Evidence is uncertain for benefit of short-stay unit hospitalization

A Cochrane review of 14 randomized trials evaluating short-stay unit hospitalization for internal medicine conditions was unable to ascertain any definite benefit or harm, compared with usual care, with concerns for heterogeneity, bias, and random error in the studies. The authors recommended conducting more trials with low risk of bias and low risk of random errors.

Citation: Strøm C et al. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev. 2018;8. CD012370. doi: 10.1002/14651858.CD012370.pub2.

Hospice use among Medicare patients with heart failure

Of the 4% percent of Medicare patients discharged to hospice from a hospitalization for heart failure, 25% died within 72 hours of discharge, leading the authors to conclude that hospice is underutilized and initiated too late in the setting of heart failure.

Citation: Warraich HJ et al. Trends in hospice discharge and relative outcomes among Medicare patients in the Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. 2018 Oct 1;3(10):917-26.

Culprit lesion PCI has similar 1-year mortality to immediate multivessel PCI

This is the follow-up study to CULPRIT-SHOCK trial , which examined percutaneous coronary intervention in culprit lesion only vs. multivessel PCI in the setting of cardiogenic shock. The initial trial showed improved 30-day mortality outcomes with culprit lesion PCI only and the follow-up demonstrated no significant difference in 1-year mortality between the two groups.

Citation: Thiele H et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018 Nov 1;379(18):1699-710 .

Evidence is uncertain for benefit of short-stay unit hospitalization

A Cochrane review of 14 randomized trials evaluating short-stay unit hospitalization for internal medicine conditions was unable to ascertain any definite benefit or harm, compared with usual care, with concerns for heterogeneity, bias, and random error in the studies. The authors recommended conducting more trials with low risk of bias and low risk of random errors.

Citation: Strøm C et al. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev. 2018;8. CD012370. doi: 10.1002/14651858.CD012370.pub2.

Hospice use among Medicare patients with heart failure

Of the 4% percent of Medicare patients discharged to hospice from a hospitalization for heart failure, 25% died within 72 hours of discharge, leading the authors to conclude that hospice is underutilized and initiated too late in the setting of heart failure.

Citation: Warraich HJ et al. Trends in hospice discharge and relative outcomes among Medicare patients in the Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. 2018 Oct 1;3(10):917-26.

Culprit lesion PCI has similar 1-year mortality to immediate multivessel PCI

This is the follow-up study to CULPRIT-SHOCK trial , which examined percutaneous coronary intervention in culprit lesion only vs. multivessel PCI in the setting of cardiogenic shock. The initial trial showed improved 30-day mortality outcomes with culprit lesion PCI only and the follow-up demonstrated no significant difference in 1-year mortality between the two groups.

Citation: Thiele H et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018 Nov 1;379(18):1699-710 .

Evidence is uncertain for benefit of short-stay unit hospitalization

A Cochrane review of 14 randomized trials evaluating short-stay unit hospitalization for internal medicine conditions was unable to ascertain any definite benefit or harm, compared with usual care, with concerns for heterogeneity, bias, and random error in the studies. The authors recommended conducting more trials with low risk of bias and low risk of random errors.

Citation: Strøm C et al. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev. 2018;8. CD012370. doi: 10.1002/14651858.CD012370.pub2.

Hospice use among Medicare patients with heart failure

Of the 4% percent of Medicare patients discharged to hospice from a hospitalization for heart failure, 25% died within 72 hours of discharge, leading the authors to conclude that hospice is underutilized and initiated too late in the setting of heart failure.

Citation: Warraich HJ et al. Trends in hospice discharge and relative outcomes among Medicare patients in the Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. 2018 Oct 1;3(10):917-26.

Culprit lesion PCI has similar 1-year mortality to immediate multivessel PCI

This is the follow-up study to CULPRIT-SHOCK trial , which examined percutaneous coronary intervention in culprit lesion only vs. multivessel PCI in the setting of cardiogenic shock. The initial trial showed improved 30-day mortality outcomes with culprit lesion PCI only and the follow-up demonstrated no significant difference in 1-year mortality between the two groups.

Citation: Thiele H et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018 Nov 1;379(18):1699-710 .

SAN DIEGO – Years of experience and an academic medical center affiliation predicted the accuracy of pathologists reviewing biopsies from patients with Barrett’s esophagus, according to the results of a multinational study.

Those with 5 or more years of experience were less likely to make major diagnostic errors in reviewing Barrett’s esophagus biopsies (odds ratio [OR], 0.48, 95% confidence interval, 0.31-0.74). Pathologists who worked in nonacademic settings were more likely to make a major diagnostic error (OR, 1.76; 95% CI, 1.15-2.69) when reviewing hematoxylin and eosin-stained slides alone, but the addition of p53 immunostaining greatly improved accuracy.

Current guidelines recommend expert evaluation of Barrett’s esophagus biopsies that show dysplasia, but exact determination of expert review status had been lacking, according to Marnix Jansen, MD, a pathologist at University College London.

“The guidelines say that biopsies with dysplasia need to be reviewed by an expert pathologist, but don’t define what makes an expert pathologist,” Dr. Jansen said in an interview at the annual Digestive Disease Week.

“We wanted to advance the field by for the first time creating objective and quantitative standards” to delineate the characteristics of an expert pathologist in reviewing Barrett’s esophagus tissue samples, said Dr. Jansen. The study’s first author is Myrtle J. van der Wel, MD, of Amsterdam University Medical Center, the Netherlands.

More than 6,000 individual case diagnoses were used in the study, which included pathologists from more than 20 countries. Before the pathologists began reviewing the case set, they answered a questionnaire about training, practice context, years of experience, case volume, and other demographic characteristics.

“We then sent those biopsies around the world to ... 55 pathologists in the U.S., in Europe, Japan, Australia, even some in South America – so really around the whole globe,” explained Dr. Jansen. Biopsies were assessed by each pathologist before and after p53 immunostaining.

“Once we had the final dataset – which is massive, because we had 6,000 case diagnoses within our dataset – we could then regress those variables back onto the consensus data,” providing a first-ever look at “clear predictors of what the pathologist looks like that will score on a par with where the experts are,” said Dr. Jansen.

The results? “You need at least 5 years of experience. On top of that, if you are a pathologist working in a [nonacademic center], you are at a slightly increased risk of making major diagnostic errors,” said Dr. Jansen. However, the analysis convincingly showed that the addition of p53 immunostaining neutralized the risk for these pathologists – a strength of having such a large dataset, he said.

The study also affirmed the safety of digital pathology for expert review, said Dr. Jansen: “One of the reassuring points of our study was that we found that the best concordance was for nondysplastic Barrett’s, and high-grade dysplasia, which really replicates known glass slide characteristics. So we can really say that digital pathology is safe for this application – which is very relevant for pathologists that are taking in cases from outside for expert review.”

Concordance rates for nondysplastic Barrett’s esophagus and high-grade dysplasia were over 70%; for low-grade dysplasia, rates were intermediate at 42%.

