Key clinical point: Applying a criterion of three lesions with the central vein sign distinguishes between multiple sclerosis and its mimics.

Major finding: The criterion has a sensitivity and specificity of 61.9% and 89.0%, respectively.

Study details: A multicenter study of 606 participants with clinically isolated syndrome, multiple sclerosis, and multiple sclerosis mimics.

Disclosures: Dr. Sinnecker reported receiving personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Actelion.

Citation: Sinnecker T et al. AAN 2019, Abstract S6.002.

Key clinical point: Applying a criterion of three lesions with the central vein sign distinguishes between multiple sclerosis and its mimics.

Major finding: The criterion has a sensitivity and specificity of 61.9% and 89.0%, respectively.

Study details: A multicenter study of 606 participants with clinically isolated syndrome, multiple sclerosis, and multiple sclerosis mimics.

Disclosures: Dr. Sinnecker reported receiving personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Actelion.

Citation: Sinnecker T et al. AAN 2019, Abstract S6.002.

Key clinical point: Applying a criterion of three lesions with the central vein sign distinguishes between multiple sclerosis and its mimics.

Major finding: The criterion has a sensitivity and specificity of 61.9% and 89.0%, respectively.

Study details: A multicenter study of 606 participants with clinically isolated syndrome, multiple sclerosis, and multiple sclerosis mimics.

Disclosures: Dr. Sinnecker reported receiving personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Actelion.

Citation: Sinnecker T et al. AAN 2019, Abstract S6.002.

Key clinical point: Women with MS may be able to have children, breastfeed, and resume treatment without experiencing an increased risk of relapse during the postpartum period.

Major finding: Patients’ annualized relapse rate was 0.39 pre-pregnancy, 0.07-0.14 during pregnancy, 0.27 in the first 3 months postpartum, and 0.37 at 4-6 months postpartum.

Study details: An analysis of prospectively collected data from 466 pregnancies among 375 women with MS between 2008 and 2016.

Disclosures: The study was supported by the National Multiple Sclerosis Society. The researchers had no disclosures.

Citation: Langer-Gould A et al. AAN 2019, Abstract S6.007.

Key clinical point: Women with MS may be able to have children, breastfeed, and resume treatment without experiencing an increased risk of relapse during the postpartum period.

Major finding: Patients’ annualized relapse rate was 0.39 pre-pregnancy, 0.07-0.14 during pregnancy, 0.27 in the first 3 months postpartum, and 0.37 at 4-6 months postpartum.

Study details: An analysis of prospectively collected data from 466 pregnancies among 375 women with MS between 2008 and 2016.

Disclosures: The study was supported by the National Multiple Sclerosis Society. The researchers had no disclosures.

Citation: Langer-Gould A et al. AAN 2019, Abstract S6.007.

Key clinical point: Women with MS may be able to have children, breastfeed, and resume treatment without experiencing an increased risk of relapse during the postpartum period.

Major finding: Patients’ annualized relapse rate was 0.39 pre-pregnancy, 0.07-0.14 during pregnancy, 0.27 in the first 3 months postpartum, and 0.37 at 4-6 months postpartum.

Study details: An analysis of prospectively collected data from 466 pregnancies among 375 women with MS between 2008 and 2016.

Disclosures: The study was supported by the National Multiple Sclerosis Society. The researchers had no disclosures.

Citation: Langer-Gould A et al. AAN 2019, Abstract S6.007.

Tumor specimens from 17% of patients with pancreatic ductal adenocarcinomas contained genomic alterations for which targeted therapies exist, researchers reported in Gastroenterology.

“We identified mutations in genes that could contribute to progression of intraductal papillary mucinous neoplasms into malignancies. These alterations might be used as biomarkers for early detection,” wrote Aatur D. Singhi, MD, PhD, of the University of Pittsburgh and associates.

