-lesion analysis. In studies where all patients had PSC, the additional yield increased dramatically to 56.05% and 45.22%, respectively.

“These findings highlight the incremental benefits of random biopsy and provide valuable insights into the management of endoscopic surveillance in patients with IBD,” the investigators wrote. “Considering the decreased additional yields in studies initiated after 2011, and the influence of PSC, endoscopy centers lacking full high-definition equipment should consider incorporating random biopsy in the standard colonoscopy surveillance for IBD patients, especially in those with PSC.”This study was supported by the National Key R&D Program of China, the Key Research and Development Program of Shaanxi Province, and the Nanchang High-Level Scientific and Technological Innovation Talents “Double Hundred Plan” project. The investigators disclosed no conflicts of interest.

Random biopsy during colonoscopy improves dysplasia detection among patients with inflammatory bowel disease (IBD), but level of benefit depends on equipment and disease characteristics, according to a recent review and meta-analysis.

Random biopsies collected in studies after 2011 provided limited additional yield, suggesting that high-definition equipment alone may be sufficient to achieve a high detection rate, lead author Li Gao, MD, of Air Force Medical University, Xi’an, China, and colleagues reported. In contrast, patients with primary sclerosing cholangitis (PSC) consistently benefited from random biopsy, offering clearer support for use in this subgroup.

“Random biopsy has been proposed as a strategy that may detect dysplastic lesions that cannot be identified endoscopically, thus minimizing the occurrence of missed colitis-associated dysplasia during colonoscopy,” the investigators wrote in Clinical Gastroenterology and Hepatology. However, the role of random biopsies in colonoscopic surveillance for patients with IBD remains a topic of ongoing debate.”

The SCENIC guidelines remain inconclusive on the role of random biopsy in IBD surveillance, the investigators noted, while other guidelines recommend random biopsy with high-definition white light endoscopy, but not chromoendoscopy. 

The present meta-analysis aimed to characterize the impact of random biopsy on dysplasia detection. The investigators aggregated prospective and retrospective studies published in English through September 2023, all of which compared random biopsy with other surveillance techniques and reported the proportion of dysplasia detected exclusively through random biopsy. 

“To the best of our knowledge, this systematic review and meta-analysis was the first comprehensive summary of the additional yield of random biopsy during colorectal cancer surveillance in patients with IBD,” Dr. Gao and colleagues noted.

The final dataset comprised 37 studies with 9,051 patients undergoing colorectal cancer surveillance for IBD. Patients had diverse baseline characteristics, including different proportions of ulcerative colitis and Crohn’s disease, as well as varying prevalence of PSC, a known risk factor for colorectal neoplasia.

The pooled additional yield of random biopsy was 10.34% in per-patient analysis and 16.20% in per-lesion analysis, meaning that approximately 1 in 10 patients and 1 in 6 lesions were detected exclusively through random biopsy. Despite these benefits, detection rates were relatively low: 1.31% per patient and 2.82% per lesion.

Subgroup analyses showed a decline in random biopsy additional yield over time. Studies conducted before 2011 reported an additional yield of 14.43% in per-patient analysis, compared to just 0.42% in studies conducted after 2011. This decline coincided with the widespread adoption of high-definition endoscopy.

PSC status strongly influenced detection rates throughout the study period. In patients without PSC (0%-10% PSC prevalence), the additional yield of random biopsy was 4.83% in per-patient analysis and 11.23% in per-lesion analysis. In studies where all patients had PSC, the additional yield increased dramatically to 56.05% and 45.22%, respectively.

“These findings highlight the incremental benefits of random biopsy and provide valuable insights into the management of endoscopic surveillance in patients with IBD,” the investigators wrote. “Considering the decreased additional yields in studies initiated after 2011, and the influence of PSC, endoscopy centers lacking full high-definition equipment should consider incorporating random biopsy in the standard colonoscopy surveillance for IBD patients, especially in those with PSC.”This study was supported by the National Key R&D Program of China, the Key Research and Development Program of Shaanxi Province, and the Nanchang High-Level Scientific and Technological Innovation Talents “Double Hundred Plan” project. The investigators disclosed no conflicts of interest.

More than one in five of new gastrointestinal (GI) cancer cases globally were attributable to suboptimal dietary intake, according to a recent study.

Writing in Gastroenterology, researchers led by Li Liu, PhD, of the department of epidemiology and biostatistics, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, reported that excessive consumption of processed meats (the biggest culprit), insufficient fruit intake, and insufficient whole grain intake were the leading dietary risk factors. In addition, the number of diet-related cases doubled from 1990 to 2018.

 

“In regions with limited access to healthy foods, policy interventions like taxing unhealthy foods and subsidizing nutritious options may help shift dietary patterns and reduce cancer risk,” Liu said in an interview.

The study examined meta-analyses from 184 countries in seven regions for the period 1990-2018 looking at rates of six major GI cancers: colorectal, liver, esophageal, pancreatic, and gallbladder/biliary tract. Among these, the age-standardized incidence of liver, pancreatic, and colorectal increased significantly over the past 3 decades.

The research team used a comparative risk assessment model to estimate the impact of diet on GI cancer independent of energy intake and adiposity. Although the principal dietary risk factors varied across individual cancers, suboptimal intake of the three aforementioned components was responsible for 66.51% of all diet-attributable GI cancers in 2018. The global mean processed meat consumption was 17 g/d in 2018, falling to a low in South Asia of 3 g/d.

The investigators also found diet-linked cancer incidence positively correlated with the Sociodemographic Index (SDI), an integrated measure of national development, income, and fertility. Incidence varied across world regions, with the highest proportion of cases in Central and Eastern Europe, Central Asia, Latin America, the Caribbean, and in high-income countries. The findings support the development of targeted diet-related public health interventions in various regions and nations to reduce GI cancer incidence, the authors wrote.

Among the study’s specific findings:

• In 2018, 21.5% (95% uncertainty interval [UI], 19.1-24.5) of incident GI cancer cases globally were attributable to suboptimal diets, a relatively stable proportion since 1990 (22.4%; 95% UI, 19.7-25.6).
• Absolute diet-attributable cases doubled from 580,862 (95% UI, 510,658-664,076) in 1990 to 1,039,877 (95% UI, 923,482-1,187,244) in 2018.
• Excessive processed meat consumption (5.9%; 95% UI, 4.2%-7.9%), insufficient fruit intake (4.8%; 95% UI, 3.8%-5.9%), and insufficient whole grain intake (3.6%; 95% UI, 2.8%-5.1%) were the most significant dietary risk factors in 2018 — a shift from 1990 when the third major concern was insufficient non-starchy vegetable intake.

Given the well-established link between diet and GI cancers, the incidence findings came as no surprise. “However, the dramatic doubling of diet-attributable cases over the past few decades was truly unexpected,” Liu said. “This increase can likely be attributed to global population growth and aging. While aging is an irreversible process, we can still reduce the growing burden of diet-related GI cancers by focusing on modifiable behaviors, particularly through targeted dietary interventions.”

 

A Modifiable Risk Factor

Commenting on the analysis but not involved in it, Andrew T. Chan, MD, MPH, a professor of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital, both in Boston, noted that his own group’s studies also support the association of diet with an increased risk for GI cancers, particularly colorectal cancers.

“Although much work needs to be done to clarify the precise mechanisms underlying this association, there are substantial data that diet may cause changes in the gut microbiome, which in turn promotes cancer,” Chan said in an interview. “Going forward, we are working to develop strategies in which diet is modified to mitigate the risk of cancer associated with suboptimal diets.”

In other study findings, Liu’s group observed that two regional groups, Central and Eastern Europe, Central Asia, Latin America, and the Caribbean, as well as high-income countries, bore the top three diet-attributable burdens worldwide in 2018, all driven mostly by an upward-trending excess of processed meat.

By regions, Central and Eastern Europe and Central Asia experienced the highest attributable burden across regions in 1990 (31.6%; UI, 27.0%-37.4%) and 2018 (31.6%; UI, 27.3%-36.5%).

As for the impact of the SDI, the authors explained that diet-attributable GI cancer burden was higher among adults with higher education and living in urban areas than among those with lower education and rural residency. “Some dietary habits tended to be worse in higher-SDI countries, specifically, higher consumption of processed meats,” they wrote.

