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Vape lung disease cases exceed 400, 3 dead
Vitamin E acetate is one possible culprit in the mysterious vaping-associated lung disease that has killed three patients, sickened 450, and baffled clinicians and investigators all summer.
Another death may be linked to the disorder, officials said during a joint press briefing held by the Centers for Disease Control and Prevention and the Food and Drug Administration. In all, 450 potential cases have been reported and e-cigarette use confirmed in 215. Cases have occurred in 33 states and one territory. A total of 84% of the patients reported having used tetrahydrocannabinol (THC) products in e-cigarette devices.
A preliminary report on the situation by Jennifer Layden, MD, of the department of public health in Illinois and colleagues – including a preliminary case definition – was simultaneously released in the New England Journal of Medicine (2019 Sep 6. doi: 10.1056/NEJMoa1911614).
No single device or substance was common to all the cases, leading officials to issue a blanket warning against e-cigarettes, especially those containing THC.
“We believe a chemical exposure is likely related, but more information is needed to determine what substances. Some labs have identified vitamin E acetate in some samples,” said Dana Meaney-Delman, MD, MPH, incident manager, CDC 2019 Lung Injury Response. “Continued investigation is needed to identify the risk associated with a specific product or substance.”
Besides vitamin E acetate, federal labs are looking at other cannabinoids, cutting agents, diluting agents, pesticides, opioids, and toxins.
Officials also issued a general warning about the products. Youths, young people, and pregnant women should never use e-cigarettes, they cautioned, and no one should buy them from a noncertified source, a street vendor, or a social contact. Even cartridges originally obtained from a certified source should never have been altered in any way.
Dr. Layden and colleagues reported that bilateral lung infiltrates was characterized in 98% of the 53 patients hospitalized with the recently reported e-cigarette–induced lung injury. Nonspecific constitutional symptoms, including fever, chills, weight loss, and fatigue, were present in all of the patients.
Patients may show some symptoms days or even weeks before acute respiratory failure develops, and many had sought medical help before that. All presented with bilateral lung infiltrates, part of an evolving case definition. Many complained of nonspecific constitutional symptoms, including fever, chills, gastrointestinal symptoms, and weight loss. Of the patients who underwent bronchoscopy, many were diagnosed as having lipoid pneumonia, a rare condition characterized by lipid-laden macrophages.
“We don’t know the significance of the lipid-containing macrophages, and we don’t know if the lipids are endogenous or exogenous,” Dr. Meaney-Delman said.
The incidence of such cases appears to be rising rapidly, Dr. Layden noted. An epidemiologic review of cases in Illinois found that the mean monthly rate of visits related to severe respiratory illness in June-August was twice that observed during the same months last year.
SOURCE: Layden JE et al. N Engl J Med. 2019 Sep 6. doi: 1 0.1056/NEJMoa1911614.
Vitamin E acetate is one possible culprit in the mysterious vaping-associated lung disease that has killed three patients, sickened 450, and baffled clinicians and investigators all summer.
Another death may be linked to the disorder, officials said during a joint press briefing held by the Centers for Disease Control and Prevention and the Food and Drug Administration. In all, 450 potential cases have been reported and e-cigarette use confirmed in 215. Cases have occurred in 33 states and one territory. A total of 84% of the patients reported having used tetrahydrocannabinol (THC) products in e-cigarette devices.
A preliminary report on the situation by Jennifer Layden, MD, of the department of public health in Illinois and colleagues – including a preliminary case definition – was simultaneously released in the New England Journal of Medicine (2019 Sep 6. doi: 10.1056/NEJMoa1911614).
No single device or substance was common to all the cases, leading officials to issue a blanket warning against e-cigarettes, especially those containing THC.
“We believe a chemical exposure is likely related, but more information is needed to determine what substances. Some labs have identified vitamin E acetate in some samples,” said Dana Meaney-Delman, MD, MPH, incident manager, CDC 2019 Lung Injury Response. “Continued investigation is needed to identify the risk associated with a specific product or substance.”
Besides vitamin E acetate, federal labs are looking at other cannabinoids, cutting agents, diluting agents, pesticides, opioids, and toxins.
Officials also issued a general warning about the products. Youths, young people, and pregnant women should never use e-cigarettes, they cautioned, and no one should buy them from a noncertified source, a street vendor, or a social contact. Even cartridges originally obtained from a certified source should never have been altered in any way.
Dr. Layden and colleagues reported that bilateral lung infiltrates was characterized in 98% of the 53 patients hospitalized with the recently reported e-cigarette–induced lung injury. Nonspecific constitutional symptoms, including fever, chills, weight loss, and fatigue, were present in all of the patients.
Patients may show some symptoms days or even weeks before acute respiratory failure develops, and many had sought medical help before that. All presented with bilateral lung infiltrates, part of an evolving case definition. Many complained of nonspecific constitutional symptoms, including fever, chills, gastrointestinal symptoms, and weight loss. Of the patients who underwent bronchoscopy, many were diagnosed as having lipoid pneumonia, a rare condition characterized by lipid-laden macrophages.
“We don’t know the significance of the lipid-containing macrophages, and we don’t know if the lipids are endogenous or exogenous,” Dr. Meaney-Delman said.
The incidence of such cases appears to be rising rapidly, Dr. Layden noted. An epidemiologic review of cases in Illinois found that the mean monthly rate of visits related to severe respiratory illness in June-August was twice that observed during the same months last year.
SOURCE: Layden JE et al. N Engl J Med. 2019 Sep 6. doi: 1 0.1056/NEJMoa1911614.
Vitamin E acetate is one possible culprit in the mysterious vaping-associated lung disease that has killed three patients, sickened 450, and baffled clinicians and investigators all summer.
Another death may be linked to the disorder, officials said during a joint press briefing held by the Centers for Disease Control and Prevention and the Food and Drug Administration. In all, 450 potential cases have been reported and e-cigarette use confirmed in 215. Cases have occurred in 33 states and one territory. A total of 84% of the patients reported having used tetrahydrocannabinol (THC) products in e-cigarette devices.
A preliminary report on the situation by Jennifer Layden, MD, of the department of public health in Illinois and colleagues – including a preliminary case definition – was simultaneously released in the New England Journal of Medicine (2019 Sep 6. doi: 10.1056/NEJMoa1911614).
No single device or substance was common to all the cases, leading officials to issue a blanket warning against e-cigarettes, especially those containing THC.
“We believe a chemical exposure is likely related, but more information is needed to determine what substances. Some labs have identified vitamin E acetate in some samples,” said Dana Meaney-Delman, MD, MPH, incident manager, CDC 2019 Lung Injury Response. “Continued investigation is needed to identify the risk associated with a specific product or substance.”
Besides vitamin E acetate, federal labs are looking at other cannabinoids, cutting agents, diluting agents, pesticides, opioids, and toxins.
Officials also issued a general warning about the products. Youths, young people, and pregnant women should never use e-cigarettes, they cautioned, and no one should buy them from a noncertified source, a street vendor, or a social contact. Even cartridges originally obtained from a certified source should never have been altered in any way.
Dr. Layden and colleagues reported that bilateral lung infiltrates was characterized in 98% of the 53 patients hospitalized with the recently reported e-cigarette–induced lung injury. Nonspecific constitutional symptoms, including fever, chills, weight loss, and fatigue, were present in all of the patients.
Patients may show some symptoms days or even weeks before acute respiratory failure develops, and many had sought medical help before that. All presented with bilateral lung infiltrates, part of an evolving case definition. Many complained of nonspecific constitutional symptoms, including fever, chills, gastrointestinal symptoms, and weight loss. Of the patients who underwent bronchoscopy, many were diagnosed as having lipoid pneumonia, a rare condition characterized by lipid-laden macrophages.
“We don’t know the significance of the lipid-containing macrophages, and we don’t know if the lipids are endogenous or exogenous,” Dr. Meaney-Delman said.
The incidence of such cases appears to be rising rapidly, Dr. Layden noted. An epidemiologic review of cases in Illinois found that the mean monthly rate of visits related to severe respiratory illness in June-August was twice that observed during the same months last year.
SOURCE: Layden JE et al. N Engl J Med. 2019 Sep 6. doi: 1 0.1056/NEJMoa1911614.
FROM A CDC TELECONFERENCE AND NEJM
NICE issues recommendation for dapagliflozin-insulin therapy in type 1 diabetes
The inadequately controlled by insulin alone.
In a review of clinical trials, NICE found that dapagliflozin plus insulin conferred small benefits in hemoglobin A1c, weight loss, and quality of life, compared with insulin alone. These benefits translated to a reduced risk of long-term complications over the lifetime of the patient.
In the new NICE guideline, dual treatment with dapagliflozin and insulin in adults with type 1 diabetes and a body mass index greater than 27 kg/m2 is recommended only when they are receiving insulin doses of more than 0.5 units/kg per day; have undergone an evidence-based, quality-assured education program; and are supervised by a physician specializing in endocrinology and diabetes.
Hemoglobin A1c levels should be assessed after 6 months and at regular intervals after that; if glycemic control is not improved, dapagliflozin should be stopped, as there is an increased risk of diabetic ketoacidosis.
Find the full technology appraisal guidance on the NICE website.