The most common genomic mutations in pancreatic ductal adenocarcinoma (PDAC) involve KRAS, TP53, CDKN2A, and SMAD4, none of which can be treated by currently approved targeted agents. But PDACs are genomically very heterogeneous and contain low levels (less than 5%) of many other mutations, the researchers noted. In small studies, these low-prevalence mutations included kinase gene amplifications and rearrangements, which may be useful as treatment targets or predictive biomarkers of response.

To further characterize PDAC mutations and their relative penetrance, the researchers performed targeted genomic profile analyses of 3,594 PDAC tumor specimens from an international cohort. The tests included capture-based targeted genomic profiling of up to 315 cancer-linked genes and the intron regions of 28 genes that are rearranged in cancer cells. The researchers classified genomic alterations based on published signaling pathways, including receptor tyrosine kinase/ras/mitogen-activated protein kinase (RTK/ras/MAPK) activation, DNA damage repair, cell cycle control, transforming growth factor beta signaling, histone modification, switching/sucrose nonfermenting complex, phosphoinositide 3-kinase/mammalian target of rapamycin signaling, Wnt/beta-catenin pathway, RNA splicing, Notch pathway, angiogenesis, and hedgehog signaling. In addition, they analyzed tumor mutation burden in 1,021 samples and microsatellite instability status in 2,563 samples.

In all, the samples contained 19,120 genomic alterations of 317 genes. A total of 608 (17%) specimens harbored mutations considered actionable targets. These involved either the RTK/ras/MAPK signaling or DNA damage repair pathways. As expected, KRAS mutations were most common, but their penetrance (88%) was lower than in prior studies. This might be because the current study covered both resectable and nonresectable PDACs, while past studies tended to focus on resected PDACs only, the researchers said. Importantly, the 12% of KRAS wild-type PDACs often harbored other potentially targetable alterations of genes in the RTK/ras/MAPK pathway, such as kinase fusion, amplification, missense mutations, and intragenic-in-frame deletions.

A total of 81% of samples contained alterations of TP53 or other genes involved in DNA damage repair. Reflecting prior studies, the penetrance of individual DNA damage repair mutations was low – usually less than 5%. Most germline mutations involved the BRCA-FANC DNA repair pathway, and these may be targetable with agents such as poly (ADP-ribose) polymerase inhibitors and DNA strand-damaging, platinum-based cytotoxic regimens, the investigators wrote.

Among 3,117 samples with clinicopathologic data, 51% were from the primary tumor and the rest were from distal metastases of the liver, lung, nonregional lymph nodes, peritoneum, omentum, and other sites. Not surprisingly, BRCA1 and BRCA2 mutations were more common in younger patients, but KRAS, SMAD4, DNMT3A, and AP mutations were more common in older patients, and mutational frequencies also varied by sex, primary versus metastatic tumor status, and site of metastasis.

“The complex genomic heterogeneity in otherwise histologically similar PDACs suggests a one-size-fits-all approach to treating patients will not be successful,” they concluded. “Targeted genomic profiling of known genomic alterations across multiple tumor types highlights potentially targetable and predictive biomarkers for treatment in a significant subset of PDACs.”

Funders included the Pancreatic Cancer Action Network, the National Pancreas Foundation, and the Sky Foundation. Dr. Singhi and two coinvestigators reported receiving honoraria from Foundation Medicine, and seven other coinvestigators reported employment by and stock ownership in Foundation Medicine. No other disclosures were reported.

SOURCE: Singhi AD et al. Gastroenterology. 2019 Mar 2. doi: 10.1053/j.gastro.2019.02.03.

Tumor specimens from 17% of patients with pancreatic ductal adenocarcinomas contained genomic alterations for which targeted therapies exist, researchers reported in Gastroenterology.

“We identified mutations in genes that could contribute to progression of intraductal papillary mucinous neoplasms into malignancies. These alterations might be used as biomarkers for early detection,” wrote Aatur D. Singhi, MD, PhD, of the University of Pittsburgh and associates.