Although the proportional attributable GI incidence remains relatively stable, they added, the doubling of absolute cases from 1990 to 2018, along with the discrepancies between urbanicity and countries/regions, supports more targeted preventive measures.

And while the diet-GI cancer connection is clear, they agreed with Chan in that “the precise pathogenesis from suboptimal diets to these cancers remains unclear and requires further basic studies to clarify the mechanism.”

In the meantime, the findings “underscore the urgent need for proactive public health interventions. Diet, as a modifiable risk factor, still offers substantial potential for improvement,” Liu said.

This study was funded by the National Natural Science Foundation of China and the American Cancer Society. The authors and Chan disclosed no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

More than one in five of new gastrointestinal (GI) cancer cases globally were attributable to suboptimal dietary intake, according to a recent study.

Writing in Gastroenterology, researchers led by Li Liu, PhD, of the department of epidemiology and biostatistics, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, reported that excessive consumption of processed meats (the biggest culprit), insufficient fruit intake, and insufficient whole grain intake were the leading dietary risk factors. In addition, the number of diet-related cases doubled from 1990 to 2018.

 

“In regions with limited access to healthy foods, policy interventions like taxing unhealthy foods and subsidizing nutritious options may help shift dietary patterns and reduce cancer risk,” Liu said in an interview.

The study examined meta-analyses from 184 countries in seven regions for the period 1990-2018 looking at rates of six major GI cancers: colorectal, liver, esophageal, pancreatic, and gallbladder/biliary tract. Among these, the age-standardized incidence of liver, pancreatic, and colorectal increased significantly over the past 3 decades.

The research team used a comparative risk assessment model to estimate the impact of diet on GI cancer independent of energy intake and adiposity. Although the principal dietary risk factors varied across individual cancers, suboptimal intake of the three aforementioned components was responsible for 66.51% of all diet-attributable GI cancers in 2018. The global mean processed meat consumption was 17 g/d in 2018, falling to a low in South Asia of 3 g/d.

The investigators also found diet-linked cancer incidence positively correlated with the Sociodemographic Index (SDI), an integrated measure of national development, income, and fertility. Incidence varied across world regions, with the highest proportion of cases in Central and Eastern Europe, Central Asia, Latin America, the Caribbean, and in high-income countries. The findings support the development of targeted diet-related public health interventions in various regions and nations to reduce GI cancer incidence, the authors wrote.

Among the study’s specific findings:

• In 2018, 21.5% (95% uncertainty interval [UI], 19.1-24.5) of incident GI cancer cases globally were attributable to suboptimal diets, a relatively stable proportion since 1990 (22.4%; 95% UI, 19.7-25.6).
• Absolute diet-attributable cases doubled from 580,862 (95% UI, 510,658-664,076) in 1990 to 1,039,877 (95% UI, 923,482-1,187,244) in 2018.
• Excessive processed meat consumption (5.9%; 95% UI, 4.2%-7.9%), insufficient fruit intake (4.8%; 95% UI, 3.8%-5.9%), and insufficient whole grain intake (3.6%; 95% UI, 2.8%-5.1%) were the most significant dietary risk factors in 2018 — a shift from 1990 when the third major concern was insufficient non-starchy vegetable intake.

Given the well-established link between diet and GI cancers, the incidence findings came as no surprise. “However, the dramatic doubling of diet-attributable cases over the past few decades was truly unexpected,” Liu said. “This increase can likely be attributed to global population growth and aging. While aging is an irreversible process, we can still reduce the growing burden of diet-related GI cancers by focusing on modifiable behaviors, particularly through targeted dietary interventions.”

 

A Modifiable Risk Factor

Commenting on the analysis but not involved in it, Andrew T. Chan, MD, MPH, a professor of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital, both in Boston, noted that his own group’s studies also support the association of diet with an increased risk for GI cancers, particularly colorectal cancers.

“Although much work needs to be done to clarify the precise mechanisms underlying this association, there are substantial data that diet may cause changes in the gut microbiome, which in turn promotes cancer,” Chan said in an interview. “Going forward, we are working to develop strategies in which diet is modified to mitigate the risk of cancer associated with suboptimal diets.”

In other study findings, Liu’s group observed that two regional groups, Central and Eastern Europe, Central Asia, Latin America, and the Caribbean, as well as high-income countries, bore the top three diet-attributable burdens worldwide in 2018, all driven mostly by an upward-trending excess of processed meat.

By regions, Central and Eastern Europe and Central Asia experienced the highest attributable burden across regions in 1990 (31.6%; UI, 27.0%-37.4%) and 2018 (31.6%; UI, 27.3%-36.5%).

As for the impact of the SDI, the authors explained that diet-attributable GI cancer burden was higher among adults with higher education and living in urban areas than among those with lower education and rural residency. “Some dietary habits tended to be worse in higher-SDI countries, specifically, higher consumption of processed meats,” they wrote.

Although the proportional attributable GI incidence remains relatively stable, they added, the doubling of absolute cases from 1990 to 2018, along with the discrepancies between urbanicity and countries/regions, supports more targeted preventive measures.

And while the diet-GI cancer connection is clear, they agreed with Chan in that “the precise pathogenesis from suboptimal diets to these cancers remains unclear and requires further basic studies to clarify the mechanism.”

In the meantime, the findings “underscore the urgent need for proactive public health interventions. Diet, as a modifiable risk factor, still offers substantial potential for improvement,” Liu said.

This study was funded by the National Natural Science Foundation of China and the American Cancer Society. The authors and Chan disclosed no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

More than one in five of new gastrointestinal (GI) cancer cases globally were attributable to suboptimal dietary intake, according to a recent study.

Writing in Gastroenterology, researchers led by Li Liu, PhD, of the department of epidemiology and biostatistics, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, reported that excessive consumption of processed meats (the biggest culprit), insufficient fruit intake, and insufficient whole grain intake were the leading dietary risk factors. In addition, the number of diet-related cases doubled from 1990 to 2018.

 

“In regions with limited access to healthy foods, policy interventions like taxing unhealthy foods and subsidizing nutritious options may help shift dietary patterns and reduce cancer risk,” Liu said in an interview.

The study examined meta-analyses from 184 countries in seven regions for the period 1990-2018 looking at rates of six major GI cancers: colorectal, liver, esophageal, pancreatic, and gallbladder/biliary tract. Among these, the age-standardized incidence of liver, pancreatic, and colorectal increased significantly over the past 3 decades.

The research team used a comparative risk assessment model to estimate the impact of diet on GI cancer independent of energy intake and adiposity. Although the principal dietary risk factors varied across individual cancers, suboptimal intake of the three aforementioned components was responsible for 66.51% of all diet-attributable GI cancers in 2018. The global mean processed meat consumption was 17 g/d in 2018, falling to a low in South Asia of 3 g/d.

The investigators also found diet-linked cancer incidence positively correlated with the Sociodemographic Index (SDI), an integrated measure of national development, income, and fertility. Incidence varied across world regions, with the highest proportion of cases in Central and Eastern Europe, Central Asia, Latin America, the Caribbean, and in high-income countries. The findings support the development of targeted diet-related public health interventions in various regions and nations to reduce GI cancer incidence, the authors wrote.

Among the study’s specific findings:

• In 2018, 21.5% (95% uncertainty interval [UI], 19.1-24.5) of incident GI cancer cases globally were attributable to suboptimal diets, a relatively stable proportion since 1990 (22.4%; 95% UI, 19.7-25.6).
• Absolute diet-attributable cases doubled from 580,862 (95% UI, 510,658-664,076) in 1990 to 1,039,877 (95% UI, 923,482-1,187,244) in 2018.
• Excessive processed meat consumption (5.9%; 95% UI, 4.2%-7.9%), insufficient fruit intake (4.8%; 95% UI, 3.8%-5.9%), and insufficient whole grain intake (3.6%; 95% UI, 2.8%-5.1%) were the most significant dietary risk factors in 2018 — a shift from 1990 when the third major concern was insufficient non-starchy vegetable intake.

Given the well-established link between diet and GI cancers, the incidence findings came as no surprise. “However, the dramatic doubling of diet-attributable cases over the past few decades was truly unexpected,” Liu said. “This increase can likely be attributed to global population growth and aging. While aging is an irreversible process, we can still reduce the growing burden of diet-related GI cancers by focusing on modifiable behaviors, particularly through targeted dietary interventions.”