Going forward, the study can inform the next iteration of guidelines for pathologist review of Barrett’s dysplasia, said Dr. Jansen. Rather than just recommending expert review, the guidelines can include a quantitative assessment of what’s needed. “You need to have to have at least 5 years of experience, and if you work in a [community hospital], to use a p53, and that is collectively what amounts to expertise in Barrett’s pathology.”

A follow-up study with a similar design is planned within the United Kingdom, the Netherlands, and the United States. This study, which Dr. Jansen said would enroll hundreds of pathologists, will include an intervention arm that administers a tutorial with the aim of improving concordance scoring.

Dr. Jansen reported no relevant conflicts of interest.

[email protected]

SAN DIEGO – Years of experience and an academic medical center affiliation predicted the accuracy of pathologists reviewing biopsies from patients with Barrett’s esophagus, according to the results of a multinational study.

Those with 5 or more years of experience were less likely to make major diagnostic errors in reviewing Barrett’s esophagus biopsies (odds ratio [OR], 0.48, 95% confidence interval, 0.31-0.74). Pathologists who worked in nonacademic settings were more likely to make a major diagnostic error (OR, 1.76; 95% CI, 1.15-2.69) when reviewing hematoxylin and eosin-stained slides alone, but the addition of p53 immunostaining greatly improved accuracy.

Current guidelines recommend expert evaluation of Barrett’s esophagus biopsies that show dysplasia, but exact determination of expert review status had been lacking, according to Marnix Jansen, MD, a pathologist at University College London.

“The guidelines say that biopsies with dysplasia need to be reviewed by an expert pathologist, but don’t define what makes an expert pathologist,” Dr. Jansen said in an interview at the annual Digestive Disease Week.

“We wanted to advance the field by for the first time creating objective and quantitative standards” to delineate the characteristics of an expert pathologist in reviewing Barrett’s esophagus tissue samples, said Dr. Jansen. The study’s first author is Myrtle J. van der Wel, MD, of Amsterdam University Medical Center, the Netherlands.

More than 6,000 individual case diagnoses were used in the study, which included pathologists from more than 20 countries. Before the pathologists began reviewing the case set, they answered a questionnaire about training, practice context, years of experience, case volume, and other demographic characteristics.

“We then sent those biopsies around the world to ... 55 pathologists in the U.S., in Europe, Japan, Australia, even some in South America – so really around the whole globe,” explained Dr. Jansen. Biopsies were assessed by each pathologist before and after p53 immunostaining.

“Once we had the final dataset – which is massive, because we had 6,000 case diagnoses within our dataset – we could then regress those variables back onto the consensus data,” providing a first-ever look at “clear predictors of what the pathologist looks like that will score on a par with where the experts are,” said Dr. Jansen.

The results? “You need at least 5 years of experience. On top of that, if you are a pathologist working in a [nonacademic center], you are at a slightly increased risk of making major diagnostic errors,” said Dr. Jansen. However, the analysis convincingly showed that the addition of p53 immunostaining neutralized the risk for these pathologists – a strength of having such a large dataset, he said.

The study also affirmed the safety of digital pathology for expert review, said Dr. Jansen: “One of the reassuring points of our study was that we found that the best concordance was for nondysplastic Barrett’s, and high-grade dysplasia, which really replicates known glass slide characteristics. So we can really say that digital pathology is safe for this application – which is very relevant for pathologists that are taking in cases from outside for expert review.”

Concordance rates for nondysplastic Barrett’s esophagus and high-grade dysplasia were over 70%; for low-grade dysplasia, rates were intermediate at 42%.

Going forward, the study can inform the next iteration of guidelines for pathologist review of Barrett’s dysplasia, said Dr. Jansen. Rather than just recommending expert review, the guidelines can include a quantitative assessment of what’s needed. “You need to have to have at least 5 years of experience, and if you work in a [community hospital], to use a p53, and that is collectively what amounts to expertise in Barrett’s pathology.”

A follow-up study with a similar design is planned within the United Kingdom, the Netherlands, and the United States. This study, which Dr. Jansen said would enroll hundreds of pathologists, will include an intervention arm that administers a tutorial with the aim of improving concordance scoring.

Dr. Jansen reported no relevant conflicts of interest.

[email protected]

SAN DIEGO – Years of experience and an academic medical center affiliation predicted the accuracy of pathologists reviewing biopsies from patients with Barrett’s esophagus, according to the results of a multinational study.

Those with 5 or more years of experience were less likely to make major diagnostic errors in reviewing Barrett’s esophagus biopsies (odds ratio [OR], 0.48, 95% confidence interval, 0.31-0.74). Pathologists who worked in nonacademic settings were more likely to make a major diagnostic error (OR, 1.76; 95% CI, 1.15-2.69) when reviewing hematoxylin and eosin-stained slides alone, but the addition of p53 immunostaining greatly improved accuracy.

Current guidelines recommend expert evaluation of Barrett’s esophagus biopsies that show dysplasia, but exact determination of expert review status had been lacking, according to Marnix Jansen, MD, a pathologist at University College London.

“The guidelines say that biopsies with dysplasia need to be reviewed by an expert pathologist, but don’t define what makes an expert pathologist,” Dr. Jansen said in an interview at the annual Digestive Disease Week.

“We wanted to advance the field by for the first time creating objective and quantitative standards” to delineate the characteristics of an expert pathologist in reviewing Barrett’s esophagus tissue samples, said Dr. Jansen. The study’s first author is Myrtle J. van der Wel, MD, of Amsterdam University Medical Center, the Netherlands.

More than 6,000 individual case diagnoses were used in the study, which included pathologists from more than 20 countries. Before the pathologists began reviewing the case set, they answered a questionnaire about training, practice context, years of experience, case volume, and other demographic characteristics.

“We then sent those biopsies around the world to ... 55 pathologists in the U.S., in Europe, Japan, Australia, even some in South America – so really around the whole globe,” explained Dr. Jansen. Biopsies were assessed by each pathologist before and after p53 immunostaining.

“Once we had the final dataset – which is massive, because we had 6,000 case diagnoses within our dataset – we could then regress those variables back onto the consensus data,” providing a first-ever look at “clear predictors of what the pathologist looks like that will score on a par with where the experts are,” said Dr. Jansen.

The results? “You need at least 5 years of experience. On top of that, if you are a pathologist working in a [nonacademic center], you are at a slightly increased risk of making major diagnostic errors,” said Dr. Jansen. However, the analysis convincingly showed that the addition of p53 immunostaining neutralized the risk for these pathologists – a strength of having such a large dataset, he said.

The study also affirmed the safety of digital pathology for expert review, said Dr. Jansen: “One of the reassuring points of our study was that we found that the best concordance was for nondysplastic Barrett’s, and high-grade dysplasia, which really replicates known glass slide characteristics. So we can really say that digital pathology is safe for this application – which is very relevant for pathologists that are taking in cases from outside for expert review.”