The most common genomic mutations in pancreatic ductal adenocarcinoma (PDAC) involve KRAS, TP53, CDKN2A, and SMAD4, none of which can be treated by currently approved targeted agents. But PDACs are genomically very heterogeneous and contain low levels (less than 5%) of many other mutations, the researchers noted. In small studies, these low-prevalence mutations included kinase gene amplifications and rearrangements, which may be useful as treatment targets or predictive biomarkers of response.

To further characterize PDAC mutations and their relative penetrance, the researchers performed targeted genomic profile analyses of 3,594 PDAC tumor specimens from an international cohort. The tests included capture-based targeted genomic profiling of up to 315 cancer-linked genes and the intron regions of 28 genes that are rearranged in cancer cells. The researchers classified genomic alterations based on published signaling pathways, including receptor tyrosine kinase/ras/mitogen-activated protein kinase (RTK/ras/MAPK) activation, DNA damage repair, cell cycle control, transforming growth factor beta signaling, histone modification, switching/sucrose nonfermenting complex, phosphoinositide 3-kinase/mammalian target of rapamycin signaling, Wnt/beta-catenin pathway, RNA splicing, Notch pathway, angiogenesis, and hedgehog signaling. In addition, they analyzed tumor mutation burden in 1,021 samples and microsatellite instability status in 2,563 samples.

In all, the samples contained 19,120 genomic alterations of 317 genes. A total of 608 (17%) specimens harbored mutations considered actionable targets. These involved either the RTK/ras/MAPK signaling or DNA damage repair pathways. As expected, KRAS mutations were most common, but their penetrance (88%) was lower than in prior studies. This might be because the current study covered both resectable and nonresectable PDACs, while past studies tended to focus on resected PDACs only, the researchers said. Importantly, the 12% of KRAS wild-type PDACs often harbored other potentially targetable alterations of genes in the RTK/ras/MAPK pathway, such as kinase fusion, amplification, missense mutations, and intragenic-in-frame deletions.

A total of 81% of samples contained alterations of TP53 or other genes involved in DNA damage repair. Reflecting prior studies, the penetrance of individual DNA damage repair mutations was low – usually less than 5%. Most germline mutations involved the BRCA-FANC DNA repair pathway, and these may be targetable with agents such as poly (ADP-ribose) polymerase inhibitors and DNA strand-damaging, platinum-based cytotoxic regimens, the investigators wrote.

Among 3,117 samples with clinicopathologic data, 51% were from the primary tumor and the rest were from distal metastases of the liver, lung, nonregional lymph nodes, peritoneum, omentum, and other sites. Not surprisingly, BRCA1 and BRCA2 mutations were more common in younger patients, but KRAS, SMAD4, DNMT3A, and AP mutations were more common in older patients, and mutational frequencies also varied by sex, primary versus metastatic tumor status, and site of metastasis.

“The complex genomic heterogeneity in otherwise histologically similar PDACs suggests a one-size-fits-all approach to treating patients will not be successful,” they concluded. “Targeted genomic profiling of known genomic alterations across multiple tumor types highlights potentially targetable and predictive biomarkers for treatment in a significant subset of PDACs.”

Funders included the Pancreatic Cancer Action Network, the National Pancreas Foundation, and the Sky Foundation. Dr. Singhi and two coinvestigators reported receiving honoraria from Foundation Medicine, and seven other coinvestigators reported employment by and stock ownership in Foundation Medicine. No other disclosures were reported.

SOURCE: Singhi AD et al. Gastroenterology. 2019 Mar 2. doi: 10.1053/j.gastro.2019.02.03.

Tumor specimens from 17% of patients with pancreatic ductal adenocarcinomas contained genomic alterations for which targeted therapies exist, researchers reported in Gastroenterology.

“We identified mutations in genes that could contribute to progression of intraductal papillary mucinous neoplasms into malignancies. These alterations might be used as biomarkers for early detection,” wrote Aatur D. Singhi, MD, PhD, of the University of Pittsburgh and associates.