 

A Modifiable Risk Factor

Commenting on the analysis but not involved in it, Andrew T. Chan, MD, MPH, a professor of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital, both in Boston, noted that his own group’s studies also support the association of diet with an increased risk for GI cancers, particularly colorectal cancers.

“Although much work needs to be done to clarify the precise mechanisms underlying this association, there are substantial data that diet may cause changes in the gut microbiome, which in turn promotes cancer,” Chan said in an interview. “Going forward, we are working to develop strategies in which diet is modified to mitigate the risk of cancer associated with suboptimal diets.”

In other study findings, Liu’s group observed that two regional groups, Central and Eastern Europe, Central Asia, Latin America, and the Caribbean, as well as high-income countries, bore the top three diet-attributable burdens worldwide in 2018, all driven mostly by an upward-trending excess of processed meat.

By regions, Central and Eastern Europe and Central Asia experienced the highest attributable burden across regions in 1990 (31.6%; UI, 27.0%-37.4%) and 2018 (31.6%; UI, 27.3%-36.5%).

As for the impact of the SDI, the authors explained that diet-attributable GI cancer burden was higher among adults with higher education and living in urban areas than among those with lower education and rural residency. “Some dietary habits tended to be worse in higher-SDI countries, specifically, higher consumption of processed meats,” they wrote.

Although the proportional attributable GI incidence remains relatively stable, they added, the doubling of absolute cases from 1990 to 2018, along with the discrepancies between urbanicity and countries/regions, supports more targeted preventive measures.

And while the diet-GI cancer connection is clear, they agreed with Chan in that “the precise pathogenesis from suboptimal diets to these cancers remains unclear and requires further basic studies to clarify the mechanism.”

In the meantime, the findings “underscore the urgent need for proactive public health interventions. Diet, as a modifiable risk factor, still offers substantial potential for improvement,” Liu said.

This study was funded by the National Natural Science Foundation of China and the American Cancer Society. The authors and Chan disclosed no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

About 18 veterans die by suicide daily, and while many received health care services in the year prior to their death, half did not receive a mental health diagnosis. 

To address this, the Veterans Health Administration (VHA) has updated or initiated programs and policies aimed at identifying at-risk veterans. Since May 2018, the VHA introduced the Suicide Risk Identification Strategy (Risk ID) program, which includes screening patients using the Columbia-Suicide Severity Rating Scale (C-SSRS). Positive screenings call for a licensed independent clinician to document a comprehensive suicide risk evaluation.

Despite these measures, challenges persist in implementation and effectiveness, outlined in reports issue by the VA Office of Inspector General (OIG) during the Biden Administration. Michael Missal, who had served as VA Inspector General since 2016 was recently dismissed by President Trump.

Risk ID

The OIG report surveyed 137 facilities regarding Risk ID processes, training, and monitoring. Findings from that review revealed gaps in training: suicide prevention training does not adequately address Risk ID requirements, leaving staff unprepared to conduct screenings and evaluations. Although the VHA has developed additional training related to Risk ID, the training is not required and the VHA does not monitor staff training completion.

The VHA requires annual screening for all patients and has established a screening clinical reminder in patients’ electronic health records. Despite this, the national screening metric remained below 60% in 2023. Conversely, same-day evaluations after positive screenings reached 82%, though this metric excludes patients who were not screened. In 2024, the VHA added Risk ID evaluation metrics to leadership performance plans, aiming to clarify standards and promote adherence.

Mental Health Treatment Coordinators

A second OIG investigation from December 2024 reviewed VHA requirements related to suicide risk identification processes and also evaluated national compliance with mental health treatment coordinator (MHTC) role requirements. 

Suicide risks peaks after discharge from mental health units, with 40% of suicidal behaviors occurring within 90 days. The VHA requires suicide risk screening within 24 hours of discharge and safety plans for high-risk patients using the C-SSRS, but the OIG found adherence issues. In a review of 200 patients discharged between October 2019 and September 2020, staff failed to complete the required screening for 27% of patients and safety plans for 12% of patients.

The VHA also requires clinicians to develop a safety plan with patients who recently attempted suicide or expressed suicidal ideation, are at risk of suicide prior to mental health unit discharge, or are determined to be at “high or intermediate acute or chronic risk” of suicide. For those patients, staff must flag the electronic health record.

OIG also found that over half of surveyed patients with an assigned MHTC were not able to identify the MHTC or another VHA staff member to contact for help with care. One-third of assigned MHTCs did not participate in patients’ transitions from inpatient to outpatient care. Despite the VHA no longer requiring 7-day follow-up appointments as of 2023, the OIG emphasized the need for guidance on scheduling postdischarge mental health appointments to promote engagement. 

Consistent with VHA’s discontinuation of a required 7-day follow-up appointment, the OIG recognizes that postdischarge follow-up appointments are most effectively scheduled in consideration of a patient’s treatment needs, preferences, and availability rather than an arbitrary timeliness expectation. Patients flagged as high-risk must attend 4 mental health visits within 30 days of discharge. However, the OIG found that only 48% met this requirement, while 34% attended 1 to 3 appointments, and 18% attended none. Among surveyed patients, self-motivation and encouragement from family or friends were key drivers of attendance.

The OIG concluded that failures in suicide risk identification and care coordination could lead to underestimated suicide risk, overestimated discharge readiness, and unmitigated risks. Inadequate safety planning may also leave patients ill-equipped to manage crises. While the VHA has updated guidelines for MHTC involvement, these measures have not significantly improved continuity of care.

About 18 veterans die by suicide daily, and while many received health care services in the year prior to their death, half did not receive a mental health diagnosis. 

To address this, the Veterans Health Administration (VHA) has updated or initiated programs and policies aimed at identifying at-risk veterans. Since May 2018, the VHA introduced the Suicide Risk Identification Strategy (Risk ID) program, which includes screening patients using the Columbia-Suicide Severity Rating Scale (C-SSRS). Positive screenings call for a licensed independent clinician to document a comprehensive suicide risk evaluation.

Despite these measures, challenges persist in implementation and effectiveness, outlined in reports issue by the VA Office of Inspector General (OIG) during the Biden Administration. Michael Missal, who had served as VA Inspector General since 2016 was recently dismissed by President Trump.

Risk ID

The OIG report surveyed 137 facilities regarding Risk ID processes, training, and monitoring. Findings from that review revealed gaps in training: suicide prevention training does not adequately address Risk ID requirements, leaving staff unprepared to conduct screenings and evaluations. Although the VHA has developed additional training related to Risk ID, the training is not required and the VHA does not monitor staff training completion.

The VHA requires annual screening for all patients and has established a screening clinical reminder in patients’ electronic health records. Despite this, the national screening metric remained below 60% in 2023. Conversely, same-day evaluations after positive screenings reached 82%, though this metric excludes patients who were not screened. In 2024, the VHA added Risk ID evaluation metrics to leadership performance plans, aiming to clarify standards and promote adherence.

Mental Health Treatment Coordinators

A second OIG investigation from December 2024 reviewed VHA requirements related to suicide risk identification processes and also evaluated national compliance with mental health treatment coordinator (MHTC) role requirements. 

Suicide risks peaks after discharge from mental health units, with 40% of suicidal behaviors occurring within 90 days. The VHA requires suicide risk screening within 24 hours of discharge and safety plans for high-risk patients using the C-SSRS, but the OIG found adherence issues. In a review of 200 patients discharged between October 2019 and September 2020, staff failed to complete the required screening for 27% of patients and safety plans for 12% of patients.

The VHA also requires clinicians to develop a safety plan with patients who recently attempted suicide or expressed suicidal ideation, are at risk of suicide prior to mental health unit discharge, or are determined to be at “high or intermediate acute or chronic risk” of suicide. For those patients, staff must flag the electronic health record.

OIG also found that over half of surveyed patients with an assigned MHTC were not able to identify the MHTC or another VHA staff member to contact for help with care. One-third of assigned MHTCs did not participate in patients’ transitions from inpatient to outpatient care. Despite the VHA no longer requiring 7-day follow-up appointments as of 2023, the OIG emphasized the need for guidance on scheduling postdischarge mental health appointments to promote engagement. 