The inadequately controlled by insulin alone.
In a review of clinical trials, NICE found that dapagliflozin plus insulin conferred small benefits in hemoglobin A1c, weight loss, and quality of life, compared with insulin alone. These benefits translated to a reduced risk of long-term complications over the lifetime of the patient.
In the new NICE guideline, dual treatment with dapagliflozin and insulin in adults with type 1 diabetes and a body mass index greater than 27 kg/m2 is recommended only when they are receiving insulin doses of more than 0.5 units/kg per day; have undergone an evidence-based, quality-assured education program; and are supervised by a physician specializing in endocrinology and diabetes.
Hemoglobin A1c levels should be assessed after 6 months and at regular intervals after that; if glycemic control is not improved, dapagliflozin should be stopped, as there is an increased risk of diabetic ketoacidosis.
Find the full technology appraisal guidance on the NICE website.
The inadequately controlled by insulin alone.
In a review of clinical trials, NICE found that dapagliflozin plus insulin conferred small benefits in hemoglobin A1c, weight loss, and quality of life, compared with insulin alone. These benefits translated to a reduced risk of long-term complications over the lifetime of the patient.
In the new NICE guideline, dual treatment with dapagliflozin and insulin in adults with type 1 diabetes and a body mass index greater than 27 kg/m2 is recommended only when they are receiving insulin doses of more than 0.5 units/kg per day; have undergone an evidence-based, quality-assured education program; and are supervised by a physician specializing in endocrinology and diabetes.
Hemoglobin A1c levels should be assessed after 6 months and at regular intervals after that; if glycemic control is not improved, dapagliflozin should be stopped, as there is an increased risk of diabetic ketoacidosis.
Find the full technology appraisal guidance on the NICE website.
Battling hospitalist burnout
Higher salaries are not sufficient
Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.
The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”
“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”
Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.
“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”
Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
Scheduling problems
The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).
A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.
Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.
Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.
“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”
Dr. Michtalik had a similar perspective.
“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”
Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.
In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.
Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.
Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.
“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
Beyond salary adjustments
Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.
Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.
The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.
A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.
Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.
Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”
“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.
“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.
If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”
Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”
Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.
She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.
At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.
“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.
As a result, a collaborative approach to such conversations tends to be more effective.
“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”
Higher salaries are not sufficient
Higher salaries are not sufficient
Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.
The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”
“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”
Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.
“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”
Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
Scheduling problems
The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).
A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.
Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.
Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.
“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”
Dr. Michtalik had a similar perspective.
“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”
Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.
In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.
Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.
Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.
“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
Beyond salary adjustments
Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.
Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.
The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.
A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.
Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.
Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”
“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.
“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.
If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”
Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”
Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.
She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.
At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.
“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.
As a result, a collaborative approach to such conversations tends to be more effective.
“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”
Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.
The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”
“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”
Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.
“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”
Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
Scheduling problems
The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).
A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.
Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.
Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.
“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”
Dr. Michtalik had a similar perspective.
“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”
Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.
In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.
Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.
Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.
“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
Beyond salary adjustments
Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.
Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.
The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.
A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.
Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.
Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”
“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.
“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.
If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”
Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”
Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.
She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.
At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.
“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.
As a result, a collaborative approach to such conversations tends to be more effective.
“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”
Migraines linked to higher risk of dementia
, according to research published online Sept. 4 in the International Journal of Geriatric Psychiatry.
In the Manitoba Study of Health and Aging, a population-based, prospective cohort study, 679 community-dwelling adults with a mean age of 75.9 years were followed for 5 years. Participants screened as cognitively intact at baseline had complete data on migraine history and all covariates at baseline and were assessed for cognitive outcomes 5 years later.
The study showed that a history of migraines was associated with a 2.97-fold greater likelihood of dementia, after adjustment for age, education, and a history of stroke, compared with individuals without a history of migraine. Individuals with Alzheimer’s disease were more than four times more likely to have a history of migraines (odds ratio 4.22).
However, researchers found no significant association between vascular dementia and a history of migraines, either before or after adjusting for confounders but particularly after incorporating a history of stroke into the model.
Lead investigator Suzanne L. Tyas, PhD, associate professor in the School of Public Health and Health Systems at the University of Waterloo, Ont., and coauthors suggested that the association between migraine and dementia was largely driven by the strong association between migraines and Alzheimer’s disease.
“This interpretation is supported by the weaker association for dementia than for Alzheimer’s disease, reflecting a dilution of the association with migraines across all types of dementia including vascular dementia, where a significant association was not found,” the researchers wrote.
The study population was 61.9% female, and no men reporting a history of migraine were diagnosed with dementia. While the study reflected a strong association between migraine and dementia in women, the researchers said they were unable to assess potential gender differences in this association.
Commenting on possible mechanisms behind the association, the authors wrote that there were overlaps underlying the biological mechanisms of migraine and dementia. Vascular risk factors such as diabetes, hypertension, heart attack, and stroke are associated with the development of dementia, and a relationship of these risk factors and migraine also has been seen.
“Many of the mechanisms involved in migraine neurophysiology, such as inflammation and reduced cerebral blood flow, are also underlying causes of dementia,” they wrote. “Repeated activation of these pathways in chronic migraineurs has been shown to cause permanent neurological and vascular damage.”
They also observed that the association could be influenced by genetic factors, as individuals with presenilin-1 mutations, which predispose them to Alzheimer’s disease, are more likely to experience migraines or recurrent headaches.
They suggested their findings could inform preventive strategies and treatments for Alzheimer’s disease, as well as interventions such as earlier screening for cognitive decline in individuals who experience migraines.
The study was funded by Manitoba Health and the National Health Research and Development Program of Health Canada. No conflicts of interest were declared.
SOURCE: Morton R et al. Int J Geriatr Psychiatry, 2019 Sep 4. doi: 10.1002/gps.5180.
, according to research published online Sept. 4 in the International Journal of Geriatric Psychiatry.
In the Manitoba Study of Health and Aging, a population-based, prospective cohort study, 679 community-dwelling adults with a mean age of 75.9 years were followed for 5 years. Participants screened as cognitively intact at baseline had complete data on migraine history and all covariates at baseline and were assessed for cognitive outcomes 5 years later.
The study showed that a history of migraines was associated with a 2.97-fold greater likelihood of dementia, after adjustment for age, education, and a history of stroke, compared with individuals without a history of migraine. Individuals with Alzheimer’s disease were more than four times more likely to have a history of migraines (odds ratio 4.22).
However, researchers found no significant association between vascular dementia and a history of migraines, either before or after adjusting for confounders but particularly after incorporating a history of stroke into the model.
Lead investigator Suzanne L. Tyas, PhD, associate professor in the School of Public Health and Health Systems at the University of Waterloo, Ont., and coauthors suggested that the association between migraine and dementia was largely driven by the strong association between migraines and Alzheimer’s disease.
“This interpretation is supported by the weaker association for dementia than for Alzheimer’s disease, reflecting a dilution of the association with migraines across all types of dementia including vascular dementia, where a significant association was not found,” the researchers wrote.
The study population was 61.9% female, and no men reporting a history of migraine were diagnosed with dementia. While the study reflected a strong association between migraine and dementia in women, the researchers said they were unable to assess potential gender differences in this association.
Commenting on possible mechanisms behind the association, the authors wrote that there were overlaps underlying the biological mechanisms of migraine and dementia. Vascular risk factors such as diabetes, hypertension, heart attack, and stroke are associated with the development of dementia, and a relationship of these risk factors and migraine also has been seen.
“Many of the mechanisms involved in migraine neurophysiology, such as inflammation and reduced cerebral blood flow, are also underlying causes of dementia,” they wrote. “Repeated activation of these pathways in chronic migraineurs has been shown to cause permanent neurological and vascular damage.”
They also observed that the association could be influenced by genetic factors, as individuals with presenilin-1 mutations, which predispose them to Alzheimer’s disease, are more likely to experience migraines or recurrent headaches.
They suggested their findings could inform preventive strategies and treatments for Alzheimer’s disease, as well as interventions such as earlier screening for cognitive decline in individuals who experience migraines.
The study was funded by Manitoba Health and the National Health Research and Development Program of Health Canada. No conflicts of interest were declared.
SOURCE: Morton R et al. Int J Geriatr Psychiatry, 2019 Sep 4. doi: 10.1002/gps.5180.
, according to research published online Sept. 4 in the International Journal of Geriatric Psychiatry.
In the Manitoba Study of Health and Aging, a population-based, prospective cohort study, 679 community-dwelling adults with a mean age of 75.9 years were followed for 5 years. Participants screened as cognitively intact at baseline had complete data on migraine history and all covariates at baseline and were assessed for cognitive outcomes 5 years later.
The study showed that a history of migraines was associated with a 2.97-fold greater likelihood of dementia, after adjustment for age, education, and a history of stroke, compared with individuals without a history of migraine. Individuals with Alzheimer’s disease were more than four times more likely to have a history of migraines (odds ratio 4.22).
However, researchers found no significant association between vascular dementia and a history of migraines, either before or after adjusting for confounders but particularly after incorporating a history of stroke into the model.
Lead investigator Suzanne L. Tyas, PhD, associate professor in the School of Public Health and Health Systems at the University of Waterloo, Ont., and coauthors suggested that the association between migraine and dementia was largely driven by the strong association between migraines and Alzheimer’s disease.