Concordance rates for nondysplastic Barrett’s esophagus and high-grade dysplasia were over 70%; for low-grade dysplasia, rates were intermediate at 42%.

Going forward, the study can inform the next iteration of guidelines for pathologist review of Barrett’s dysplasia, said Dr. Jansen. Rather than just recommending expert review, the guidelines can include a quantitative assessment of what’s needed. “You need to have to have at least 5 years of experience, and if you work in a [community hospital], to use a p53, and that is collectively what amounts to expertise in Barrett’s pathology.”

A follow-up study with a similar design is planned within the United Kingdom, the Netherlands, and the United States. This study, which Dr. Jansen said would enroll hundreds of pathologists, will include an intervention arm that administers a tutorial with the aim of improving concordance scoring.

Dr. Jansen reported no relevant conflicts of interest.

[email protected]

SAN FRANCISCO – Is it possible have a “normal” childhood when one or both parents are psychiatrists? Research into how the children of psychiatrists fare psychologically is sparse. But anecdotally, children report that having a psychiatrist parent is a gift – not only for them – but for their friends’ families, Michelle B. Riba, MD, said at the annual meeting of the American Psychiatric Association.

Vidyard Video

In this video, Dr. Riba is interviewed by Carol A. Bernstein, MD, about what she expected when she helped start the Children of Psychiatrists workshop at the APA meeting with Leah J. Dickstein, MD, and how it draws a standing room–only crowd each year.

“In general ... people feel very appreciative of having an empathic, knowledgeable parent to help guide them – and not overguide them,” Dr. Riba said. Psychiatrists also can provide insight into the causes of societal challenges such as homelessness. One audience member in this year’s workshop discussed the value of having a psychiatrist parent put a school suicide into perspective. Dr. Bernstein said she is viewed by her daughter’s friends as “the psychiatrist in residence.”

The children of psychiatrists who spoke on the panel this year said they liked being able to facilitate care for their friends. “They didn’t feel burdened by [having a psychiatrist parent],” Dr. Riba said. “We asked about that very question today.”

Dr. Riba, a past president of the APA, is professor of psychiatry at the University of Michigan, Ann Arbor. She also serves as director of the consultation-liaison fellowship, and director of the PsychOncology program at the university’s Rogel Cancer Center. She had no disclosures.

Dr. Bernstein, also an APA past president, is professor of psychiatry and obstetrics and gynecology, and vice chair for faculty development in psychiatry at the Albert Einstein College of Medicine, New York. She previously served as vice chair for education in psychiatry and director of residency training in psychiatry at the NYU School of Medicine. Dr. Bernstein had no disclosures.

[email protected]

SAN FRANCISCO – Is it possible have a “normal” childhood when one or both parents are psychiatrists? Research into how the children of psychiatrists fare psychologically is sparse. But anecdotally, children report that having a psychiatrist parent is a gift – not only for them – but for their friends’ families, Michelle B. Riba, MD, said at the annual meeting of the American Psychiatric Association.

Vidyard Video

In this video, Dr. Riba is interviewed by Carol A. Bernstein, MD, about what she expected when she helped start the Children of Psychiatrists workshop at the APA meeting with Leah J. Dickstein, MD, and how it draws a standing room–only crowd each year.

“In general ... people feel very appreciative of having an empathic, knowledgeable parent to help guide them – and not overguide them,” Dr. Riba said. Psychiatrists also can provide insight into the causes of societal challenges such as homelessness. One audience member in this year’s workshop discussed the value of having a psychiatrist parent put a school suicide into perspective. Dr. Bernstein said she is viewed by her daughter’s friends as “the psychiatrist in residence.”

The children of psychiatrists who spoke on the panel this year said they liked being able to facilitate care for their friends. “They didn’t feel burdened by [having a psychiatrist parent],” Dr. Riba said. “We asked about that very question today.”

Dr. Riba, a past president of the APA, is professor of psychiatry at the University of Michigan, Ann Arbor. She also serves as director of the consultation-liaison fellowship, and director of the PsychOncology program at the university’s Rogel Cancer Center. She had no disclosures.

Dr. Bernstein, also an APA past president, is professor of psychiatry and obstetrics and gynecology, and vice chair for faculty development in psychiatry at the Albert Einstein College of Medicine, New York. She previously served as vice chair for education in psychiatry and director of residency training in psychiatry at the NYU School of Medicine. Dr. Bernstein had no disclosures.

[email protected]

SAN FRANCISCO – Is it possible have a “normal” childhood when one or both parents are psychiatrists? Research into how the children of psychiatrists fare psychologically is sparse. But anecdotally, children report that having a psychiatrist parent is a gift – not only for them – but for their friends’ families, Michelle B. Riba, MD, said at the annual meeting of the American Psychiatric Association.

Vidyard Video

In this video, Dr. Riba is interviewed by Carol A. Bernstein, MD, about what she expected when she helped start the Children of Psychiatrists workshop at the APA meeting with Leah J. Dickstein, MD, and how it draws a standing room–only crowd each year.

“In general ... people feel very appreciative of having an empathic, knowledgeable parent to help guide them – and not overguide them,” Dr. Riba said. Psychiatrists also can provide insight into the causes of societal challenges such as homelessness. One audience member in this year’s workshop discussed the value of having a psychiatrist parent put a school suicide into perspective. Dr. Bernstein said she is viewed by her daughter’s friends as “the psychiatrist in residence.”

The children of psychiatrists who spoke on the panel this year said they liked being able to facilitate care for their friends. “They didn’t feel burdened by [having a psychiatrist parent],” Dr. Riba said. “We asked about that very question today.”

Dr. Riba, a past president of the APA, is professor of psychiatry at the University of Michigan, Ann Arbor. She also serves as director of the consultation-liaison fellowship, and director of the PsychOncology program at the university’s Rogel Cancer Center. She had no disclosures.

Dr. Bernstein, also an APA past president, is professor of psychiatry and obstetrics and gynecology, and vice chair for faculty development in psychiatry at the Albert Einstein College of Medicine, New York. She previously served as vice chair for education in psychiatry and director of residency training in psychiatry at the NYU School of Medicine. Dr. Bernstein had no disclosures.

[email protected]

Just how good are you? Are you a pretty good doc? A better-than-average leader? Or, are you truly an eminently qualified physician?

For all the talk about maintenance of certification and continuing medical education, it isn’t easy to know if you really are a good physician, teacher, or leader. In medicine, we’re careful to show respect to each other and tend to be slow to be critical. This might seem a kind approach to feedback, but I wonder if it is.

There are other professions where evaluations and feedback are more direct. In the military, performance standards are often quite explicit. The Marines, for instance, take performance evaluations seriously. This is evident if you’ve ever completed, or been a recipient of, a U.S. Marine Corps fitness report. Reading it, I realized many of the criteria could apply to us in medicine. Here are a few examples from that form (lightly modified for physicians).