Consistent with VHA’s discontinuation of a required 7-day follow-up appointment, the OIG recognizes that postdischarge follow-up appointments are most effectively scheduled in consideration of a patient’s treatment needs, preferences, and availability rather than an arbitrary timeliness expectation. Patients flagged as high-risk must attend 4 mental health visits within 30 days of discharge. However, the OIG found that only 48% met this requirement, while 34% attended 1 to 3 appointments, and 18% attended none. Among surveyed patients, self-motivation and encouragement from family or friends were key drivers of attendance.

The OIG concluded that failures in suicide risk identification and care coordination could lead to underestimated suicide risk, overestimated discharge readiness, and unmitigated risks. Inadequate safety planning may also leave patients ill-equipped to manage crises. While the VHA has updated guidelines for MHTC involvement, these measures have not significantly improved continuity of care.

About 18 veterans die by suicide daily, and while many received health care services in the year prior to their death, half did not receive a mental health diagnosis. 

To address this, the Veterans Health Administration (VHA) has updated or initiated programs and policies aimed at identifying at-risk veterans. Since May 2018, the VHA introduced the Suicide Risk Identification Strategy (Risk ID) program, which includes screening patients using the Columbia-Suicide Severity Rating Scale (C-SSRS). Positive screenings call for a licensed independent clinician to document a comprehensive suicide risk evaluation.

Despite these measures, challenges persist in implementation and effectiveness, outlined in reports issue by the VA Office of Inspector General (OIG) during the Biden Administration. Michael Missal, who had served as VA Inspector General since 2016 was recently dismissed by President Trump.

Risk ID

The OIG report surveyed 137 facilities regarding Risk ID processes, training, and monitoring. Findings from that review revealed gaps in training: suicide prevention training does not adequately address Risk ID requirements, leaving staff unprepared to conduct screenings and evaluations. Although the VHA has developed additional training related to Risk ID, the training is not required and the VHA does not monitor staff training completion.

The VHA requires annual screening for all patients and has established a screening clinical reminder in patients’ electronic health records. Despite this, the national screening metric remained below 60% in 2023. Conversely, same-day evaluations after positive screenings reached 82%, though this metric excludes patients who were not screened. In 2024, the VHA added Risk ID evaluation metrics to leadership performance plans, aiming to clarify standards and promote adherence.

Mental Health Treatment Coordinators

A second OIG investigation from December 2024 reviewed VHA requirements related to suicide risk identification processes and also evaluated national compliance with mental health treatment coordinator (MHTC) role requirements. 

Suicide risks peaks after discharge from mental health units, with 40% of suicidal behaviors occurring within 90 days. The VHA requires suicide risk screening within 24 hours of discharge and safety plans for high-risk patients using the C-SSRS, but the OIG found adherence issues. In a review of 200 patients discharged between October 2019 and September 2020, staff failed to complete the required screening for 27% of patients and safety plans for 12% of patients.

The VHA also requires clinicians to develop a safety plan with patients who recently attempted suicide or expressed suicidal ideation, are at risk of suicide prior to mental health unit discharge, or are determined to be at “high or intermediate acute or chronic risk” of suicide. For those patients, staff must flag the electronic health record.

OIG also found that over half of surveyed patients with an assigned MHTC were not able to identify the MHTC or another VHA staff member to contact for help with care. One-third of assigned MHTCs did not participate in patients’ transitions from inpatient to outpatient care. Despite the VHA no longer requiring 7-day follow-up appointments as of 2023, the OIG emphasized the need for guidance on scheduling postdischarge mental health appointments to promote engagement. 

Consistent with VHA’s discontinuation of a required 7-day follow-up appointment, the OIG recognizes that postdischarge follow-up appointments are most effectively scheduled in consideration of a patient’s treatment needs, preferences, and availability rather than an arbitrary timeliness expectation. Patients flagged as high-risk must attend 4 mental health visits within 30 days of discharge. However, the OIG found that only 48% met this requirement, while 34% attended 1 to 3 appointments, and 18% attended none. Among surveyed patients, self-motivation and encouragement from family or friends were key drivers of attendance.

The OIG concluded that failures in suicide risk identification and care coordination could lead to underestimated suicide risk, overestimated discharge readiness, and unmitigated risks. Inadequate safety planning may also leave patients ill-equipped to manage crises. While the VHA has updated guidelines for MHTC involvement, these measures have not significantly improved continuity of care.

A recent study found that despite their growing presence in inflammatory bowel disease (IBD) research, women investigators were inequitably represented at scientific presentations sponsored by the pharmaceutical industry. The study was published in Gastroenterology  and also appeared concurrently in Clinical Gastroenterology and Hepatology .

Indeed, among gastrointestinal (GI) subspecialties, IBD was selected by 26.5% of all women GI physicians, compared with 18.9% of all their male counterparts, according to a 2021 study.

Thus, conference organizers and pharmaceutical companies should promote speaker diversity by seeking out women presenters, according to a group led by Maria A. Quintero, MD, of the Division of Gastroenterology at the Leonard Miller School of Medicine at the University of Miami, Florida.

“Seeing more women IBD leaders at the podium will inspire other women to engage in IBD clinical research,” Quintero and associates wrote.

In addition, women investigators should be included at every stage of the study process in industry-sponsored research, both as principal investigators and members of steering committees involved in study design, the authors said. Training more women clinical trial investigators in the IBD setting is another way forward.

In another recommendation, pharmaceutical companies need to be more transparent about the way first and senior authors on IBD studies are chosen because in the past the principal investigator who enrolled the most patients became the first author of the study. “That is no longer the case. However, it remains unclear whether all investigators have an equal opportunity to be the first or senior author,” Quintero and associates wrote.

The Study

The investigators analyzed IBD abstracts of presentations at five conferences for two large GI meetings, Digestive Disease Week (DDW) and United European Gastroenterology (UEG) in the period 2021-2023.

They asked whether women investigators were as likely as their male counterparts to present abstracts based on results from industry-supported clinical trials. As a point of comparison, they also looked for possible gender differences in invited-speaker vs investigator-initiated IBD sessions. To do this, they examined all IBD-related abstracts from the two meetings, identified the lead author of each oral presentation, and divided them into women or men. They also assessed whether the presentation was pharma-sponsored, investigator-initiated, or presented by an invited speaker.

Among the study findings: 

• Across categories there were 178 invited lectures, 336 investigator-submitted presentations, and 150 industry-supported presentations for UEG (2021, 2022, and 2023) and DDW (2022 and 2023).
• The gender gap for men vs women was significant for industry-supported oral presentations (78.7% vs 21.3%; P < .0001) and for invited lectures (67.4% vs 32.6%; P < .0001) — but not for investigator-submitted abstracts (49.7% vs 50.3%; P = .91).
• The gender gap for industry-supported abstracts, however, was significantly larger than for investigator-submitted abstracts (57.3% vs 0.6%; P < .0001) and larger than for invited lectures (57.3% vs 34.9%; P = .09).
• The gender gap for invited lectures was significantly larger than for investigator-submitted oral presentations (34.9% vs 0.6%; P = .0009).

Why the Discordance?

This disparity may be due to the paucity of women investigators on steering committees for clinical trials. “Although the number of women doing IBD research continues to increase, then number of women senior investigators is still smaller than the number of men senior investigators,” the researchers wrote. “Ideally, there would be transparency in terms of the metrics used by pharma to choose who will be a presenting author and more intentional recruitment of women investigators to steering committees.”

Commenting on the study but not involved in it, internist Shannon M. Ruzycki, MD, MPH, an assistant professor in the Cumming School of Medicine at the University of Calgary Medical Centre in Alberta, Canada, said the findings are not surprising. “In nearly every setting where gender differences are studied in academic medicine, women are found to be disadvantaged compared to men. These differences are not attributable to skill, merit, or career attainment, but rather appear to be arbitrary and due to biases. They add up across time and likely contribute to the larger differences we see between men and women in promotion, compensation, and awards.”

Ruzycki, lead author of a study of women presenters at medical conferences, noted that differences in gender representation in academia, academic medicine, and clinical trials are similar “because the underlying causes are similar.” On the positive side, she added, conference planning committees are using strategies to reduce bias in how presenters are selected by masking the names and/or institutions of those are submitting abstracts and are being more intentional in inviting a diverse panel of qualified speakers.