“This interpretation is supported by the weaker association for dementia than for Alzheimer’s disease, reflecting a dilution of the association with migraines across all types of dementia including vascular dementia, where a significant association was not found,” the researchers wrote.
The study population was 61.9% female, and no men reporting a history of migraine were diagnosed with dementia. While the study reflected a strong association between migraine and dementia in women, the researchers said they were unable to assess potential gender differences in this association.
Commenting on possible mechanisms behind the association, the authors wrote that there were overlaps underlying the biological mechanisms of migraine and dementia. Vascular risk factors such as diabetes, hypertension, heart attack, and stroke are associated with the development of dementia, and a relationship of these risk factors and migraine also has been seen.
“Many of the mechanisms involved in migraine neurophysiology, such as inflammation and reduced cerebral blood flow, are also underlying causes of dementia,” they wrote. “Repeated activation of these pathways in chronic migraineurs has been shown to cause permanent neurological and vascular damage.”
They also observed that the association could be influenced by genetic factors, as individuals with presenilin-1 mutations, which predispose them to Alzheimer’s disease, are more likely to experience migraines or recurrent headaches.
They suggested their findings could inform preventive strategies and treatments for Alzheimer’s disease, as well as interventions such as earlier screening for cognitive decline in individuals who experience migraines.
The study was funded by Manitoba Health and the National Health Research and Development Program of Health Canada. No conflicts of interest were declared.
SOURCE: Morton R et al. Int J Geriatr Psychiatry, 2019 Sep 4. doi: 10.1002/gps.5180.
FROM THE INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY
Thread lifts making a comeback, but long-term effects remain unclear
SAN DIEGO – The use of threads to improve skin laxity is making a comeback, thanks largely to advances in absorbable sutures.
“Thread lifts were popularized in the 1990s, but I think they were misrepresented as an alternative to a surgical face-lift, which remains the gold standard,” Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium. “A thread lift is certainly not like a traditional face-lift; it’s much more subtle.”
In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from polydioxanone (PDO) and poly-
“There are some nice benefits to thread lifts,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego. “You get immediate results, which is always nice for patients, but with tissue tightening using energy-based devices, results are unpredictable and it can take 6 months to see the results. With resorbable sutures, we’re seeing fewer complications, and the amount of lifting is more predictable because you’re physically lifting the tissue. In some cases, threads are able to lift tissue more than energy-based devices. There is minimal recovery, it requires local anesthesia, and it’s less expensive than a surgical face-lift, which can run $10,000-$15,000 or more.”
For skin lifting, clinicians implant threads subcutaneously. When tugged in the opposite direction, the barbs anchor in adipose tissue, increasing tensile strength while suspended in the dermis and overlying tissue. This produces a fibrous adhesion capsule that helps to solidify anchorage of the suture long term. Fibrosis has been shown to increase local collagen production. PDO and PLLA are known collagen stimulants and are postulated to stimulate a long-term benefit in rejuvenation, Dr. Ortiz said, but overall evidence regarding their use in thread lifts is weak.
“Existing studies have a very short follow-up period and there is really no standardized protocol, so we don’t know really know a lot about them yet,” she said. Lana Tong, MD, and Evan A. Rieder, MD, of New York University recently published a systematic review of the literature on the topic (Dermatol Surg. 2019 45[7]:931-40).
PDO is biodegradable by hydrolysis over 4-8 months and is used as absorbable suture material for prolonged tension–bearing areas. “It causes neocollagenesis with a foreign-body reaction,” Dr. Ortiz said. Meanwhile, PLLA is a collagen stimulator used for prolonged volume restoration. “It’s used an aesthetic filler, but a known complication with PLLA injections is the formation of subcutaneous nodules and late onset granulomas,” she said.
Early in 2019, Korean researchers published results of a study that set out to evaluate the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model (J Cosmet Dermatol. 2019 Feb 27. doi: 10.1111/jocd.12894). “It showed both PDO and PLLA induced granulomatous reactions and collagen formation, but this decreased at 12 weeks,” said Dr. Ortiz, who was not involved with the work. “PDO had slightly more collagen formation than PLLA.”
Indications for thread lifts, she continued, are for jawline lift, cheek enhancement, brow lift, wrinkle reduction, body contouring, acne scarring, and texturing. “Choose patients with good skin quality: not too thick/heavy, and not too thin. Patients with moderate skin sagging are going to better candidates than those with severe skin sagging.”
One type of absorbable suspension suture, the Silhouette InstaLift, is made of polyglycolide/
In terms of adverse events following thread lift procedures, patients usually feel tender for about a week or 2. “They can have some bruising, mostly from the anesthesia,” she said.
To prevent temporary dimpling, Dr. Ortiz undermines with an 18-gauge needle and inserts perpendicular to the skin surface. “Extrusions can still occur,” she said. To prevent this, she pulls on the end and makes sure it’s buried subcutaneously.
Dr. Ortiz reported having financial relationships with numerous pharmaceutical and device companies, though none related to the content of her presentation. She is also cochair of the Masters of Aesthetics symposium.
SAN DIEGO – The use of threads to improve skin laxity is making a comeback, thanks largely to advances in absorbable sutures.
“Thread lifts were popularized in the 1990s, but I think they were misrepresented as an alternative to a surgical face-lift, which remains the gold standard,” Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium. “A thread lift is certainly not like a traditional face-lift; it’s much more subtle.”
In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from polydioxanone (PDO) and poly-
“There are some nice benefits to thread lifts,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego. “You get immediate results, which is always nice for patients, but with tissue tightening using energy-based devices, results are unpredictable and it can take 6 months to see the results. With resorbable sutures, we’re seeing fewer complications, and the amount of lifting is more predictable because you’re physically lifting the tissue. In some cases, threads are able to lift tissue more than energy-based devices. There is minimal recovery, it requires local anesthesia, and it’s less expensive than a surgical face-lift, which can run $10,000-$15,000 or more.”
For skin lifting, clinicians implant threads subcutaneously. When tugged in the opposite direction, the barbs anchor in adipose tissue, increasing tensile strength while suspended in the dermis and overlying tissue. This produces a fibrous adhesion capsule that helps to solidify anchorage of the suture long term. Fibrosis has been shown to increase local collagen production. PDO and PLLA are known collagen stimulants and are postulated to stimulate a long-term benefit in rejuvenation, Dr. Ortiz said, but overall evidence regarding their use in thread lifts is weak.
“Existing studies have a very short follow-up period and there is really no standardized protocol, so we don’t know really know a lot about them yet,” she said. Lana Tong, MD, and Evan A. Rieder, MD, of New York University recently published a systematic review of the literature on the topic (Dermatol Surg. 2019 45[7]:931-40).
PDO is biodegradable by hydrolysis over 4-8 months and is used as absorbable suture material for prolonged tension–bearing areas. “It causes neocollagenesis with a foreign-body reaction,” Dr. Ortiz said. Meanwhile, PLLA is a collagen stimulator used for prolonged volume restoration. “It’s used an aesthetic filler, but a known complication with PLLA injections is the formation of subcutaneous nodules and late onset granulomas,” she said.
Early in 2019, Korean researchers published results of a study that set out to evaluate the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model (J Cosmet Dermatol. 2019 Feb 27. doi: 10.1111/jocd.12894). “It showed both PDO and PLLA induced granulomatous reactions and collagen formation, but this decreased at 12 weeks,” said Dr. Ortiz, who was not involved with the work. “PDO had slightly more collagen formation than PLLA.”
Indications for thread lifts, she continued, are for jawline lift, cheek enhancement, brow lift, wrinkle reduction, body contouring, acne scarring, and texturing. “Choose patients with good skin quality: not too thick/heavy, and not too thin. Patients with moderate skin sagging are going to better candidates than those with severe skin sagging.”
One type of absorbable suspension suture, the Silhouette InstaLift, is made of polyglycolide/
In terms of adverse events following thread lift procedures, patients usually feel tender for about a week or 2. “They can have some bruising, mostly from the anesthesia,” she said.
To prevent temporary dimpling, Dr. Ortiz undermines with an 18-gauge needle and inserts perpendicular to the skin surface. “Extrusions can still occur,” she said. To prevent this, she pulls on the end and makes sure it’s buried subcutaneously.
Dr. Ortiz reported having financial relationships with numerous pharmaceutical and device companies, though none related to the content of her presentation. She is also cochair of the Masters of Aesthetics symposium.
SAN DIEGO – The use of threads to improve skin laxity is making a comeback, thanks largely to advances in absorbable sutures.
“Thread lifts were popularized in the 1990s, but I think they were misrepresented as an alternative to a surgical face-lift, which remains the gold standard,” Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium. “A thread lift is certainly not like a traditional face-lift; it’s much more subtle.”
In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from polydioxanone (PDO) and poly-
“There are some nice benefits to thread lifts,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego. “You get immediate results, which is always nice for patients, but with tissue tightening using energy-based devices, results are unpredictable and it can take 6 months to see the results. With resorbable sutures, we’re seeing fewer complications, and the amount of lifting is more predictable because you’re physically lifting the tissue. In some cases, threads are able to lift tissue more than energy-based devices. There is minimal recovery, it requires local anesthesia, and it’s less expensive than a surgical face-lift, which can run $10,000-$15,000 or more.”