The most common genomic mutations in pancreatic ductal adenocarcinoma (PDAC) involve KRAS, TP53, CDKN2A, and SMAD4, none of which can be treated by currently approved targeted agents. But PDACs are genomically very heterogeneous and contain low levels (less than 5%) of many other mutations, the researchers noted. In small studies, these low-prevalence mutations included kinase gene amplifications and rearrangements, which may be useful as treatment targets or predictive biomarkers of response.

To further characterize PDAC mutations and their relative penetrance, the researchers performed targeted genomic profile analyses of 3,594 PDAC tumor specimens from an international cohort. The tests included capture-based targeted genomic profiling of up to 315 cancer-linked genes and the intron regions of 28 genes that are rearranged in cancer cells. The researchers classified genomic alterations based on published signaling pathways, including receptor tyrosine kinase/ras/mitogen-activated protein kinase (RTK/ras/MAPK) activation, DNA damage repair, cell cycle control, transforming growth factor beta signaling, histone modification, switching/sucrose nonfermenting complex, phosphoinositide 3-kinase/mammalian target of rapamycin signaling, Wnt/beta-catenin pathway, RNA splicing, Notch pathway, angiogenesis, and hedgehog signaling. In addition, they analyzed tumor mutation burden in 1,021 samples and microsatellite instability status in 2,563 samples.

In all, the samples contained 19,120 genomic alterations of 317 genes. A total of 608 (17%) specimens harbored mutations considered actionable targets. These involved either the RTK/ras/MAPK signaling or DNA damage repair pathways. As expected, KRAS mutations were most common, but their penetrance (88%) was lower than in prior studies. This might be because the current study covered both resectable and nonresectable PDACs, while past studies tended to focus on resected PDACs only, the researchers said. Importantly, the 12% of KRAS wild-type PDACs often harbored other potentially targetable alterations of genes in the RTK/ras/MAPK pathway, such as kinase fusion, amplification, missense mutations, and intragenic-in-frame deletions.

A total of 81% of samples contained alterations of TP53 or other genes involved in DNA damage repair. Reflecting prior studies, the penetrance of individual DNA damage repair mutations was low – usually less than 5%. Most germline mutations involved the BRCA-FANC DNA repair pathway, and these may be targetable with agents such as poly (ADP-ribose) polymerase inhibitors and DNA strand-damaging, platinum-based cytotoxic regimens, the investigators wrote.

Among 3,117 samples with clinicopathologic data, 51% were from the primary tumor and the rest were from distal metastases of the liver, lung, nonregional lymph nodes, peritoneum, omentum, and other sites. Not surprisingly, BRCA1 and BRCA2 mutations were more common in younger patients, but KRAS, SMAD4, DNMT3A, and AP mutations were more common in older patients, and mutational frequencies also varied by sex, primary versus metastatic tumor status, and site of metastasis.

“The complex genomic heterogeneity in otherwise histologically similar PDACs suggests a one-size-fits-all approach to treating patients will not be successful,” they concluded. “Targeted genomic profiling of known genomic alterations across multiple tumor types highlights potentially targetable and predictive biomarkers for treatment in a significant subset of PDACs.”

Funders included the Pancreatic Cancer Action Network, the National Pancreas Foundation, and the Sky Foundation. Dr. Singhi and two coinvestigators reported receiving honoraria from Foundation Medicine, and seven other coinvestigators reported employment by and stock ownership in Foundation Medicine. No other disclosures were reported.

SOURCE: Singhi AD et al. Gastroenterology. 2019 Mar 2. doi: 10.1053/j.gastro.2019.02.03.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

CHICAGO – An evaluation of the measles threat in the modern era gives no indication that the risk of complications or death is any different than it was before a vaccine became available, according to an analysis of inpatient complications between 2002 and 2013.

In 2000, measles was declared eliminated in the United States, but for those who have been infected since that time, the risk of serious complications and death has not diminished, noted Raj Chovatiya, MD, PhD, in a session at the annual meeting of the Society for Investigative Dermatology.