“However, one strategy alone is unlikely to address such an insidious problem that affects all parts of selection,” she said. “For example, if pharmaceutical companies believe that men presenters are seen as more authoritative or knowledgeable than women presenters, they will select men to be the first author on submitted abstracts which could deprive these opportunities for deserving women candidates.”

Ruzycki attributed the imbalance to systems (academia, medicine, science) designed by men who lack empathy for the experiences of women. “In the same way you can never really understand how exhausting it is to be a parent until you become a parent or how challenging it can be to have a physical disability until you break a leg and have to navigate the world on crutches, it is really challenging for men to understand how cold and hostile these settings can be for women.”

Many of the things that make conferences, academia, and medicine so challenging for women have straightforward solutions, however, Ruzycki added. Onsite childcare, scrubs that fit women, operating room equipment that is ergonomic for women surgeons — even more washroom stalls would help. “If only we listened and cared about things that didn’t directly impact us.”

This study was supported by the 2023 Travel Grant from the International Organization for the Study of Inflammatory Bowel Diseases. One coauthor serves as a consultant or on advisory boards for AbbVie, Amgen, Bristol Myers Squibb, Celsius Therapeutics, Eli Lilly, Gilead Sciences, Janssen Pharmaceuticals, and Pfizer Pharmaceutical. She is a teacher, lecturer, and speaker for Janssen and Takeda Pharmaceuticals. The remaining authors disclosed no conflicts. Ruzycki had no relevant conflicts of interest to declare. 

A version of this article appeared on Medscape.com.

A recent study found that despite their growing presence in inflammatory bowel disease (IBD) research, women investigators were inequitably represented at scientific presentations sponsored by the pharmaceutical industry. The study was published in Gastroenterology  and also appeared concurrently in Clinical Gastroenterology and Hepatology .

Indeed, among gastrointestinal (GI) subspecialties, IBD was selected by 26.5% of all women GI physicians, compared with 18.9% of all their male counterparts, according to a 2021 study.

Thus, conference organizers and pharmaceutical companies should promote speaker diversity by seeking out women presenters, according to a group led by Maria A. Quintero, MD, of the Division of Gastroenterology at the Leonard Miller School of Medicine at the University of Miami, Florida.

“Seeing more women IBD leaders at the podium will inspire other women to engage in IBD clinical research,” Quintero and associates wrote.

In addition, women investigators should be included at every stage of the study process in industry-sponsored research, both as principal investigators and members of steering committees involved in study design, the authors said. Training more women clinical trial investigators in the IBD setting is another way forward.

In another recommendation, pharmaceutical companies need to be more transparent about the way first and senior authors on IBD studies are chosen because in the past the principal investigator who enrolled the most patients became the first author of the study. “That is no longer the case. However, it remains unclear whether all investigators have an equal opportunity to be the first or senior author,” Quintero and associates wrote.

The Study

The investigators analyzed IBD abstracts of presentations at five conferences for two large GI meetings, Digestive Disease Week (DDW) and United European Gastroenterology (UEG) in the period 2021-2023.

They asked whether women investigators were as likely as their male counterparts to present abstracts based on results from industry-supported clinical trials. As a point of comparison, they also looked for possible gender differences in invited-speaker vs investigator-initiated IBD sessions. To do this, they examined all IBD-related abstracts from the two meetings, identified the lead author of each oral presentation, and divided them into women or men. They also assessed whether the presentation was pharma-sponsored, investigator-initiated, or presented by an invited speaker.

Among the study findings: 

• Across categories there were 178 invited lectures, 336 investigator-submitted presentations, and 150 industry-supported presentations for UEG (2021, 2022, and 2023) and DDW (2022 and 2023).
• The gender gap for men vs women was significant for industry-supported oral presentations (78.7% vs 21.3%; P < .0001) and for invited lectures (67.4% vs 32.6%; P < .0001) — but not for investigator-submitted abstracts (49.7% vs 50.3%; P = .91).
• The gender gap for industry-supported abstracts, however, was significantly larger than for investigator-submitted abstracts (57.3% vs 0.6%; P < .0001) and larger than for invited lectures (57.3% vs 34.9%; P = .09).
• The gender gap for invited lectures was significantly larger than for investigator-submitted oral presentations (34.9% vs 0.6%; P = .0009).

Why the Discordance?

This disparity may be due to the paucity of women investigators on steering committees for clinical trials. “Although the number of women doing IBD research continues to increase, then number of women senior investigators is still smaller than the number of men senior investigators,” the researchers wrote. “Ideally, there would be transparency in terms of the metrics used by pharma to choose who will be a presenting author and more intentional recruitment of women investigators to steering committees.”

Commenting on the study but not involved in it, internist Shannon M. Ruzycki, MD, MPH, an assistant professor in the Cumming School of Medicine at the University of Calgary Medical Centre in Alberta, Canada, said the findings are not surprising. “In nearly every setting where gender differences are studied in academic medicine, women are found to be disadvantaged compared to men. These differences are not attributable to skill, merit, or career attainment, but rather appear to be arbitrary and due to biases. They add up across time and likely contribute to the larger differences we see between men and women in promotion, compensation, and awards.”

Ruzycki, lead author of a study of women presenters at medical conferences, noted that differences in gender representation in academia, academic medicine, and clinical trials are similar “because the underlying causes are similar.” On the positive side, she added, conference planning committees are using strategies to reduce bias in how presenters are selected by masking the names and/or institutions of those are submitting abstracts and are being more intentional in inviting a diverse panel of qualified speakers.

“However, one strategy alone is unlikely to address such an insidious problem that affects all parts of selection,” she said. “For example, if pharmaceutical companies believe that men presenters are seen as more authoritative or knowledgeable than women presenters, they will select men to be the first author on submitted abstracts which could deprive these opportunities for deserving women candidates.”

Ruzycki attributed the imbalance to systems (academia, medicine, science) designed by men who lack empathy for the experiences of women. “In the same way you can never really understand how exhausting it is to be a parent until you become a parent or how challenging it can be to have a physical disability until you break a leg and have to navigate the world on crutches, it is really challenging for men to understand how cold and hostile these settings can be for women.”

Many of the things that make conferences, academia, and medicine so challenging for women have straightforward solutions, however, Ruzycki added. Onsite childcare, scrubs that fit women, operating room equipment that is ergonomic for women surgeons — even more washroom stalls would help. “If only we listened and cared about things that didn’t directly impact us.”

This study was supported by the 2023 Travel Grant from the International Organization for the Study of Inflammatory Bowel Diseases. One coauthor serves as a consultant or on advisory boards for AbbVie, Amgen, Bristol Myers Squibb, Celsius Therapeutics, Eli Lilly, Gilead Sciences, Janssen Pharmaceuticals, and Pfizer Pharmaceutical. She is a teacher, lecturer, and speaker for Janssen and Takeda Pharmaceuticals. The remaining authors disclosed no conflicts. Ruzycki had no relevant conflicts of interest to declare. 

A version of this article appeared on Medscape.com.

A recent study found that despite their growing presence in inflammatory bowel disease (IBD) research, women investigators were inequitably represented at scientific presentations sponsored by the pharmaceutical industry. The study was published in Gastroenterology  and also appeared concurrently in Clinical Gastroenterology and Hepatology .

Indeed, among gastrointestinal (GI) subspecialties, IBD was selected by 26.5% of all women GI physicians, compared with 18.9% of all their male counterparts, according to a 2021 study.

Thus, conference organizers and pharmaceutical companies should promote speaker diversity by seeking out women presenters, according to a group led by Maria A. Quintero, MD, of the Division of Gastroenterology at the Leonard Miller School of Medicine at the University of Miami, Florida.

“Seeing more women IBD leaders at the podium will inspire other women to engage in IBD clinical research,” Quintero and associates wrote.

In addition, women investigators should be included at every stage of the study process in industry-sponsored research, both as principal investigators and members of steering committees involved in study design, the authors said. Training more women clinical trial investigators in the IBD setting is another way forward.

In another recommendation, pharmaceutical companies need to be more transparent about the way first and senior authors on IBD studies are chosen because in the past the principal investigator who enrolled the most patients became the first author of the study. “That is no longer the case. However, it remains unclear whether all investigators have an equal opportunity to be the first or senior author,” Quintero and associates wrote.