Think about your clinical and technical expertise. Would you grade yourself as “competent. Possesses requisite range of skills and knowledge commensurate with training and experience?” Or maybe the next grade “demonstrates mastery of all required skills. Expertise, education and experience consistently enhance department. Innovative troubleshooter and problem solver. Effectively imparts skills to trainees.” Or perhaps you’re a “true expert in the field. Knowledge and skills impact far beyond those of peers. Translates broad-based education into forward-thinking, innovative actions. Makes immeasurable impact on department. Peerless teacher, selflessly imparts expertise to peers, residents, students.”

What about your effectiveness under stress?

Do you act “commensurate with your training and role?” Or do you have an “uncanny ability to anticipate requirements and quickly formulate original solutions?” Do you always “take decisive, effective action?”

How about your leadership performance?

Are you simply “engaged, providing instruction and direction?” Or do you “achieve a highly effective balance between direction and delegation, effectively tasking subordinates and clearly delineating standards expected?” A few of us even “engender willing loyalty and trust that allow subordinates to overcome their perceived limitations.” And exhibit “leadership that fosters the highest levels of motivation and morale, ensuring accomplishment in the most difficult circumstances.”

We might even mitigate physician burnout better if we had better performance standards. For example, do you simply “deal confidently with issues pertinent to subordinate welfare and recognize suitable courses of action?” Maybe you’re at the next level, “actively fostering the development of and uses of support systems for subordinates which improve their ability to perform.” I’m fortunate to know a few physician leaders who “noticeably enhance subordinate well-being, resulting in measurable increase in department effectiveness and proactively energize team members to ‘take care of their own.’ Widely recognized for techniques and policies that produce results and build morale.” By codifying what the standard should be, we can better hold ourselves accountable for our performance. In doing so, we might be better at recognizing and reducing burnout in our direct reports and peers.

The final question on the Marine fitness report is a comparative assessment. The evaluating officer checks one of the following boxes: 1. Unsatisfactory; 2. A qualified Marine; 3. One of many highly qualified Marines; 4. One of the few exceptionally qualified Marines; or, 5. The eminently qualified Marine.

Which are you? Can you describe yourself as “the eminently qualified physician?” You’ll have to define that standard in order to reach it.

This post was inspired by the “Set Standards. Aspire to Achieve Them” episode of Jocko Podcast.

Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Just how good are you? Are you a pretty good doc? A better-than-average leader? Or, are you truly an eminently qualified physician?

For all the talk about maintenance of certification and continuing medical education, it isn’t easy to know if you really are a good physician, teacher, or leader. In medicine, we’re careful to show respect to each other and tend to be slow to be critical. This might seem a kind approach to feedback, but I wonder if it is.

There are other professions where evaluations and feedback are more direct. In the military, performance standards are often quite explicit. The Marines, for instance, take performance evaluations seriously. This is evident if you’ve ever completed, or been a recipient of, a U.S. Marine Corps fitness report. Reading it, I realized many of the criteria could apply to us in medicine. Here are a few examples from that form (lightly modified for physicians).

Think about your clinical and technical expertise. Would you grade yourself as “competent. Possesses requisite range of skills and knowledge commensurate with training and experience?” Or maybe the next grade “demonstrates mastery of all required skills. Expertise, education and experience consistently enhance department. Innovative troubleshooter and problem solver. Effectively imparts skills to trainees.” Or perhaps you’re a “true expert in the field. Knowledge and skills impact far beyond those of peers. Translates broad-based education into forward-thinking, innovative actions. Makes immeasurable impact on department. Peerless teacher, selflessly imparts expertise to peers, residents, students.”

What about your effectiveness under stress?

Do you act “commensurate with your training and role?” Or do you have an “uncanny ability to anticipate requirements and quickly formulate original solutions?” Do you always “take decisive, effective action?”

How about your leadership performance?

Are you simply “engaged, providing instruction and direction?” Or do you “achieve a highly effective balance between direction and delegation, effectively tasking subordinates and clearly delineating standards expected?” A few of us even “engender willing loyalty and trust that allow subordinates to overcome their perceived limitations.” And exhibit “leadership that fosters the highest levels of motivation and morale, ensuring accomplishment in the most difficult circumstances.”

We might even mitigate physician burnout better if we had better performance standards. For example, do you simply “deal confidently with issues pertinent to subordinate welfare and recognize suitable courses of action?” Maybe you’re at the next level, “actively fostering the development of and uses of support systems for subordinates which improve their ability to perform.” I’m fortunate to know a few physician leaders who “noticeably enhance subordinate well-being, resulting in measurable increase in department effectiveness and proactively energize team members to ‘take care of their own.’ Widely recognized for techniques and policies that produce results and build morale.” By codifying what the standard should be, we can better hold ourselves accountable for our performance. In doing so, we might be better at recognizing and reducing burnout in our direct reports and peers.

The final question on the Marine fitness report is a comparative assessment. The evaluating officer checks one of the following boxes: 1. Unsatisfactory; 2. A qualified Marine; 3. One of many highly qualified Marines; 4. One of the few exceptionally qualified Marines; or, 5. The eminently qualified Marine.

Which are you? Can you describe yourself as “the eminently qualified physician?” You’ll have to define that standard in order to reach it.

This post was inspired by the “Set Standards. Aspire to Achieve Them” episode of Jocko Podcast.

Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Just how good are you? Are you a pretty good doc? A better-than-average leader? Or, are you truly an eminently qualified physician?

For all the talk about maintenance of certification and continuing medical education, it isn’t easy to know if you really are a good physician, teacher, or leader. In medicine, we’re careful to show respect to each other and tend to be slow to be critical. This might seem a kind approach to feedback, but I wonder if it is.

There are other professions where evaluations and feedback are more direct. In the military, performance standards are often quite explicit. The Marines, for instance, take performance evaluations seriously. This is evident if you’ve ever completed, or been a recipient of, a U.S. Marine Corps fitness report. Reading it, I realized many of the criteria could apply to us in medicine. Here are a few examples from that form (lightly modified for physicians).

Think about your clinical and technical expertise. Would you grade yourself as “competent. Possesses requisite range of skills and knowledge commensurate with training and experience?” Or maybe the next grade “demonstrates mastery of all required skills. Expertise, education and experience consistently enhance department. Innovative troubleshooter and problem solver. Effectively imparts skills to trainees.” Or perhaps you’re a “true expert in the field. Knowledge and skills impact far beyond those of peers. Translates broad-based education into forward-thinking, innovative actions. Makes immeasurable impact on department. Peerless teacher, selflessly imparts expertise to peers, residents, students.”

What about your effectiveness under stress?

Do you act “commensurate with your training and role?” Or do you have an “uncanny ability to anticipate requirements and quickly formulate original solutions?” Do you always “take decisive, effective action?”

How about your leadership performance?