For skin lifting, clinicians implant threads subcutaneously. When tugged in the opposite direction, the barbs anchor in adipose tissue, increasing tensile strength while suspended in the dermis and overlying tissue. This produces a fibrous adhesion capsule that helps to solidify anchorage of the suture long term. Fibrosis has been shown to increase local collagen production. PDO and PLLA are known collagen stimulants and are postulated to stimulate a long-term benefit in rejuvenation, Dr. Ortiz said, but overall evidence regarding their use in thread lifts is weak.
“Existing studies have a very short follow-up period and there is really no standardized protocol, so we don’t know really know a lot about them yet,” she said. Lana Tong, MD, and Evan A. Rieder, MD, of New York University recently published a systematic review of the literature on the topic (Dermatol Surg. 2019 45[7]:931-40).
PDO is biodegradable by hydrolysis over 4-8 months and is used as absorbable suture material for prolonged tension–bearing areas. “It causes neocollagenesis with a foreign-body reaction,” Dr. Ortiz said. Meanwhile, PLLA is a collagen stimulator used for prolonged volume restoration. “It’s used an aesthetic filler, but a known complication with PLLA injections is the formation of subcutaneous nodules and late onset granulomas,” she said.
Early in 2019, Korean researchers published results of a study that set out to evaluate the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model (J Cosmet Dermatol. 2019 Feb 27. doi: 10.1111/jocd.12894). “It showed both PDO and PLLA induced granulomatous reactions and collagen formation, but this decreased at 12 weeks,” said Dr. Ortiz, who was not involved with the work. “PDO had slightly more collagen formation than PLLA.”
Indications for thread lifts, she continued, are for jawline lift, cheek enhancement, brow lift, wrinkle reduction, body contouring, acne scarring, and texturing. “Choose patients with good skin quality: not too thick/heavy, and not too thin. Patients with moderate skin sagging are going to better candidates than those with severe skin sagging.”
One type of absorbable suspension suture, the Silhouette InstaLift, is made of polyglycolide/
In terms of adverse events following thread lift procedures, patients usually feel tender for about a week or 2. “They can have some bruising, mostly from the anesthesia,” she said.
To prevent temporary dimpling, Dr. Ortiz undermines with an 18-gauge needle and inserts perpendicular to the skin surface. “Extrusions can still occur,” she said. To prevent this, she pulls on the end and makes sure it’s buried subcutaneously.
Dr. Ortiz reported having financial relationships with numerous pharmaceutical and device companies, though none related to the content of her presentation. She is also cochair of the Masters of Aesthetics symposium.
EXPERT ANALYSIS FROM MOA 2019
#Dermlife and the Burned-out Resident
Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”1 Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.2 Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00
Burnout in Dermatology Residents
Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties3; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al3 found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.3
Comparison to Residents in Other Specialties
Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).4 Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.
Preventing Burnout
Several burnout prevention and coping strategies across specialties have been suggested.
Mindfulness and Self-awareness
A study by Chaukos et al5 found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.6 Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.7
Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.3 Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.6
Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,7 yet it has been reported that 72% of dermatology residents fall into this category.3 Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.7
Social Support
Focusing on peers may foster the inner strength to endure suffering.1 Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.6 Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.7 Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.3
Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.6
Final Thoughts
Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”8
- Benabio J. Burnout. Dermatology News. November 14, 2017. https://www.mdedge.com/edermatologynews/article/152098/business-medicine/burnout. Accessed August 14, 2019.
- Martin KL. Medscape Physician Lifestyle & Happiness Report 2019. Medscape website. https://www.medscape.com/slideshow/2019-lifestyle-happiness-6011057. Published January 9, 2019. Accessed August 14, 2019.
- Shoimer I, Patten S, Mydlarski P. Burnout in dermatology residents: a Canadian perspective. Br J Dermatol. 2018;178:270-271.
- Dyrbye LN, Burke SE, Hardeman RR, et al. Association of clinical specialty with symptoms of burnout and career choice regret among us resident physicians. JAMA. 2018;320:1114-1130.
- Chaukos D, Chaed-Friedman E, Mehta D, et al. Risk and resilience factors associated with resident burnout. Acad Psychiatry. 2017;41:189-194.
- Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;2:236-242.
- Tolentino J, Guo W, Ricca R, et al. What’s new in academic medicine: can we effectively address the burnout epidemic in healthcare? Int J Acad Med. 2017;3.
- Maslach C. Burnout: a multidimensional perspective. In: Schaufeli W, Maslach C, Marek T, eds. Professional Burnout: Recent Developments in Theory and Research. Washington, DC: Taylor and Francis; 1993:19-32.
Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”1 Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.2 Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00
Burnout in Dermatology Residents
Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties3; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al3 found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.3
Comparison to Residents in Other Specialties
Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).4 Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.
Preventing Burnout
Several burnout prevention and coping strategies across specialties have been suggested.
Mindfulness and Self-awareness
A study by Chaukos et al5 found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.6 Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.7
Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.3 Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.6
Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,7 yet it has been reported that 72% of dermatology residents fall into this category.3 Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.7
Social Support
Focusing on peers may foster the inner strength to endure suffering.1 Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.6 Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.7 Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.3
Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.6
Final Thoughts
Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”8
Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”1 Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.2 Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00
Burnout in Dermatology Residents
Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties3; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al3 found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.3
Comparison to Residents in Other Specialties
Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).4 Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.
Preventing Burnout
Several burnout prevention and coping strategies across specialties have been suggested.
Mindfulness and Self-awareness
A study by Chaukos et al5 found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.6 Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.7
Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.3 Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.6
Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,7 yet it has been reported that 72% of dermatology residents fall into this category.3 Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.7
Social Support
Focusing on peers may foster the inner strength to endure suffering.1 Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.6 Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.7 Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.3
Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.6
Final Thoughts
Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”8
- Benabio J. Burnout. Dermatology News. November 14, 2017. https://www.mdedge.com/edermatologynews/article/152098/business-medicine/burnout. Accessed August 14, 2019.
- Martin KL. Medscape Physician Lifestyle & Happiness Report 2019. Medscape website. https://www.medscape.com/slideshow/2019-lifestyle-happiness-6011057. Published January 9, 2019. Accessed August 14, 2019.
- Shoimer I, Patten S, Mydlarski P. Burnout in dermatology residents: a Canadian perspective. Br J Dermatol. 2018;178:270-271.
- Dyrbye LN, Burke SE, Hardeman RR, et al. Association of clinical specialty with symptoms of burnout and career choice regret among us resident physicians. JAMA. 2018;320:1114-1130.
- Chaukos D, Chaed-Friedman E, Mehta D, et al. Risk and resilience factors associated with resident burnout. Acad Psychiatry. 2017;41:189-194.
- Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;2:236-242.
- Tolentino J, Guo W, Ricca R, et al. What’s new in academic medicine: can we effectively address the burnout epidemic in healthcare? Int J Acad Med. 2017;3.
- Maslach C. Burnout: a multidimensional perspective. In: Schaufeli W, Maslach C, Marek T, eds. Professional Burnout: Recent Developments in Theory and Research. Washington, DC: Taylor and Francis; 1993:19-32.
- Benabio J. Burnout. Dermatology News. November 14, 2017. https://www.mdedge.com/edermatologynews/article/152098/business-medicine/burnout. Accessed August 14, 2019.
- Martin KL. Medscape Physician Lifestyle & Happiness Report 2019. Medscape website. https://www.medscape.com/slideshow/2019-lifestyle-happiness-6011057. Published January 9, 2019. Accessed August 14, 2019.
- Shoimer I, Patten S, Mydlarski P. Burnout in dermatology residents: a Canadian perspective. Br J Dermatol. 2018;178:270-271.
- Dyrbye LN, Burke SE, Hardeman RR, et al. Association of clinical specialty with symptoms of burnout and career choice regret among us resident physicians. JAMA. 2018;320:1114-1130.
- Chaukos D, Chaed-Friedman E, Mehta D, et al. Risk and resilience factors associated with resident burnout. Acad Psychiatry. 2017;41:189-194.
- Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;2:236-242.
- Tolentino J, Guo W, Ricca R, et al. What’s new in academic medicine: can we effectively address the burnout epidemic in healthcare? Int J Acad Med. 2017;3.
- Maslach C. Burnout: a multidimensional perspective. In: Schaufeli W, Maslach C, Marek T, eds. Professional Burnout: Recent Developments in Theory and Research. Washington, DC: Taylor and Francis; 1993:19-32.
Resident Pearl
- Reported techniques for preventing and coping with resident burnout include mindfulness and self-awareness, optimization of workplace factors, adequate sleep, social support, and physical exercise.
How does diet affect the risk of IBD?
CHICAGO – , according to a lecture delivered at Freston Conference 2019, sponsored by the American Gastroenterological Association.
Although the literature is highly consistent, it contains discordant findings, and many questions remain unanswered. “We need more rigorous studies, and particularly more interventions, to truly understand the role diet may play in patients with IBD,” said Ashwin N. Ananthakrishnan, MD, MPH, associate professor of medicine at Massachusetts General Hospital in Boston.