The Study

The investigators analyzed IBD abstracts of presentations at five conferences for two large GI meetings, Digestive Disease Week (DDW) and United European Gastroenterology (UEG) in the period 2021-2023.

They asked whether women investigators were as likely as their male counterparts to present abstracts based on results from industry-supported clinical trials. As a point of comparison, they also looked for possible gender differences in invited-speaker vs investigator-initiated IBD sessions. To do this, they examined all IBD-related abstracts from the two meetings, identified the lead author of each oral presentation, and divided them into women or men. They also assessed whether the presentation was pharma-sponsored, investigator-initiated, or presented by an invited speaker.

Among the study findings: 

• Across categories there were 178 invited lectures, 336 investigator-submitted presentations, and 150 industry-supported presentations for UEG (2021, 2022, and 2023) and DDW (2022 and 2023).
• The gender gap for men vs women was significant for industry-supported oral presentations (78.7% vs 21.3%; P < .0001) and for invited lectures (67.4% vs 32.6%; P < .0001) — but not for investigator-submitted abstracts (49.7% vs 50.3%; P = .91).
• The gender gap for industry-supported abstracts, however, was significantly larger than for investigator-submitted abstracts (57.3% vs 0.6%; P < .0001) and larger than for invited lectures (57.3% vs 34.9%; P = .09).
• The gender gap for invited lectures was significantly larger than for investigator-submitted oral presentations (34.9% vs 0.6%; P = .0009).

Why the Discordance?

This disparity may be due to the paucity of women investigators on steering committees for clinical trials. “Although the number of women doing IBD research continues to increase, then number of women senior investigators is still smaller than the number of men senior investigators,” the researchers wrote. “Ideally, there would be transparency in terms of the metrics used by pharma to choose who will be a presenting author and more intentional recruitment of women investigators to steering committees.”

Commenting on the study but not involved in it, internist Shannon M. Ruzycki, MD, MPH, an assistant professor in the Cumming School of Medicine at the University of Calgary Medical Centre in Alberta, Canada, said the findings are not surprising. “In nearly every setting where gender differences are studied in academic medicine, women are found to be disadvantaged compared to men. These differences are not attributable to skill, merit, or career attainment, but rather appear to be arbitrary and due to biases. They add up across time and likely contribute to the larger differences we see between men and women in promotion, compensation, and awards.”

Ruzycki, lead author of a study of women presenters at medical conferences, noted that differences in gender representation in academia, academic medicine, and clinical trials are similar “because the underlying causes are similar.” On the positive side, she added, conference planning committees are using strategies to reduce bias in how presenters are selected by masking the names and/or institutions of those are submitting abstracts and are being more intentional in inviting a diverse panel of qualified speakers.

“However, one strategy alone is unlikely to address such an insidious problem that affects all parts of selection,” she said. “For example, if pharmaceutical companies believe that men presenters are seen as more authoritative or knowledgeable than women presenters, they will select men to be the first author on submitted abstracts which could deprive these opportunities for deserving women candidates.”

Ruzycki attributed the imbalance to systems (academia, medicine, science) designed by men who lack empathy for the experiences of women. “In the same way you can never really understand how exhausting it is to be a parent until you become a parent or how challenging it can be to have a physical disability until you break a leg and have to navigate the world on crutches, it is really challenging for men to understand how cold and hostile these settings can be for women.”

Many of the things that make conferences, academia, and medicine so challenging for women have straightforward solutions, however, Ruzycki added. Onsite childcare, scrubs that fit women, operating room equipment that is ergonomic for women surgeons — even more washroom stalls would help. “If only we listened and cared about things that didn’t directly impact us.”

This study was supported by the 2023 Travel Grant from the International Organization for the Study of Inflammatory Bowel Diseases. One coauthor serves as a consultant or on advisory boards for AbbVie, Amgen, Bristol Myers Squibb, Celsius Therapeutics, Eli Lilly, Gilead Sciences, Janssen Pharmaceuticals, and Pfizer Pharmaceutical. She is a teacher, lecturer, and speaker for Janssen and Takeda Pharmaceuticals. The remaining authors disclosed no conflicts. Ruzycki had no relevant conflicts of interest to declare. 

A version of this article appeared on Medscape.com.

Clinicians should be aware of the latest developments in the diagnosis and management of eosinophilic esophagitis (EoE), including new biologics approved for treatment and the elimination of proton pump inhibitor (PPI) trials for diagnosis, according to a new clinical guideline from the American College of Gastroenterology (ACG).

As an update to the 2013 version, the guideline covers paradigm-shifting changes in EoE knowledge about risk factors, pathogenesis, validated outcome metrics, new nomenclature, and pediatric-specific considerations.

 

“There have been multiple advances across diagnosis, treatment, monitoring, and other aspects of EoE management in the decade since the last ACG guidelines and in the 5 years since the last AGA [American Gastroenterological Association] guidelines, including new drug approvals globally for EoE,” said lead author Evan Dellon, MD, AGAF, professor of gastroenterology and hepatology and director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, Chapel Hill.

“The guidelines aimed to provide practical and evidence-based recommendations that could be implemented in daily practice, as well as to provide advice on a number of aspects of diagnosis and management of EoE where there might not be a definitive evidence base, but where clinical questions commonly arise,” he said.

The update was published online in The American Journal of Gastroenterology.

 

EoE Diagnosis

EoE is a chronic allergen-induced, type 2 immune-mediated disease of the esophagus, which is characterized by symptoms of esophageal dysfunction (such as dysphagia and food impaction) and an eosinophilic predominant infiltrate in the esophagus, the authors wrote.

A diagnosis should be based on the presence of esophageal dysfunction symptoms and at least 15 eosinophils per high-power field on esophageal biopsy, particularly after ruling out non-EoE disorders. A critical change from the 2013 guideline eliminates the requirement of a PPI trial for diagnosis.

Endoscopic evaluation is critical for diagnosis, assessing treatment response, and long-term monitoring, the authors wrote. The guideline advises using the EoE endoscopic reference score (EREFS) to characterize endoscopic findings, a recommendation that was also endorsed in 2022 guidelines by the American Society for Gastrointestinal Endoscopy. EREFS classifies five key EoE features, including edema, rings, exudates, furrows, and strictures, by severity.

To assess for histologic features of EoE, at least six esophageal biopsies should be taken from at least two esophageal levels (such as proximal/mid and distal halves), specifically targeted in areas of furrows or exudates.

In addition, peak eosinophil counts should be quantified on esophageal biopsies from every endoscopy performed for EoE, which will help with subsequent management and monitoring.

As new research expands on the role of mast cells, T cells, basophils, NK cells, and fibroblasts in EoE, the authors postulate that using the EoE histologic scoring system may become more relevant in the future, particularly around findings such as persistent basal zone hyperplasia or lamina propria fibrosis as drivers of ongoing symptoms when eosinophil counts decline.

 

A Better Understanding of Pathogenesis 

“While EoE is considered a relatively new disease, there has been a concerted effort by researchers and clinicians to work together, in partnership with patients, to better understand the basic disease pathogenesis and develop the best treatment approaches,” said Marc Rothenberg, MD, PhD, director of allergy and immunology at Cincinnati Children’s Hospital Medical Center, Ohio. Rothenberg wasn’t involved with the update.

“A lot of progress has been made since the initial thought that esophageal eosinophilia was a ramification of acid reflux disease,” said Rothenberg, the founding director and a principal investigator of the Consortium of Eosinophilic Gastrointestinal Disease Researchers.

“We now understand that the esophagus is an immune-responsive organ and that food allergies can be manifested as EoE. Investment in science is paying off as the basic disease pathoetiology has been uncovered, and this has led to successful strategies for disease intervention, including precision therapy.”

When treating EoE, the goals include improving patient symptoms and quality of life, improving endoscopic and histologic findings, normalizing growth and development in children, maintaining nutrition, and preventing complications such as food impaction or perforation.

This means addressing both the inflammatory and fibrostenotic aspects of the disease, the authors wrote. Pharmacologic or dietary therapies can treat the inflammatory component and may lead to esophageal improvements, whereas esophageal dilation can treat strictures and luminal narrowing. Notably, treatment choices should be individualized based on disease characteristics and patient preferences.