Are you simply “engaged, providing instruction and direction?” Or do you “achieve a highly effective balance between direction and delegation, effectively tasking subordinates and clearly delineating standards expected?” A few of us even “engender willing loyalty and trust that allow subordinates to overcome their perceived limitations.” And exhibit “leadership that fosters the highest levels of motivation and morale, ensuring accomplishment in the most difficult circumstances.”

We might even mitigate physician burnout better if we had better performance standards. For example, do you simply “deal confidently with issues pertinent to subordinate welfare and recognize suitable courses of action?” Maybe you’re at the next level, “actively fostering the development of and uses of support systems for subordinates which improve their ability to perform.” I’m fortunate to know a few physician leaders who “noticeably enhance subordinate well-being, resulting in measurable increase in department effectiveness and proactively energize team members to ‘take care of their own.’ Widely recognized for techniques and policies that produce results and build morale.” By codifying what the standard should be, we can better hold ourselves accountable for our performance. In doing so, we might be better at recognizing and reducing burnout in our direct reports and peers.

The final question on the Marine fitness report is a comparative assessment. The evaluating officer checks one of the following boxes: 1. Unsatisfactory; 2. A qualified Marine; 3. One of many highly qualified Marines; 4. One of the few exceptionally qualified Marines; or, 5. The eminently qualified Marine.

Which are you? Can you describe yourself as “the eminently qualified physician?” You’ll have to define that standard in order to reach it.

This post was inspired by the “Set Standards. Aspire to Achieve Them” episode of Jocko Podcast.

Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

SAN DIEGO – A button battery lodged in a child’s esophagus is an acknowledged emergency, but there is less evidence about retrieval of button batteries that have passed to the stomach. Observation alone has been recommended when an x-ray determines that the button battery has passed to the stomach within 2 hours of ingestion, when the battery is less than 20 mm, and the child is aged at least 5 years.

At the annual Digestive Disease Week, Racha Khalaf, MD, and Thomas Walker, MD, both of Children’s Hospital Colorado, Aurora, presented data that call this approach into question. Their retrospective cohort study of 4 years’ worth of records from four pediatric centers in the United States identified 68 cases in which a pediatric gastroenterologist had endoscopically removed the button battery. In 60% of those cases, the battery had already caused mucosal damage varying from minor to deep necrosis and perforation.

Further, the degree of injury was not correlated with symptoms, strengthening the recommendation for retrieving the button battery from the stomach.

In our exclusive video interview, Dr. Khalaf and Dr. Walker discussed the impact of their findings for guidelines for pediatric gastroenterologists and Poison Control Center advice to parents about ingestion of button batteries.

Their study was partly supported by a Cystic Fibrosis Foundational Grant Award and by National Institutes of Health Training Grants.

[email protected]

SAN DIEGO – A button battery lodged in a child’s esophagus is an acknowledged emergency, but there is less evidence about retrieval of button batteries that have passed to the stomach. Observation alone has been recommended when an x-ray determines that the button battery has passed to the stomach within 2 hours of ingestion, when the battery is less than 20 mm, and the child is aged at least 5 years.

At the annual Digestive Disease Week, Racha Khalaf, MD, and Thomas Walker, MD, both of Children’s Hospital Colorado, Aurora, presented data that call this approach into question. Their retrospective cohort study of 4 years’ worth of records from four pediatric centers in the United States identified 68 cases in which a pediatric gastroenterologist had endoscopically removed the button battery. In 60% of those cases, the battery had already caused mucosal damage varying from minor to deep necrosis and perforation.

Further, the degree of injury was not correlated with symptoms, strengthening the recommendation for retrieving the button battery from the stomach.

In our exclusive video interview, Dr. Khalaf and Dr. Walker discussed the impact of their findings for guidelines for pediatric gastroenterologists and Poison Control Center advice to parents about ingestion of button batteries.

Their study was partly supported by a Cystic Fibrosis Foundational Grant Award and by National Institutes of Health Training Grants.

[email protected]

SAN DIEGO – A button battery lodged in a child’s esophagus is an acknowledged emergency, but there is less evidence about retrieval of button batteries that have passed to the stomach. Observation alone has been recommended when an x-ray determines that the button battery has passed to the stomach within 2 hours of ingestion, when the battery is less than 20 mm, and the child is aged at least 5 years.

At the annual Digestive Disease Week, Racha Khalaf, MD, and Thomas Walker, MD, both of Children’s Hospital Colorado, Aurora, presented data that call this approach into question. Their retrospective cohort study of 4 years’ worth of records from four pediatric centers in the United States identified 68 cases in which a pediatric gastroenterologist had endoscopically removed the button battery. In 60% of those cases, the battery had already caused mucosal damage varying from minor to deep necrosis and perforation.

Further, the degree of injury was not correlated with symptoms, strengthening the recommendation for retrieving the button battery from the stomach.

In our exclusive video interview, Dr. Khalaf and Dr. Walker discussed the impact of their findings for guidelines for pediatric gastroenterologists and Poison Control Center advice to parents about ingestion of button batteries.

Their study was partly supported by a Cystic Fibrosis Foundational Grant Award and by National Institutes of Health Training Grants.

[email protected]

SAN DIEGO – Rifaximin relieves symptoms and reduces the risk of disease-related complications in patients with symptomatic uncomplicated diverticular disease (SUDD) of the colon, results from a retrospective study showed.

Doug Brunk/MDedge News

“The majority of studies published on this topic are not exactly the picture of real life, because they’re conducted on a selected sample of patients queued into the hospital,” lead study author Francesco Di Mario, MD, said at the annual Digestive Disease Week. Dr. Di Mario sought long-term data “from general practitioners – data from real life.”

For an 8-year follow-up study, Dr. Di Mario, professor of gastroenterology at the University of Parma (Italy), and colleagues at several general physician practices in Italy enrolled two groups of patients. The study group (group A) consisted of 346 SUDD patients who were treated with rifaximin 800 mg/day for 7 days every month. Their median age was 64 years, and 63% were female. The control group (group B) included 470 SUDD patients who were taking spasmolithics or any other treatment on demand. Their median age was 65 years, and 61% were female.


The researchers administered a 10-point visual analog scale (VAS) to assess left lower abdominal pain and bloating, with a score of 10 representing the most severe symptoms. Daily bowel movements were also reported.

The median baseline VAS score for pain was 6 in groups A and B. After 8 years of follow-up, the VAS scores for the two groups were 3 and 6, respectively (P less than .0001), and both bloating and daily bowel movements were significantly reduced in group A (P less than .0001).

As for the impact of rifaximin on other outcomes, acute diverticulitis occurred in 9 patients in group A (2.6%) and in 21 patients in group B (4.5%), a difference that reached statistical significance (P = .155). In addition, four patients (1.2%) in group A and nine patients (1.9%) in group B had surgery (P = .432). No disease-related deaths occurred in group A, but two patients in group B died (0.4%; P = .239). No side effects were recorded during the entire study period.

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Rifaximin relieves symptoms and reduces the risk of disease-related complications in patients with symptomatic uncomplicated diverticular disease (SUDD) of the colon, results from a retrospective study showed.