Food can cause symptoms in IBD
Many patients with IBD are convinced that their diet caused their disease. A relevant point for physicians to consider is that these patients are at least as likely as is the general population to have intolerance or sensitivity to food components such as lactose and gluten. In a prospective questionnaire of 400 consecutive patients with IBD in the United Kingdom, 48% expressed the belief that diet could initiate IBD, and 57% said that diet could trigger a flare-up. In addition, 60% of respondents reported worsening of symptoms after eating certain foods, and about two-thirds deprived themselves of their favorite foods to prevent relapses (Inflamm Bowel Dis. 2016;22[1]:164-70). A French study found similar results. “Clearly there’s something there,” said Dr. Ananthakrishnan. Patients’ beliefs about the relationship between food and their symptoms are not simply misconceptions, he added.
A Canadian study published in 2016 found that almost one-third of patients with IBD avoid many food groups. “But there is significant heterogeneity in the foods that are avoided, and sometimes we mistake this heterogeneity for a lack of association between diet and symptoms in IBD,” said Dr. Ananthakrishnan. A larger number of patients avoid certain foods during periods of active disease, which suggests that food exacerbates their symptoms, he added. The same study showed that patients with IBD have more restrictive diets than do community controls. Patients eat fewer fruits and vegetables and generally consume less iron-rich food and less protein-rich food than healthy controls. GI intolerance, rather than professional advice, is the most common reason that patients with IBD restrict their diets (JPEN J Parenter Enteral Nutr. 2016;40[3]:405-11.).
A cross-sectional survey of 130 patients with IBD and 70 controls yielded similar results. Among patients, GI symptoms that resulted from consuming foods were not related to disease activity, disease location, or prior surgery. Patients with IBD tended to have greater frequency of GI intolerance to foods than did controls (Scand J Gastroenterol. 1997;32[6]:569-71.).
Diet may cause intestinal inflammation
International research has recorded increases in the consumption of sugar and fat (particularly saturated fat) and concomitant decreases in fiber consumption during the past several decades. The incidence of IBD has increased in parallel with these dietary changes with a remarkably similar trajectory, said Dr. Ananthakrishnan. The correlation between dietary changes and IBD incidence “holds true even more strikingly in countries that are now experiencing Westernization,” he added. These countries have undergone more rapid dietary changes, and their IBD incidence has doubled or tripled. The transition to “less traditional diets” appears to promote intestinal inflammation, said Dr. Ananthakrishnan.
An analysis of data from the European Prospective Investigation into Cancer (EPIC) study found an association between high consumption of sugar and soft drinks, together with low consumption of vegetables, and risk of ulcerative colitis (Inflamm Bowel Dis. 2016;22[2]:345-54.). A subsequent analysis of data from two prospective Swedish cohorts, however, found no association between consumption of sugary beverages and risk of Crohn’s disease or ulcerative colitis (Clin Gastroenterol Hepatol. 2019;17[1]:123-9.).
Although the data on sugar are mixed, data on the association between other macronutrient groups and risk of IBD are more consistent. When Dr. Ananthakrishnan and colleagues examined data from the Nurses’ Health Study, they found that the highest quintile of dietary fiber intake was associated with a 40% reduction in risk of Crohn’s disease, compared with the lowest quintile. The observed reduction of risk seemed to be greatest for fiber derived from fruits. Fiber from cereals, whole grains, or legumes, however, did not affect risk of Crohn’s disease (Gastroenterology. 2013;145[5]:970-7.).
A separate analysis of the Nurses’ Health Study suggested that high intake of n-3 polyunsaturated fatty acids (PUFAs) and low intake of n-6 PUFAs was associated with a 31% reduction in risk of ulcerative colitis and a 15% reduction in the risk of Crohn’s disease. These data were consistent with a previous analysis of EPIC data that found that high intake of n-6 PUFAs was associated with increased risk of ulcerative colitis (Gut. 2009;58[12]:1606-11.). Other analyses indicate that genetic polymorphisms likely modify the association between PUFAs and risk of ulcerative colitis, said Dr. Ananthakrishnan. “There may be an additional layer of complexity beyond just measuring your dietary intake.”
In addition to macronutrients, micronutrients can modify a patient’s risk of ulcerative colitis or Crohn’s disease. When Dr. Ananthakrishnan and colleagues examined the Nurses’ Health Study, they found an inverse association between vitamin D intake and risk of Crohn’s disease (Gastroenterology. 2012;142[3]:482-9.). In a separate study, they found that a zinc intake greater than 16 mg/day was associated with reduced risk of Crohn’s disease (Int J Epidemiol. 2015;44[6]:1995-2005.).
Patients aged older than 40 years and patients of European ancestry tend to be overrepresented in cohort studies, which reduces the generalizability of their conclusions, said Dr. Ananthakrishnan. Furthermore, cohort studies have not produced consistent findings regarding the relationship between various dietary components and risk of IBD. Nevertheless, the data suggest that dietary patterns may be associated with incident Crohn’s disease or ulcerative colitis.
An influence of diet on IBD risk is plausible
One mechanism through which diet may exercise a causal influence on the risk of IBD is by affecting the microbiome. In 2011, investigators studied 98 healthy volunteers who answered questionnaires about their diet. The researchers also used 16s rDNA sequencing to characterize the population’s stool samples. A diet high in animal protein, amino acids, and saturated fats was associated with large populations of Bacteroides. A diet low in fat and in animal protein, but high in carbohydrates and simple sugars was associated with large populations of Prevotella. When the investigators conducted a controlled-feeding study of 10 patients, microbiome composition changed within 1 day of initiating a high-fat-and-low-fiber or a low-fat-and-high-fiber diet (Science. 2011;334[6052]:105-8.). A more recent study showed that the diversity of the microbiome increased with the adoption of an animal-based diet (Nature. 2014;505[7484]:559-63.).
Diet also may exert a causal influence on IBD risk by altering the intestinal barrier. In an experimental model, 5-mg/mL concentrations of fiber from plantain and broccoli significantly reduced the translocation of Escherichia coli through a human intestinal epithelial barrier (Gut. 2010;59[10]:1331-9.). Increased fiber intake may thus result in reduced intestinal inflammation, said Dr. Ananthakrishnan.
Observational and experimental evidence thus support an effect of diet on the risk of IBD, and experimental evidence indicates that this effect is biologically plausible. Nevertheless, “there are many missing links,” and further study will clarify the role of diet in IBD incidence, said Dr. Ananthakrishnan.
CHICAGO – , according to a lecture delivered at Freston Conference 2019, sponsored by the American Gastroenterological Association.
Although the literature is highly consistent, it contains discordant findings, and many questions remain unanswered. “We need more rigorous studies, and particularly more interventions, to truly understand the role diet may play in patients with IBD,” said Ashwin N. Ananthakrishnan, MD, MPH, associate professor of medicine at Massachusetts General Hospital in Boston.
Food can cause symptoms in IBD
Many patients with IBD are convinced that their diet caused their disease. A relevant point for physicians to consider is that these patients are at least as likely as is the general population to have intolerance or sensitivity to food components such as lactose and gluten. In a prospective questionnaire of 400 consecutive patients with IBD in the United Kingdom, 48% expressed the belief that diet could initiate IBD, and 57% said that diet could trigger a flare-up. In addition, 60% of respondents reported worsening of symptoms after eating certain foods, and about two-thirds deprived themselves of their favorite foods to prevent relapses (Inflamm Bowel Dis. 2016;22[1]:164-70). A French study found similar results. “Clearly there’s something there,” said Dr. Ananthakrishnan. Patients’ beliefs about the relationship between food and their symptoms are not simply misconceptions, he added.
A Canadian study published in 2016 found that almost one-third of patients with IBD avoid many food groups. “But there is significant heterogeneity in the foods that are avoided, and sometimes we mistake this heterogeneity for a lack of association between diet and symptoms in IBD,” said Dr. Ananthakrishnan. A larger number of patients avoid certain foods during periods of active disease, which suggests that food exacerbates their symptoms, he added. The same study showed that patients with IBD have more restrictive diets than do community controls. Patients eat fewer fruits and vegetables and generally consume less iron-rich food and less protein-rich food than healthy controls. GI intolerance, rather than professional advice, is the most common reason that patients with IBD restrict their diets (JPEN J Parenter Enteral Nutr. 2016;40[3]:405-11.).
A cross-sectional survey of 130 patients with IBD and 70 controls yielded similar results. Among patients, GI symptoms that resulted from consuming foods were not related to disease activity, disease location, or prior surgery. Patients with IBD tended to have greater frequency of GI intolerance to foods than did controls (Scand J Gastroenterol. 1997;32[6]:569-71.).
Diet may cause intestinal inflammation
International research has recorded increases in the consumption of sugar and fat (particularly saturated fat) and concomitant decreases in fiber consumption during the past several decades. The incidence of IBD has increased in parallel with these dietary changes with a remarkably similar trajectory, said Dr. Ananthakrishnan. The correlation between dietary changes and IBD incidence “holds true even more strikingly in countries that are now experiencing Westernization,” he added. These countries have undergone more rapid dietary changes, and their IBD incidence has doubled or tripled. The transition to “less traditional diets” appears to promote intestinal inflammation, said Dr. Ananthakrishnan.