In general, PPIs are suggested as treatment, even beyond reflux symptoms. In EoE, PPIs can decrease eotaxin-3 cytokines that recruit eosinophils to the esophagus, improve esophageal barrier function, and maintain esophageal epithelial transcriptional homeostasis. Although potassium-competitive acid blocker medications have been studied in EoE, data remains limited. H2 receptor blockers don’t appear to be effective for EoE.

Swallowed topical corticosteroids have shown histologic efficacy, the authors reported, particularly in recent phase 3 trials of budesonide oral suspension (BOS) and budesonide orodispersible tablet (BOT). BOS was approved for EoE by the Food and Drug Administration (FDA) in 2024, and BOT was approved for EoE by the European Medicines Agency in 2018.

In terms of dietary elimination, a range of options appear to be effective for patients, including the six-food elimination diet, which has been studied most. However, less restrictive or step-up approaches (such as four-food elimination or one-food elimination of milk) may be better for patients, the authors wrote. Ultimately, the “optimal” choice is one that patients and families can adhere to and have the resources to complete.

In addition, they noted that allergy test-directed elimination diets aren’t currently recommended because EoE has delayed hypersensitivity, so skin prick, patch, or serum Ig allergy tests tend to have limited success in predicting EoE food triggers.

In terms of biologic treatments, dupilumab is recommended for ages 12 years or older who don’t respond to PPI therapy, as well as suggested for ages 1-11 years based on previous clinical trial data. The FDA approved the use of dupilumab for ages 1-11 years in February 2024.

In this update, the authors declined to make recommendations about other biologics such as cendakimab, benralizumab, lirentelimab, mepolizumab, or reslizumab. They also advised against using omaluzumab as a treatment for EoE.

 

“This new 2025 guideline summarizes and synthesizes key studies in support of proton pump inhibitors, topical steroids, dietary therapy, and biologics for EoE. Additionally, the guidelines are clinically relevant in providing practical suggestions (such as medication dosing) and expert opinions on key concepts in managing EoE,” said Joy Weiling Chang, MD, assistant professor of gastroenterology at the University of Michigan, Ann Arbor, who specializes in patient-physician preferences and decision-making in EoE care.

“It’s an exciting time to take care of patients with EoE with many new therapies, but the rapidly evolving options can be overwhelming,” said Chang, who wasn’t involved with the update. “Since there are no clinical effectiveness studies between the various treatments, and therapies can differ so much (with delivery and daily use, monitoring, cost), electing EoE treatment is an ideal opportunity for shared decision-making. Equipped with these clinical guidelines, clinicians can be empowered to elicit and consider patient preferences and values in the management of this chronic disease.”

The authors received no specific funding for this update. Dellon and Rothenberg reported receiving research funding and consultant roles with numerous pharmaceutical companies and organizations. Chang reported no relevant disclosures.

A version of this article appeared on Medscape.com.

Clinicians should be aware of the latest developments in the diagnosis and management of eosinophilic esophagitis (EoE), including new biologics approved for treatment and the elimination of proton pump inhibitor (PPI) trials for diagnosis, according to a new clinical guideline from the American College of Gastroenterology (ACG).

As an update to the 2013 version, the guideline covers paradigm-shifting changes in EoE knowledge about risk factors, pathogenesis, validated outcome metrics, new nomenclature, and pediatric-specific considerations.

 

“There have been multiple advances across diagnosis, treatment, monitoring, and other aspects of EoE management in the decade since the last ACG guidelines and in the 5 years since the last AGA [American Gastroenterological Association] guidelines, including new drug approvals globally for EoE,” said lead author Evan Dellon, MD, AGAF, professor of gastroenterology and hepatology and director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, Chapel Hill.

“The guidelines aimed to provide practical and evidence-based recommendations that could be implemented in daily practice, as well as to provide advice on a number of aspects of diagnosis and management of EoE where there might not be a definitive evidence base, but where clinical questions commonly arise,” he said.

The update was published online in The American Journal of Gastroenterology.

 

EoE Diagnosis

EoE is a chronic allergen-induced, type 2 immune-mediated disease of the esophagus, which is characterized by symptoms of esophageal dysfunction (such as dysphagia and food impaction) and an eosinophilic predominant infiltrate in the esophagus, the authors wrote.

A diagnosis should be based on the presence of esophageal dysfunction symptoms and at least 15 eosinophils per high-power field on esophageal biopsy, particularly after ruling out non-EoE disorders. A critical change from the 2013 guideline eliminates the requirement of a PPI trial for diagnosis.

Endoscopic evaluation is critical for diagnosis, assessing treatment response, and long-term monitoring, the authors wrote. The guideline advises using the EoE endoscopic reference score (EREFS) to characterize endoscopic findings, a recommendation that was also endorsed in 2022 guidelines by the American Society for Gastrointestinal Endoscopy. EREFS classifies five key EoE features, including edema, rings, exudates, furrows, and strictures, by severity.

To assess for histologic features of EoE, at least six esophageal biopsies should be taken from at least two esophageal levels (such as proximal/mid and distal halves), specifically targeted in areas of furrows or exudates.

In addition, peak eosinophil counts should be quantified on esophageal biopsies from every endoscopy performed for EoE, which will help with subsequent management and monitoring.

As new research expands on the role of mast cells, T cells, basophils, NK cells, and fibroblasts in EoE, the authors postulate that using the EoE histologic scoring system may become more relevant in the future, particularly around findings such as persistent basal zone hyperplasia or lamina propria fibrosis as drivers of ongoing symptoms when eosinophil counts decline.

 

A Better Understanding of Pathogenesis 

“While EoE is considered a relatively new disease, there has been a concerted effort by researchers and clinicians to work together, in partnership with patients, to better understand the basic disease pathogenesis and develop the best treatment approaches,” said Marc Rothenberg, MD, PhD, director of allergy and immunology at Cincinnati Children’s Hospital Medical Center, Ohio. Rothenberg wasn’t involved with the update.

“A lot of progress has been made since the initial thought that esophageal eosinophilia was a ramification of acid reflux disease,” said Rothenberg, the founding director and a principal investigator of the Consortium of Eosinophilic Gastrointestinal Disease Researchers.

“We now understand that the esophagus is an immune-responsive organ and that food allergies can be manifested as EoE. Investment in science is paying off as the basic disease pathoetiology has been uncovered, and this has led to successful strategies for disease intervention, including precision therapy.”

When treating EoE, the goals include improving patient symptoms and quality of life, improving endoscopic and histologic findings, normalizing growth and development in children, maintaining nutrition, and preventing complications such as food impaction or perforation.

This means addressing both the inflammatory and fibrostenotic aspects of the disease, the authors wrote. Pharmacologic or dietary therapies can treat the inflammatory component and may lead to esophageal improvements, whereas esophageal dilation can treat strictures and luminal narrowing. Notably, treatment choices should be individualized based on disease characteristics and patient preferences.

In general, PPIs are suggested as treatment, even beyond reflux symptoms. In EoE, PPIs can decrease eotaxin-3 cytokines that recruit eosinophils to the esophagus, improve esophageal barrier function, and maintain esophageal epithelial transcriptional homeostasis. Although potassium-competitive acid blocker medications have been studied in EoE, data remains limited. H2 receptor blockers don’t appear to be effective for EoE.

Swallowed topical corticosteroids have shown histologic efficacy, the authors reported, particularly in recent phase 3 trials of budesonide oral suspension (BOS) and budesonide orodispersible tablet (BOT). BOS was approved for EoE by the Food and Drug Administration (FDA) in 2024, and BOT was approved for EoE by the European Medicines Agency in 2018.

In terms of dietary elimination, a range of options appear to be effective for patients, including the six-food elimination diet, which has been studied most. However, less restrictive or step-up approaches (such as four-food elimination or one-food elimination of milk) may be better for patients, the authors wrote. Ultimately, the “optimal” choice is one that patients and families can adhere to and have the resources to complete.

In addition, they noted that allergy test-directed elimination diets aren’t currently recommended because EoE has delayed hypersensitivity, so skin prick, patch, or serum Ig allergy tests tend to have limited success in predicting EoE food triggers.

In terms of biologic treatments, dupilumab is recommended for ages 12 years or older who don’t respond to PPI therapy, as well as suggested for ages 1-11 years based on previous clinical trial data. The FDA approved the use of dupilumab for ages 1-11 years in February 2024.