Doug Brunk/MDedge News

“The majority of studies published on this topic are not exactly the picture of real life, because they’re conducted on a selected sample of patients queued into the hospital,” lead study author Francesco Di Mario, MD, said at the annual Digestive Disease Week. Dr. Di Mario sought long-term data “from general practitioners – data from real life.”

For an 8-year follow-up study, Dr. Di Mario, professor of gastroenterology at the University of Parma (Italy), and colleagues at several general physician practices in Italy enrolled two groups of patients. The study group (group A) consisted of 346 SUDD patients who were treated with rifaximin 800 mg/day for 7 days every month. Their median age was 64 years, and 63% were female. The control group (group B) included 470 SUDD patients who were taking spasmolithics or any other treatment on demand. Their median age was 65 years, and 61% were female.


The researchers administered a 10-point visual analog scale (VAS) to assess left lower abdominal pain and bloating, with a score of 10 representing the most severe symptoms. Daily bowel movements were also reported.

The median baseline VAS score for pain was 6 in groups A and B. After 8 years of follow-up, the VAS scores for the two groups were 3 and 6, respectively (P less than .0001), and both bloating and daily bowel movements were significantly reduced in group A (P less than .0001).

As for the impact of rifaximin on other outcomes, acute diverticulitis occurred in 9 patients in group A (2.6%) and in 21 patients in group B (4.5%), a difference that reached statistical significance (P = .155). In addition, four patients (1.2%) in group A and nine patients (1.9%) in group B had surgery (P = .432). No disease-related deaths occurred in group A, but two patients in group B died (0.4%; P = .239). No side effects were recorded during the entire study period.

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Rifaximin relieves symptoms and reduces the risk of disease-related complications in patients with symptomatic uncomplicated diverticular disease (SUDD) of the colon, results from a retrospective study showed.

Doug Brunk/MDedge News

“The majority of studies published on this topic are not exactly the picture of real life, because they’re conducted on a selected sample of patients queued into the hospital,” lead study author Francesco Di Mario, MD, said at the annual Digestive Disease Week. Dr. Di Mario sought long-term data “from general practitioners – data from real life.”

For an 8-year follow-up study, Dr. Di Mario, professor of gastroenterology at the University of Parma (Italy), and colleagues at several general physician practices in Italy enrolled two groups of patients. The study group (group A) consisted of 346 SUDD patients who were treated with rifaximin 800 mg/day for 7 days every month. Their median age was 64 years, and 63% were female. The control group (group B) included 470 SUDD patients who were taking spasmolithics or any other treatment on demand. Their median age was 65 years, and 61% were female.


The researchers administered a 10-point visual analog scale (VAS) to assess left lower abdominal pain and bloating, with a score of 10 representing the most severe symptoms. Daily bowel movements were also reported.

The median baseline VAS score for pain was 6 in groups A and B. After 8 years of follow-up, the VAS scores for the two groups were 3 and 6, respectively (P less than .0001), and both bloating and daily bowel movements were significantly reduced in group A (P less than .0001).

As for the impact of rifaximin on other outcomes, acute diverticulitis occurred in 9 patients in group A (2.6%) and in 21 patients in group B (4.5%), a difference that reached statistical significance (P = .155). In addition, four patients (1.2%) in group A and nine patients (1.9%) in group B had surgery (P = .432). No disease-related deaths occurred in group A, but two patients in group B died (0.4%; P = .239). No side effects were recorded during the entire study period.

The researchers reported having no financial disclosures.

[email protected]

To the Editor:

Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.¹ The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.² However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.³ The clear cell variant has been found to be associated with diabetes mellitus.⁴ Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.⁵ We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.

A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.

Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.

To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.

To the Editor:

Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.¹ The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.² However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.³ The clear cell variant has been found to be associated with diabetes mellitus.⁴ Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.⁵ We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.

A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.

Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.

To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.

To the Editor:

Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.¹ The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.² However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.³ The clear cell variant has been found to be associated with diabetes mellitus.⁴ Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.⁵ We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.

A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.

Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.

To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.

Among adults aged over age 65 years, taking a statin within 90 days after a concussion was associated with a 13% reduced risk of developing dementia in the subsequent 5 years, compared with similar adults not taking statins.

The findings come from a population-based double cohort study of 28,815 patients in the Ontario Health Insurance Plan. Study patients were enrolled over 20 years, and had a minimum follow-up of 3 years. The study excluded patients hospitalized caused by a severe concussion, those previously diagnosed with delirium or dementia, and those who died within 90 days of their concussions.

Concussions are a common injury in older adults and dementia may be a frequent outcome years afterward, Donald A. Redelmeier, MD, of the University of Toronto and colleagues wrote in a study published in JAMA Neurology. A concussion should not be interpreted as a reason to stop statins, and a potential neuroprotective benefit may encourage medication adherence among patients who are already prescribed a statin.

Of the 28,815 patients studied, 4,727 patients (1 case per 6 patients) developed dementia over the mean follow-up period of 3.9 years. The 7,058 patients who received a statin had a 13% reduced risk of developing dementia, compared with the 21,757 patients who did not (relative risk, 0.87; 95% confidence interval, 0.81-0.93; P less than .001).

Even though statin use was associated with a lower risk, the subsequent incidence of dementia was still twice the population norm in statin users who had concussions, the researchers wrote. The findings indicate concussions are a common injury in older adults and dementia may be a frequent outcome years after concussions.

Statin users who had concussions continued to have a reduced risk of developing dementia after adjustment for patient characteristics, use of other cardiovascular medications, dosage, and depression risk. The statin associated with the greatest risk reduction was rosuvastatin; simvastatin was associated with the least risk reduction. With the possible exception of angiotensin II receptor blockers, no other cardiovascular or noncardiovascular medications were associated with a decreased risk of dementia after a concussion, the researchers wrote.

They also examined data for elderly patients using statins after an ankle sprain and found the risk of dementia was similar for those who did and did not receive statins after the injury.

Factors such as smoking status, exercise, drug adherence, and other unknown aspects of patient health might have influenced the results of the study, the researchers acknowledged. Additionally, a secondary analysis was not statistically powered to distinguish the relative efficacy of statin use before a concussion.

This study was funded in part by a Canada Research Chair in Medical Decision Sciences, the Canadian Institutes of Health Research, the BrightFocus Foundation, and the Comprehensive Research Experience for Medical Students at the University of Toronto. The authors reported no relevant conflicts of interest.

SOURCE: Redelmeier DA et al. JAMA Neurol. 2019 May 20. doi: 10.1001/jamaneurol.2019.1148.

Among adults aged over age 65 years, taking a statin within 90 days after a concussion was associated with a 13% reduced risk of developing dementia in the subsequent 5 years, compared with similar adults not taking statins.