An analysis of data from the European Prospective Investigation into Cancer (EPIC) study found an association between high consumption of sugar and soft drinks, together with low consumption of vegetables, and risk of ulcerative colitis (Inflamm Bowel Dis. 2016;22[2]:345-54.). A subsequent analysis of data from two prospective Swedish cohorts, however, found no association between consumption of sugary beverages and risk of Crohn’s disease or ulcerative colitis (Clin Gastroenterol Hepatol. 2019;17[1]:123-9.).
Although the data on sugar are mixed, data on the association between other macronutrient groups and risk of IBD are more consistent. When Dr. Ananthakrishnan and colleagues examined data from the Nurses’ Health Study, they found that the highest quintile of dietary fiber intake was associated with a 40% reduction in risk of Crohn’s disease, compared with the lowest quintile. The observed reduction of risk seemed to be greatest for fiber derived from fruits. Fiber from cereals, whole grains, or legumes, however, did not affect risk of Crohn’s disease (Gastroenterology. 2013;145[5]:970-7.).
A separate analysis of the Nurses’ Health Study suggested that high intake of n-3 polyunsaturated fatty acids (PUFAs) and low intake of n-6 PUFAs was associated with a 31% reduction in risk of ulcerative colitis and a 15% reduction in the risk of Crohn’s disease. These data were consistent with a previous analysis of EPIC data that found that high intake of n-6 PUFAs was associated with increased risk of ulcerative colitis (Gut. 2009;58[12]:1606-11.). Other analyses indicate that genetic polymorphisms likely modify the association between PUFAs and risk of ulcerative colitis, said Dr. Ananthakrishnan. “There may be an additional layer of complexity beyond just measuring your dietary intake.”
In addition to macronutrients, micronutrients can modify a patient’s risk of ulcerative colitis or Crohn’s disease. When Dr. Ananthakrishnan and colleagues examined the Nurses’ Health Study, they found an inverse association between vitamin D intake and risk of Crohn’s disease (Gastroenterology. 2012;142[3]:482-9.). In a separate study, they found that a zinc intake greater than 16 mg/day was associated with reduced risk of Crohn’s disease (Int J Epidemiol. 2015;44[6]:1995-2005.).
Patients aged older than 40 years and patients of European ancestry tend to be overrepresented in cohort studies, which reduces the generalizability of their conclusions, said Dr. Ananthakrishnan. Furthermore, cohort studies have not produced consistent findings regarding the relationship between various dietary components and risk of IBD. Nevertheless, the data suggest that dietary patterns may be associated with incident Crohn’s disease or ulcerative colitis.
An influence of diet on IBD risk is plausible
One mechanism through which diet may exercise a causal influence on the risk of IBD is by affecting the microbiome. In 2011, investigators studied 98 healthy volunteers who answered questionnaires about their diet. The researchers also used 16s rDNA sequencing to characterize the population’s stool samples. A diet high in animal protein, amino acids, and saturated fats was associated with large populations of Bacteroides. A diet low in fat and in animal protein, but high in carbohydrates and simple sugars was associated with large populations of Prevotella. When the investigators conducted a controlled-feeding study of 10 patients, microbiome composition changed within 1 day of initiating a high-fat-and-low-fiber or a low-fat-and-high-fiber diet (Science. 2011;334[6052]:105-8.). A more recent study showed that the diversity of the microbiome increased with the adoption of an animal-based diet (Nature. 2014;505[7484]:559-63.).
Diet also may exert a causal influence on IBD risk by altering the intestinal barrier. In an experimental model, 5-mg/mL concentrations of fiber from plantain and broccoli significantly reduced the translocation of Escherichia coli through a human intestinal epithelial barrier (Gut. 2010;59[10]:1331-9.). Increased fiber intake may thus result in reduced intestinal inflammation, said Dr. Ananthakrishnan.
Observational and experimental evidence thus support an effect of diet on the risk of IBD, and experimental evidence indicates that this effect is biologically plausible. Nevertheless, “there are many missing links,” and further study will clarify the role of diet in IBD incidence, said Dr. Ananthakrishnan.
CHICAGO – , according to a lecture delivered at Freston Conference 2019, sponsored by the American Gastroenterological Association.
Although the literature is highly consistent, it contains discordant findings, and many questions remain unanswered. “We need more rigorous studies, and particularly more interventions, to truly understand the role diet may play in patients with IBD,” said Ashwin N. Ananthakrishnan, MD, MPH, associate professor of medicine at Massachusetts General Hospital in Boston.
Food can cause symptoms in IBD
Many patients with IBD are convinced that their diet caused their disease. A relevant point for physicians to consider is that these patients are at least as likely as is the general population to have intolerance or sensitivity to food components such as lactose and gluten. In a prospective questionnaire of 400 consecutive patients with IBD in the United Kingdom, 48% expressed the belief that diet could initiate IBD, and 57% said that diet could trigger a flare-up. In addition, 60% of respondents reported worsening of symptoms after eating certain foods, and about two-thirds deprived themselves of their favorite foods to prevent relapses (Inflamm Bowel Dis. 2016;22[1]:164-70). A French study found similar results. “Clearly there’s something there,” said Dr. Ananthakrishnan. Patients’ beliefs about the relationship between food and their symptoms are not simply misconceptions, he added.
A Canadian study published in 2016 found that almost one-third of patients with IBD avoid many food groups. “But there is significant heterogeneity in the foods that are avoided, and sometimes we mistake this heterogeneity for a lack of association between diet and symptoms in IBD,” said Dr. Ananthakrishnan. A larger number of patients avoid certain foods during periods of active disease, which suggests that food exacerbates their symptoms, he added. The same study showed that patients with IBD have more restrictive diets than do community controls. Patients eat fewer fruits and vegetables and generally consume less iron-rich food and less protein-rich food than healthy controls. GI intolerance, rather than professional advice, is the most common reason that patients with IBD restrict their diets (JPEN J Parenter Enteral Nutr. 2016;40[3]:405-11.).
A cross-sectional survey of 130 patients with IBD and 70 controls yielded similar results. Among patients, GI symptoms that resulted from consuming foods were not related to disease activity, disease location, or prior surgery. Patients with IBD tended to have greater frequency of GI intolerance to foods than did controls (Scand J Gastroenterol. 1997;32[6]:569-71.).
Diet may cause intestinal inflammation
International research has recorded increases in the consumption of sugar and fat (particularly saturated fat) and concomitant decreases in fiber consumption during the past several decades. The incidence of IBD has increased in parallel with these dietary changes with a remarkably similar trajectory, said Dr. Ananthakrishnan. The correlation between dietary changes and IBD incidence “holds true even more strikingly in countries that are now experiencing Westernization,” he added. These countries have undergone more rapid dietary changes, and their IBD incidence has doubled or tripled. The transition to “less traditional diets” appears to promote intestinal inflammation, said Dr. Ananthakrishnan.
An analysis of data from the European Prospective Investigation into Cancer (EPIC) study found an association between high consumption of sugar and soft drinks, together with low consumption of vegetables, and risk of ulcerative colitis (Inflamm Bowel Dis. 2016;22[2]:345-54.). A subsequent analysis of data from two prospective Swedish cohorts, however, found no association between consumption of sugary beverages and risk of Crohn’s disease or ulcerative colitis (Clin Gastroenterol Hepatol. 2019;17[1]:123-9.).
Although the data on sugar are mixed, data on the association between other macronutrient groups and risk of IBD are more consistent. When Dr. Ananthakrishnan and colleagues examined data from the Nurses’ Health Study, they found that the highest quintile of dietary fiber intake was associated with a 40% reduction in risk of Crohn’s disease, compared with the lowest quintile. The observed reduction of risk seemed to be greatest for fiber derived from fruits. Fiber from cereals, whole grains, or legumes, however, did not affect risk of Crohn’s disease (Gastroenterology. 2013;145[5]:970-7.).
A separate analysis of the Nurses’ Health Study suggested that high intake of n-3 polyunsaturated fatty acids (PUFAs) and low intake of n-6 PUFAs was associated with a 31% reduction in risk of ulcerative colitis and a 15% reduction in the risk of Crohn’s disease. These data were consistent with a previous analysis of EPIC data that found that high intake of n-6 PUFAs was associated with increased risk of ulcerative colitis (Gut. 2009;58[12]:1606-11.). Other analyses indicate that genetic polymorphisms likely modify the association between PUFAs and risk of ulcerative colitis, said Dr. Ananthakrishnan. “There may be an additional layer of complexity beyond just measuring your dietary intake.”
In addition to macronutrients, micronutrients can modify a patient’s risk of ulcerative colitis or Crohn’s disease. When Dr. Ananthakrishnan and colleagues examined the Nurses’ Health Study, they found an inverse association between vitamin D intake and risk of Crohn’s disease (Gastroenterology. 2012;142[3]:482-9.). In a separate study, they found that a zinc intake greater than 16 mg/day was associated with reduced risk of Crohn’s disease (Int J Epidemiol. 2015;44[6]:1995-2005.).