In this update, the authors declined to make recommendations about other biologics such as cendakimab, benralizumab, lirentelimab, mepolizumab, or reslizumab. They also advised against using omaluzumab as a treatment for EoE.

 

“This new 2025 guideline summarizes and synthesizes key studies in support of proton pump inhibitors, topical steroids, dietary therapy, and biologics for EoE. Additionally, the guidelines are clinically relevant in providing practical suggestions (such as medication dosing) and expert opinions on key concepts in managing EoE,” said Joy Weiling Chang, MD, assistant professor of gastroenterology at the University of Michigan, Ann Arbor, who specializes in patient-physician preferences and decision-making in EoE care.

“It’s an exciting time to take care of patients with EoE with many new therapies, but the rapidly evolving options can be overwhelming,” said Chang, who wasn’t involved with the update. “Since there are no clinical effectiveness studies between the various treatments, and therapies can differ so much (with delivery and daily use, monitoring, cost), electing EoE treatment is an ideal opportunity for shared decision-making. Equipped with these clinical guidelines, clinicians can be empowered to elicit and consider patient preferences and values in the management of this chronic disease.”

The authors received no specific funding for this update. Dellon and Rothenberg reported receiving research funding and consultant roles with numerous pharmaceutical companies and organizations. Chang reported no relevant disclosures.

A version of this article appeared on Medscape.com.

Clinicians should be aware of the latest developments in the diagnosis and management of eosinophilic esophagitis (EoE), including new biologics approved for treatment and the elimination of proton pump inhibitor (PPI) trials for diagnosis, according to a new clinical guideline from the American College of Gastroenterology (ACG).

As an update to the 2013 version, the guideline covers paradigm-shifting changes in EoE knowledge about risk factors, pathogenesis, validated outcome metrics, new nomenclature, and pediatric-specific considerations.

 

“There have been multiple advances across diagnosis, treatment, monitoring, and other aspects of EoE management in the decade since the last ACG guidelines and in the 5 years since the last AGA [American Gastroenterological Association] guidelines, including new drug approvals globally for EoE,” said lead author Evan Dellon, MD, AGAF, professor of gastroenterology and hepatology and director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, Chapel Hill.

“The guidelines aimed to provide practical and evidence-based recommendations that could be implemented in daily practice, as well as to provide advice on a number of aspects of diagnosis and management of EoE where there might not be a definitive evidence base, but where clinical questions commonly arise,” he said.

The update was published online in The American Journal of Gastroenterology.

 

EoE Diagnosis

EoE is a chronic allergen-induced, type 2 immune-mediated disease of the esophagus, which is characterized by symptoms of esophageal dysfunction (such as dysphagia and food impaction) and an eosinophilic predominant infiltrate in the esophagus, the authors wrote.

A diagnosis should be based on the presence of esophageal dysfunction symptoms and at least 15 eosinophils per high-power field on esophageal biopsy, particularly after ruling out non-EoE disorders. A critical change from the 2013 guideline eliminates the requirement of a PPI trial for diagnosis.

Endoscopic evaluation is critical for diagnosis, assessing treatment response, and long-term monitoring, the authors wrote. The guideline advises using the EoE endoscopic reference score (EREFS) to characterize endoscopic findings, a recommendation that was also endorsed in 2022 guidelines by the American Society for Gastrointestinal Endoscopy. EREFS classifies five key EoE features, including edema, rings, exudates, furrows, and strictures, by severity.

To assess for histologic features of EoE, at least six esophageal biopsies should be taken from at least two esophageal levels (such as proximal/mid and distal halves), specifically targeted in areas of furrows or exudates.

In addition, peak eosinophil counts should be quantified on esophageal biopsies from every endoscopy performed for EoE, which will help with subsequent management and monitoring.

As new research expands on the role of mast cells, T cells, basophils, NK cells, and fibroblasts in EoE, the authors postulate that using the EoE histologic scoring system may become more relevant in the future, particularly around findings such as persistent basal zone hyperplasia or lamina propria fibrosis as drivers of ongoing symptoms when eosinophil counts decline.

 

A Better Understanding of Pathogenesis 

“While EoE is considered a relatively new disease, there has been a concerted effort by researchers and clinicians to work together, in partnership with patients, to better understand the basic disease pathogenesis and develop the best treatment approaches,” said Marc Rothenberg, MD, PhD, director of allergy and immunology at Cincinnati Children’s Hospital Medical Center, Ohio. Rothenberg wasn’t involved with the update.

“A lot of progress has been made since the initial thought that esophageal eosinophilia was a ramification of acid reflux disease,” said Rothenberg, the founding director and a principal investigator of the Consortium of Eosinophilic Gastrointestinal Disease Researchers.

“We now understand that the esophagus is an immune-responsive organ and that food allergies can be manifested as EoE. Investment in science is paying off as the basic disease pathoetiology has been uncovered, and this has led to successful strategies for disease intervention, including precision therapy.”

When treating EoE, the goals include improving patient symptoms and quality of life, improving endoscopic and histologic findings, normalizing growth and development in children, maintaining nutrition, and preventing complications such as food impaction or perforation.

This means addressing both the inflammatory and fibrostenotic aspects of the disease, the authors wrote. Pharmacologic or dietary therapies can treat the inflammatory component and may lead to esophageal improvements, whereas esophageal dilation can treat strictures and luminal narrowing. Notably, treatment choices should be individualized based on disease characteristics and patient preferences.

In general, PPIs are suggested as treatment, even beyond reflux symptoms. In EoE, PPIs can decrease eotaxin-3 cytokines that recruit eosinophils to the esophagus, improve esophageal barrier function, and maintain esophageal epithelial transcriptional homeostasis. Although potassium-competitive acid blocker medications have been studied in EoE, data remains limited. H2 receptor blockers don’t appear to be effective for EoE.

Swallowed topical corticosteroids have shown histologic efficacy, the authors reported, particularly in recent phase 3 trials of budesonide oral suspension (BOS) and budesonide orodispersible tablet (BOT). BOS was approved for EoE by the Food and Drug Administration (FDA) in 2024, and BOT was approved for EoE by the European Medicines Agency in 2018.

In terms of dietary elimination, a range of options appear to be effective for patients, including the six-food elimination diet, which has been studied most. However, less restrictive or step-up approaches (such as four-food elimination or one-food elimination of milk) may be better for patients, the authors wrote. Ultimately, the “optimal” choice is one that patients and families can adhere to and have the resources to complete.

In addition, they noted that allergy test-directed elimination diets aren’t currently recommended because EoE has delayed hypersensitivity, so skin prick, patch, or serum Ig allergy tests tend to have limited success in predicting EoE food triggers.

In terms of biologic treatments, dupilumab is recommended for ages 12 years or older who don’t respond to PPI therapy, as well as suggested for ages 1-11 years based on previous clinical trial data. The FDA approved the use of dupilumab for ages 1-11 years in February 2024.

In this update, the authors declined to make recommendations about other biologics such as cendakimab, benralizumab, lirentelimab, mepolizumab, or reslizumab. They also advised against using omaluzumab as a treatment for EoE.

 

“This new 2025 guideline summarizes and synthesizes key studies in support of proton pump inhibitors, topical steroids, dietary therapy, and biologics for EoE. Additionally, the guidelines are clinically relevant in providing practical suggestions (such as medication dosing) and expert opinions on key concepts in managing EoE,” said Joy Weiling Chang, MD, assistant professor of gastroenterology at the University of Michigan, Ann Arbor, who specializes in patient-physician preferences and decision-making in EoE care.

“It’s an exciting time to take care of patients with EoE with many new therapies, but the rapidly evolving options can be overwhelming,” said Chang, who wasn’t involved with the update. “Since there are no clinical effectiveness studies between the various treatments, and therapies can differ so much (with delivery and daily use, monitoring, cost), electing EoE treatment is an ideal opportunity for shared decision-making. Equipped with these clinical guidelines, clinicians can be empowered to elicit and consider patient preferences and values in the management of this chronic disease.”

The authors received no specific funding for this update. Dellon and Rothenberg reported receiving research funding and consultant roles with numerous pharmaceutical companies and organizations. Chang reported no relevant disclosures.

A version of this article appeared on Medscape.com.