The findings come from a population-based double cohort study of 28,815 patients in the Ontario Health Insurance Plan. Study patients were enrolled over 20 years, and had a minimum follow-up of 3 years. The study excluded patients hospitalized caused by a severe concussion, those previously diagnosed with delirium or dementia, and those who died within 90 days of their concussions.

Concussions are a common injury in older adults and dementia may be a frequent outcome years afterward, Donald A. Redelmeier, MD, of the University of Toronto and colleagues wrote in a study published in JAMA Neurology. A concussion should not be interpreted as a reason to stop statins, and a potential neuroprotective benefit may encourage medication adherence among patients who are already prescribed a statin.

Of the 28,815 patients studied, 4,727 patients (1 case per 6 patients) developed dementia over the mean follow-up period of 3.9 years. The 7,058 patients who received a statin had a 13% reduced risk of developing dementia, compared with the 21,757 patients who did not (relative risk, 0.87; 95% confidence interval, 0.81-0.93; P less than .001).

Even though statin use was associated with a lower risk, the subsequent incidence of dementia was still twice the population norm in statin users who had concussions, the researchers wrote. The findings indicate concussions are a common injury in older adults and dementia may be a frequent outcome years after concussions.

Statin users who had concussions continued to have a reduced risk of developing dementia after adjustment for patient characteristics, use of other cardiovascular medications, dosage, and depression risk. The statin associated with the greatest risk reduction was rosuvastatin; simvastatin was associated with the least risk reduction. With the possible exception of angiotensin II receptor blockers, no other cardiovascular or noncardiovascular medications were associated with a decreased risk of dementia after a concussion, the researchers wrote.

They also examined data for elderly patients using statins after an ankle sprain and found the risk of dementia was similar for those who did and did not receive statins after the injury.

Factors such as smoking status, exercise, drug adherence, and other unknown aspects of patient health might have influenced the results of the study, the researchers acknowledged. Additionally, a secondary analysis was not statistically powered to distinguish the relative efficacy of statin use before a concussion.

This study was funded in part by a Canada Research Chair in Medical Decision Sciences, the Canadian Institutes of Health Research, the BrightFocus Foundation, and the Comprehensive Research Experience for Medical Students at the University of Toronto. The authors reported no relevant conflicts of interest.

SOURCE: Redelmeier DA et al. JAMA Neurol. 2019 May 20. doi: 10.1001/jamaneurol.2019.1148.

Among adults aged over age 65 years, taking a statin within 90 days after a concussion was associated with a 13% reduced risk of developing dementia in the subsequent 5 years, compared with similar adults not taking statins.

The findings come from a population-based double cohort study of 28,815 patients in the Ontario Health Insurance Plan. Study patients were enrolled over 20 years, and had a minimum follow-up of 3 years. The study excluded patients hospitalized caused by a severe concussion, those previously diagnosed with delirium or dementia, and those who died within 90 days of their concussions.

Concussions are a common injury in older adults and dementia may be a frequent outcome years afterward, Donald A. Redelmeier, MD, of the University of Toronto and colleagues wrote in a study published in JAMA Neurology. A concussion should not be interpreted as a reason to stop statins, and a potential neuroprotective benefit may encourage medication adherence among patients who are already prescribed a statin.

Of the 28,815 patients studied, 4,727 patients (1 case per 6 patients) developed dementia over the mean follow-up period of 3.9 years. The 7,058 patients who received a statin had a 13% reduced risk of developing dementia, compared with the 21,757 patients who did not (relative risk, 0.87; 95% confidence interval, 0.81-0.93; P less than .001).

Even though statin use was associated with a lower risk, the subsequent incidence of dementia was still twice the population norm in statin users who had concussions, the researchers wrote. The findings indicate concussions are a common injury in older adults and dementia may be a frequent outcome years after concussions.

Statin users who had concussions continued to have a reduced risk of developing dementia after adjustment for patient characteristics, use of other cardiovascular medications, dosage, and depression risk. The statin associated with the greatest risk reduction was rosuvastatin; simvastatin was associated with the least risk reduction. With the possible exception of angiotensin II receptor blockers, no other cardiovascular or noncardiovascular medications were associated with a decreased risk of dementia after a concussion, the researchers wrote.

They also examined data for elderly patients using statins after an ankle sprain and found the risk of dementia was similar for those who did and did not receive statins after the injury.

Factors such as smoking status, exercise, drug adherence, and other unknown aspects of patient health might have influenced the results of the study, the researchers acknowledged. Additionally, a secondary analysis was not statistically powered to distinguish the relative efficacy of statin use before a concussion.

This study was funded in part by a Canada Research Chair in Medical Decision Sciences, the Canadian Institutes of Health Research, the BrightFocus Foundation, and the Comprehensive Research Experience for Medical Students at the University of Toronto. The authors reported no relevant conflicts of interest.

SOURCE: Redelmeier DA et al. JAMA Neurol. 2019 May 20. doi: 10.1001/jamaneurol.2019.1148.

At the Annual Business Meeting, 12 to 1:30 p.m. Saturday, June 15, SVS members (Active, Seniors and/or Distinguished Fellows) will be asked to elect individuals to fill the positions of Secretary and Vice President and then approve the full slate of SVS Officers for 2019-20. The Nominating Committee unanimously identified one person felt to be uniquely qualified to assume the position of Vice President; as in the past, that candidate will be announced at the meeting. Members will select among three highly qualified candidates for Secretary: Keith Calligaro, Michael Conte and Amy Reed. Find information from each of them here. 

At the Annual Business Meeting, 12 to 1:30 p.m. Saturday, June 15, SVS members (Active, Seniors and/or Distinguished Fellows) will be asked to elect individuals to fill the positions of Secretary and Vice President and then approve the full slate of SVS Officers for 2019-20. The Nominating Committee unanimously identified one person felt to be uniquely qualified to assume the position of Vice President; as in the past, that candidate will be announced at the meeting. Members will select among three highly qualified candidates for Secretary: Keith Calligaro, Michael Conte and Amy Reed. Find information from each of them here. 

At the Annual Business Meeting, 12 to 1:30 p.m. Saturday, June 15, SVS members (Active, Seniors and/or Distinguished Fellows) will be asked to elect individuals to fill the positions of Secretary and Vice President and then approve the full slate of SVS Officers for 2019-20. The Nominating Committee unanimously identified one person felt to be uniquely qualified to assume the position of Vice President; as in the past, that candidate will be announced at the meeting. Members will select among three highly qualified candidates for Secretary: Keith Calligaro, Michael Conte and Amy Reed. Find information from each of them here. 

Male teens who were even slightly overweight were at significantly greater risk than their lean peers of developing cardiomyopathy in adulthood, and their risk increased as body mass index increased, according to the results of a nationwide, prospective, registry-based cohort study from Sweden.