Patients aged older than 40 years and patients of European ancestry tend to be overrepresented in cohort studies, which reduces the generalizability of their conclusions, said Dr. Ananthakrishnan. Furthermore, cohort studies have not produced consistent findings regarding the relationship between various dietary components and risk of IBD. Nevertheless, the data suggest that dietary patterns may be associated with incident Crohn’s disease or ulcerative colitis.
An influence of diet on IBD risk is plausible
One mechanism through which diet may exercise a causal influence on the risk of IBD is by affecting the microbiome. In 2011, investigators studied 98 healthy volunteers who answered questionnaires about their diet. The researchers also used 16s rDNA sequencing to characterize the population’s stool samples. A diet high in animal protein, amino acids, and saturated fats was associated with large populations of Bacteroides. A diet low in fat and in animal protein, but high in carbohydrates and simple sugars was associated with large populations of Prevotella. When the investigators conducted a controlled-feeding study of 10 patients, microbiome composition changed within 1 day of initiating a high-fat-and-low-fiber or a low-fat-and-high-fiber diet (Science. 2011;334[6052]:105-8.). A more recent study showed that the diversity of the microbiome increased with the adoption of an animal-based diet (Nature. 2014;505[7484]:559-63.).
Diet also may exert a causal influence on IBD risk by altering the intestinal barrier. In an experimental model, 5-mg/mL concentrations of fiber from plantain and broccoli significantly reduced the translocation of Escherichia coli through a human intestinal epithelial barrier (Gut. 2010;59[10]:1331-9.). Increased fiber intake may thus result in reduced intestinal inflammation, said Dr. Ananthakrishnan.
Observational and experimental evidence thus support an effect of diet on the risk of IBD, and experimental evidence indicates that this effect is biologically plausible. Nevertheless, “there are many missing links,” and further study will clarify the role of diet in IBD incidence, said Dr. Ananthakrishnan.
REPORTING FROM FRESTON CONFERENCE 2019
Health care–associated infection rates going down
Background: HAIs are key drivers of morbidity and mortality for hospitalized patients. In 2011, the Centers for Disease Control and Prevention (CDC) conducted a point-prevalence survey that revealed an HAI in 4% of hospitalized patients. The most common infections included pneumonia, gastrointestinal infections, and surgical-site infections. Over time, efforts in patient safety and quality have expanded to reduce the rate of HAIs. This same survey was repeated in 2015 to assess for improvements.
Study design: Point-prevalence survey.
Setting: A collection of 199 Emerging Infection Program hospitals in 10 states.
Synopsis: Of 12,299 patients surveyed, 3.2% (95% confidence interval, 2.9%-3.5%) were found to have at least one HAI. This was a statistically significant reduction compared to the prevalence of 4% (95% CI, 3.7%-4.4%) found in the 2011 study. Approximately 75% of patients were on a medical ward, and 15% of patients were in the ICU. The age and sex of patients were similar to those of patients in the 2011 study.
The reduction in HAIs was primarily driven by a reduction in surgical-site infections and urinary tract infections. There was no reduction in the prevalence of health care–associated pneumonia, Clostridium difficile infection, or mortality. Consequently, this emphasizes the necessity of further work in these domains.
Bottom line: The overall prevalence of HAIs has decreased, but further quality improvement work is needed in order to expand this reduction to health care–associated pneumonia, C. difficile infection, and mortality from HAIs.
Citation: Magill SS et al. Changes in prevalence of heath care–associated infections in U.S. hospitals. N Engl J Med. 2018;379(18):1732-44.
Dr. McIntyre is an associate physician in the division of hospital medicine at the University of California, San Diego.
Background: HAIs are key drivers of morbidity and mortality for hospitalized patients. In 2011, the Centers for Disease Control and Prevention (CDC) conducted a point-prevalence survey that revealed an HAI in 4% of hospitalized patients. The most common infections included pneumonia, gastrointestinal infections, and surgical-site infections. Over time, efforts in patient safety and quality have expanded to reduce the rate of HAIs. This same survey was repeated in 2015 to assess for improvements.
Study design: Point-prevalence survey.
Setting: A collection of 199 Emerging Infection Program hospitals in 10 states.
Synopsis: Of 12,299 patients surveyed, 3.2% (95% confidence interval, 2.9%-3.5%) were found to have at least one HAI. This was a statistically significant reduction compared to the prevalence of 4% (95% CI, 3.7%-4.4%) found in the 2011 study. Approximately 75% of patients were on a medical ward, and 15% of patients were in the ICU. The age and sex of patients were similar to those of patients in the 2011 study.
The reduction in HAIs was primarily driven by a reduction in surgical-site infections and urinary tract infections. There was no reduction in the prevalence of health care–associated pneumonia, Clostridium difficile infection, or mortality. Consequently, this emphasizes the necessity of further work in these domains.
Bottom line: The overall prevalence of HAIs has decreased, but further quality improvement work is needed in order to expand this reduction to health care–associated pneumonia, C. difficile infection, and mortality from HAIs.
Citation: Magill SS et al. Changes in prevalence of heath care–associated infections in U.S. hospitals. N Engl J Med. 2018;379(18):1732-44.
Dr. McIntyre is an associate physician in the division of hospital medicine at the University of California, San Diego.
Background: HAIs are key drivers of morbidity and mortality for hospitalized patients. In 2011, the Centers for Disease Control and Prevention (CDC) conducted a point-prevalence survey that revealed an HAI in 4% of hospitalized patients. The most common infections included pneumonia, gastrointestinal infections, and surgical-site infections. Over time, efforts in patient safety and quality have expanded to reduce the rate of HAIs. This same survey was repeated in 2015 to assess for improvements.
Study design: Point-prevalence survey.
Setting: A collection of 199 Emerging Infection Program hospitals in 10 states.
Synopsis: Of 12,299 patients surveyed, 3.2% (95% confidence interval, 2.9%-3.5%) were found to have at least one HAI. This was a statistically significant reduction compared to the prevalence of 4% (95% CI, 3.7%-4.4%) found in the 2011 study. Approximately 75% of patients were on a medical ward, and 15% of patients were in the ICU. The age and sex of patients were similar to those of patients in the 2011 study.
The reduction in HAIs was primarily driven by a reduction in surgical-site infections and urinary tract infections. There was no reduction in the prevalence of health care–associated pneumonia, Clostridium difficile infection, or mortality. Consequently, this emphasizes the necessity of further work in these domains.
Bottom line: The overall prevalence of HAIs has decreased, but further quality improvement work is needed in order to expand this reduction to health care–associated pneumonia, C. difficile infection, and mortality from HAIs.
Citation: Magill SS et al. Changes in prevalence of heath care–associated infections in U.S. hospitals. N Engl J Med. 2018;379(18):1732-44.
Dr. McIntyre is an associate physician in the division of hospital medicine at the University of California, San Diego.
Rules of incivility
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Progressive myeloma after induction? Go straight to transplant
Patients with multiple myeloma who don’t respond to induction therapy may be better off advancing straight to autologous stem cell therapy, rather than undergoing salvage therapy before transplant, according to findings of an analysis that included both real-world and clinical trial patients.
Joanna Blocka, MD, of the University Hospital of Heidelberg (Germany) and colleagues found similar progression-free and overall survival rates for patients who had progressive disease and underwent autologous stem cell therapy (ASCT), compared with patients who underwent salvage therapy and improved to at least stable disease before proceeding to transplant. The findings were published in Leukemia & Lymphoma.
The real-world analysis included 1,599 patients with multiple myeloma who had undergone ASCT between 1991 and 2016. More than half of the patients (58%) were not enrolled in clinical trials. The remainder were split between the German-Speaking Myeloma Multicenter Group (GMMG)-HD3 and GMMG-HD4 trials, which compared various induction regimens.
Just 23 patients in the analysis received salvage therapy because of progressive disease and deepened their response before ASCT. Of these patients, 12 received novel agents in induction therapy and 11 received older medications.
Looking across all 1,599 patients, 5.3% achieved complete remission before first ASCT. Most patients (71.8%) achieved partial remission, 9.7% had a minimal response, and 5.7% had stable disease. A group of 120 patients (7.5%) progressed between the last course of induction and ASCT.
The researchers compared the progression-free and overall survival rates of patients with progressive disease versus those who had stable disease or better before their first transplant. Both univariable and multivariable analysis showed no statistically significant differences in either survival outcome between the two groups.
In the multivariable analysis, there was a hazard ratio of 1.23 (95% confidence interval, 0.98-1.56) for progression-free survival for patients with progressive disease versus those who responded to induction therapy. Similarly, the HR for overall survival between the two groups was 1.24 (95% CI, 0.93-1.65).
The researchers also analyzed the groups based on whether they received novel or older agents during induction.
Patients with progressive disease who received novel agents had significantly worse progression-free survival (22.2 months), compared with patients who responded to treatment with novel agents (22.2 months vs. 29.1 months; P = .03). The same trend was seen with overall survival in these groups (54.4 months vs. 97.5 months; P less than .001).
Rates of survival were similar for patients with progressive disease and responders who had received older medications at induction.
“This might be explained by a prognostically disadvantageous disease biology in patients nonresponsive to novel agents,” the researchers wrote.