The association was strongest for dilated cardiomyopathy, wrote Josefina Robertson, MD, and associates at the University of Gothenburg (Sweden). Over a median of 27 years of follow-up, the risk for dilated cardiomyopathy in adulthood was approximately 38% greater when adolescent body mass index was 22.5-25.0 kg/m², using a lean but not underweight BMI (18.5-20.0 kg/m²) as the reference group. The increase in risk for dilated cardiomyopathy continued to rise with adolescent BMI and exceeded 700% at a BMI over 35.

The rate of hospitalizations for heart failure caused by cardiomyopathy more than doubled in Sweden from 1987 to 2006, the researchers noted. Adolescent obesity is strongly linked to early heart failure, but few studies have assessed whether adiposity as measured by BMI is associated with cardiomyopathy, and none have confirmed diagnostic validity or looked at subtypes of cardiomyopathy.

“The already marked importance of weight control in youth is further strengthened by [our] findings,” the researchers wrote, “as well as greater evidence for obesity as a potential important cause of adverse cardiac remodeling independent of clinically evident ischemic heart disease.”

The study included 1,668,893 male adolescents who had enlisted for military service in Sweden between 1969 and 2005, when compulsory enlistment ended. It excluded women and the small proportion of men lacking weight or height data. A total of 4,477 cases of cardiomyopathy were diagnosed during follow-up, 59% were dilated cardiomyopathy, 15% were hypertrophic cardiomyopathy, and 11% were alcohol or drug-related cardiomyopathy.

The link between even slightly elevated BMI and dilated cardiomyopathy did not depend on age, year, location, or baseline comorbidities. For each unit increase in BMI, the adjusted risk of dilated cardiomyopathy rose by approximately 15%, the risk of hypertrophic cardiomyopathy rose by 9%, and the risk for drug- or alcohol-related cardiomyopathy rose by 10%. Estimated risks were generally similar after controlling for blood pressure, cardiorespiratory fitness, muscle strength, parents’ level of education, and alcohol or substance use disorders.

Funders included the Swedish government; Swedish Research Council; Swedish Heart and Lung Foundation; and Swedish Council for Health, Working Life, and Welfare. The researchers reported having no conflicts of interest.

SOURCE: Robertson J et al. Circulation. 2019 May 20.

Male teens who were even slightly overweight were at significantly greater risk than their lean peers of developing cardiomyopathy in adulthood, and their risk increased as body mass index increased, according to the results of a nationwide, prospective, registry-based cohort study from Sweden.

The association was strongest for dilated cardiomyopathy, wrote Josefina Robertson, MD, and associates at the University of Gothenburg (Sweden). Over a median of 27 years of follow-up, the risk for dilated cardiomyopathy in adulthood was approximately 38% greater when adolescent body mass index was 22.5-25.0 kg/m², using a lean but not underweight BMI (18.5-20.0 kg/m²) as the reference group. The increase in risk for dilated cardiomyopathy continued to rise with adolescent BMI and exceeded 700% at a BMI over 35.

The rate of hospitalizations for heart failure caused by cardiomyopathy more than doubled in Sweden from 1987 to 2006, the researchers noted. Adolescent obesity is strongly linked to early heart failure, but few studies have assessed whether adiposity as measured by BMI is associated with cardiomyopathy, and none have confirmed diagnostic validity or looked at subtypes of cardiomyopathy.

“The already marked importance of weight control in youth is further strengthened by [our] findings,” the researchers wrote, “as well as greater evidence for obesity as a potential important cause of adverse cardiac remodeling independent of clinically evident ischemic heart disease.”

The study included 1,668,893 male adolescents who had enlisted for military service in Sweden between 1969 and 2005, when compulsory enlistment ended. It excluded women and the small proportion of men lacking weight or height data. A total of 4,477 cases of cardiomyopathy were diagnosed during follow-up, 59% were dilated cardiomyopathy, 15% were hypertrophic cardiomyopathy, and 11% were alcohol or drug-related cardiomyopathy.

The link between even slightly elevated BMI and dilated cardiomyopathy did not depend on age, year, location, or baseline comorbidities. For each unit increase in BMI, the adjusted risk of dilated cardiomyopathy rose by approximately 15%, the risk of hypertrophic cardiomyopathy rose by 9%, and the risk for drug- or alcohol-related cardiomyopathy rose by 10%. Estimated risks were generally similar after controlling for blood pressure, cardiorespiratory fitness, muscle strength, parents’ level of education, and alcohol or substance use disorders.

Funders included the Swedish government; Swedish Research Council; Swedish Heart and Lung Foundation; and Swedish Council for Health, Working Life, and Welfare. The researchers reported having no conflicts of interest.

SOURCE: Robertson J et al. Circulation. 2019 May 20.

Male teens who were even slightly overweight were at significantly greater risk than their lean peers of developing cardiomyopathy in adulthood, and their risk increased as body mass index increased, according to the results of a nationwide, prospective, registry-based cohort study from Sweden.

The association was strongest for dilated cardiomyopathy, wrote Josefina Robertson, MD, and associates at the University of Gothenburg (Sweden). Over a median of 27 years of follow-up, the risk for dilated cardiomyopathy in adulthood was approximately 38% greater when adolescent body mass index was 22.5-25.0 kg/m², using a lean but not underweight BMI (18.5-20.0 kg/m²) as the reference group. The increase in risk for dilated cardiomyopathy continued to rise with adolescent BMI and exceeded 700% at a BMI over 35.

The rate of hospitalizations for heart failure caused by cardiomyopathy more than doubled in Sweden from 1987 to 2006, the researchers noted. Adolescent obesity is strongly linked to early heart failure, but few studies have assessed whether adiposity as measured by BMI is associated with cardiomyopathy, and none have confirmed diagnostic validity or looked at subtypes of cardiomyopathy.

“The already marked importance of weight control in youth is further strengthened by [our] findings,” the researchers wrote, “as well as greater evidence for obesity as a potential important cause of adverse cardiac remodeling independent of clinically evident ischemic heart disease.”

The study included 1,668,893 male adolescents who had enlisted for military service in Sweden between 1969 and 2005, when compulsory enlistment ended. It excluded women and the small proportion of men lacking weight or height data. A total of 4,477 cases of cardiomyopathy were diagnosed during follow-up, 59% were dilated cardiomyopathy, 15% were hypertrophic cardiomyopathy, and 11% were alcohol or drug-related cardiomyopathy.

The link between even slightly elevated BMI and dilated cardiomyopathy did not depend on age, year, location, or baseline comorbidities. For each unit increase in BMI, the adjusted risk of dilated cardiomyopathy rose by approximately 15%, the risk of hypertrophic cardiomyopathy rose by 9%, and the risk for drug- or alcohol-related cardiomyopathy rose by 10%. Estimated risks were generally similar after controlling for blood pressure, cardiorespiratory fitness, muscle strength, parents’ level of education, and alcohol or substance use disorders.

Funders included the Swedish government; Swedish Research Council; Swedish Heart and Lung Foundation; and Swedish Council for Health, Working Life, and Welfare. The researchers reported having no conflicts of interest.

SOURCE: Robertson J et al. Circulation. 2019 May 20.