The researchers also compared survival outcomes for the 120 patients who underwent ASCT with progressive disease versus the 23 patients who received salvage therapy and improved their response to at least stable disease before transplant. Univariable analysis showed that salvage patients actually did worse than those with progressive disease who proceeded straight to transplant – 12.1 months versus 22.9 months of progression-free survival (P = .04) and 33.1 versus 69.5 months of overall survival (P = .08). But on multivariable analysis, there was no significant difference between the two groups for progression-free survival (HR, 0.71; 95% CI, 0.28-1.80; P = .5) or overall survival (HR, 0.77; 95% CI, 0.30-1.95; P = .6). The use of novel agents did not appear to affect the survival outcomes in these patients.
The worse outcomes seen among salvage patients observed in univariable analysis “might be due to a cumulative toxic effect of salvage therapy,” the researchers suggested. “An alternative explanation could be that the patients who were offered salvage therapy might have had more aggressive disease than those who did not undergo salvage therapy.”
Dr. Blocka reported having no relevant financial disclosures. Other coauthors reported relationships with Janssen, Amgen, Bristol-Myers Squibb, Celgene, and others.
SOURCE: Blocka J et al. Leuk Lymphoma. 2019 Aug 19. doi: 10.1080/10428194.2019.1646905.
Patients with multiple myeloma who don’t respond to induction therapy may be better off advancing straight to autologous stem cell therapy, rather than undergoing salvage therapy before transplant, according to findings of an analysis that included both real-world and clinical trial patients.
Joanna Blocka, MD, of the University Hospital of Heidelberg (Germany) and colleagues found similar progression-free and overall survival rates for patients who had progressive disease and underwent autologous stem cell therapy (ASCT), compared with patients who underwent salvage therapy and improved to at least stable disease before proceeding to transplant. The findings were published in Leukemia & Lymphoma.
The real-world analysis included 1,599 patients with multiple myeloma who had undergone ASCT between 1991 and 2016. More than half of the patients (58%) were not enrolled in clinical trials. The remainder were split between the German-Speaking Myeloma Multicenter Group (GMMG)-HD3 and GMMG-HD4 trials, which compared various induction regimens.
Just 23 patients in the analysis received salvage therapy because of progressive disease and deepened their response before ASCT. Of these patients, 12 received novel agents in induction therapy and 11 received older medications.
Looking across all 1,599 patients, 5.3% achieved complete remission before first ASCT. Most patients (71.8%) achieved partial remission, 9.7% had a minimal response, and 5.7% had stable disease. A group of 120 patients (7.5%) progressed between the last course of induction and ASCT.
The researchers compared the progression-free and overall survival rates of patients with progressive disease versus those who had stable disease or better before their first transplant. Both univariable and multivariable analysis showed no statistically significant differences in either survival outcome between the two groups.
In the multivariable analysis, there was a hazard ratio of 1.23 (95% confidence interval, 0.98-1.56) for progression-free survival for patients with progressive disease versus those who responded to induction therapy. Similarly, the HR for overall survival between the two groups was 1.24 (95% CI, 0.93-1.65).
The researchers also analyzed the groups based on whether they received novel or older agents during induction.
Patients with progressive disease who received novel agents had significantly worse progression-free survival (22.2 months), compared with patients who responded to treatment with novel agents (22.2 months vs. 29.1 months; P = .03). The same trend was seen with overall survival in these groups (54.4 months vs. 97.5 months; P less than .001).
Rates of survival were similar for patients with progressive disease and responders who had received older medications at induction.
“This might be explained by a prognostically disadvantageous disease biology in patients nonresponsive to novel agents,” the researchers wrote.
The researchers also compared survival outcomes for the 120 patients who underwent ASCT with progressive disease versus the 23 patients who received salvage therapy and improved their response to at least stable disease before transplant. Univariable analysis showed that salvage patients actually did worse than those with progressive disease who proceeded straight to transplant – 12.1 months versus 22.9 months of progression-free survival (P = .04) and 33.1 versus 69.5 months of overall survival (P = .08). But on multivariable analysis, there was no significant difference between the two groups for progression-free survival (HR, 0.71; 95% CI, 0.28-1.80; P = .5) or overall survival (HR, 0.77; 95% CI, 0.30-1.95; P = .6). The use of novel agents did not appear to affect the survival outcomes in these patients.
The worse outcomes seen among salvage patients observed in univariable analysis “might be due to a cumulative toxic effect of salvage therapy,” the researchers suggested. “An alternative explanation could be that the patients who were offered salvage therapy might have had more aggressive disease than those who did not undergo salvage therapy.”
Dr. Blocka reported having no relevant financial disclosures. Other coauthors reported relationships with Janssen, Amgen, Bristol-Myers Squibb, Celgene, and others.
SOURCE: Blocka J et al. Leuk Lymphoma. 2019 Aug 19. doi: 10.1080/10428194.2019.1646905.
Patients with multiple myeloma who don’t respond to induction therapy may be better off advancing straight to autologous stem cell therapy, rather than undergoing salvage therapy before transplant, according to findings of an analysis that included both real-world and clinical trial patients.
Joanna Blocka, MD, of the University Hospital of Heidelberg (Germany) and colleagues found similar progression-free and overall survival rates for patients who had progressive disease and underwent autologous stem cell therapy (ASCT), compared with patients who underwent salvage therapy and improved to at least stable disease before proceeding to transplant. The findings were published in Leukemia & Lymphoma.
The real-world analysis included 1,599 patients with multiple myeloma who had undergone ASCT between 1991 and 2016. More than half of the patients (58%) were not enrolled in clinical trials. The remainder were split between the German-Speaking Myeloma Multicenter Group (GMMG)-HD3 and GMMG-HD4 trials, which compared various induction regimens.
Just 23 patients in the analysis received salvage therapy because of progressive disease and deepened their response before ASCT. Of these patients, 12 received novel agents in induction therapy and 11 received older medications.
Looking across all 1,599 patients, 5.3% achieved complete remission before first ASCT. Most patients (71.8%) achieved partial remission, 9.7% had a minimal response, and 5.7% had stable disease. A group of 120 patients (7.5%) progressed between the last course of induction and ASCT.
The researchers compared the progression-free and overall survival rates of patients with progressive disease versus those who had stable disease or better before their first transplant. Both univariable and multivariable analysis showed no statistically significant differences in either survival outcome between the two groups.
In the multivariable analysis, there was a hazard ratio of 1.23 (95% confidence interval, 0.98-1.56) for progression-free survival for patients with progressive disease versus those who responded to induction therapy. Similarly, the HR for overall survival between the two groups was 1.24 (95% CI, 0.93-1.65).
The researchers also analyzed the groups based on whether they received novel or older agents during induction.
Patients with progressive disease who received novel agents had significantly worse progression-free survival (22.2 months), compared with patients who responded to treatment with novel agents (22.2 months vs. 29.1 months; P = .03). The same trend was seen with overall survival in these groups (54.4 months vs. 97.5 months; P less than .001).
Rates of survival were similar for patients with progressive disease and responders who had received older medications at induction.
“This might be explained by a prognostically disadvantageous disease biology in patients nonresponsive to novel agents,” the researchers wrote.
The researchers also compared survival outcomes for the 120 patients who underwent ASCT with progressive disease versus the 23 patients who received salvage therapy and improved their response to at least stable disease before transplant. Univariable analysis showed that salvage patients actually did worse than those with progressive disease who proceeded straight to transplant – 12.1 months versus 22.9 months of progression-free survival (P = .04) and 33.1 versus 69.5 months of overall survival (P = .08). But on multivariable analysis, there was no significant difference between the two groups for progression-free survival (HR, 0.71; 95% CI, 0.28-1.80; P = .5) or overall survival (HR, 0.77; 95% CI, 0.30-1.95; P = .6). The use of novel agents did not appear to affect the survival outcomes in these patients.
The worse outcomes seen among salvage patients observed in univariable analysis “might be due to a cumulative toxic effect of salvage therapy,” the researchers suggested. “An alternative explanation could be that the patients who were offered salvage therapy might have had more aggressive disease than those who did not undergo salvage therapy.”
Dr. Blocka reported having no relevant financial disclosures. Other coauthors reported relationships with Janssen, Amgen, Bristol-Myers Squibb, Celgene, and others.
SOURCE: Blocka J et al. Leuk Lymphoma. 2019 Aug 19. doi: 10.1080/10428194.2019.1646905.
FROM LEUKEMIA & LYMPHOMA
Key clinical point:
Major finding: There was no difference between patients with progressive disease who went straight to ASCT and patients who received salvage therapy, both in terms of progression-free survival (hazard ratio, 0.71; 95% confidence interval, 0.28-1.80; P = .5) and overall survival (HR, 0.77; 95% CI, 0.30-1.95; P = .6).
Study details: An analysis of 1,599 patients with multiple myeloma who underwent ASCT. A subanalysis compared 120 patients with progressive disease before ASCT with 23 patients who received salvage treatment before ASCT.
Disclosures: Dr. Blocka reported having no relevant financial disclosures. Other coauthors reported relationships with Janssen, Amgen, Bristol-Myers Squibb, Celgene, and others.
Source: Blocka J et al. Leuk Lymphoma. 2019 Aug 19. doi: 10.1080/10428194.2019.1646905.