By eliminated, the Centers of Disease Control and Prevention – which reported 86 confirmed cases of measles in 2000 – was referring to a technical definition of no new endemic or continuous transmissions in the previous 12 months. It was expected that a modest number of cases of this reportable disease would continue to accrue for an infection that remains common elsewhere in the world.

“Worldwide there are about 20 million cases of measles annually with an estimated 100,000 deaths attributed to this cause,” said Dr. Chovatiya, who is a dermatology resident at Northwestern University, Chicago.

Courtesy Dr. Gary White

Characteristic of measles, the majority of the 582 hospitalizations evaluated over this period occurred in children aged between 1 and 9 years. The proportion of patients with preexisting chronic comorbid conditions was low. Rather, “most were pretty healthy” prior to admission, according to Dr. Chovatiya, who said that the majority of admissions were from an emergency department.

“I want to point out that these are just direct inpatient costs,” Dr. Chovatiya said. Extrapolating from published data about indirect expenses, he said that the total health cost burden “is absolutely staggering.”

Courtesy Dr. Gary White

CHICAGO – An evaluation of the measles threat in the modern era gives no indication that the risk of complications or death is any different than it was before a vaccine became available, according to an analysis of inpatient complications between 2002 and 2013.

In 2000, measles was declared eliminated in the United States, but for those who have been infected since that time, the risk of serious complications and death has not diminished, noted Raj Chovatiya, MD, PhD, in a session at the annual meeting of the Society for Investigative Dermatology.

By eliminated, the Centers of Disease Control and Prevention – which reported 86 confirmed cases of measles in 2000 – was referring to a technical definition of no new endemic or continuous transmissions in the previous 12 months. It was expected that a modest number of cases of this reportable disease would continue to accrue for an infection that remains common elsewhere in the world.

“Worldwide there are about 20 million cases of measles annually with an estimated 100,000 deaths attributed to this cause,” said Dr. Chovatiya, who is a dermatology resident at Northwestern University, Chicago.

Courtesy Dr. Gary White

Characteristic of measles, the majority of the 582 hospitalizations evaluated over this period occurred in children aged between 1 and 9 years. The proportion of patients with preexisting chronic comorbid conditions was low. Rather, “most were pretty healthy” prior to admission, according to Dr. Chovatiya, who said that the majority of admissions were from an emergency department.

“I want to point out that these are just direct inpatient costs,” Dr. Chovatiya said. Extrapolating from published data about indirect expenses, he said that the total health cost burden “is absolutely staggering.”

Courtesy Dr. Gary White

CHICAGO – An evaluation of the measles threat in the modern era gives no indication that the risk of complications or death is any different than it was before a vaccine became available, according to an analysis of inpatient complications between 2002 and 2013.

In 2000, measles was declared eliminated in the United States, but for those who have been infected since that time, the risk of serious complications and death has not diminished, noted Raj Chovatiya, MD, PhD, in a session at the annual meeting of the Society for Investigative Dermatology.

By eliminated, the Centers of Disease Control and Prevention – which reported 86 confirmed cases of measles in 2000 – was referring to a technical definition of no new endemic or continuous transmissions in the previous 12 months. It was expected that a modest number of cases of this reportable disease would continue to accrue for an infection that remains common elsewhere in the world.

“Worldwide there are about 20 million cases of measles annually with an estimated 100,000 deaths attributed to this cause,” said Dr. Chovatiya, who is a dermatology resident at Northwestern University, Chicago.

Courtesy Dr. Gary White

Characteristic of measles, the majority of the 582 hospitalizations evaluated over this period occurred in children aged between 1 and 9 years. The proportion of patients with preexisting chronic comorbid conditions was low. Rather, “most were pretty healthy” prior to admission, according to Dr. Chovatiya, who said that the majority of admissions were from an emergency department.

“I want to point out that these are just direct inpatient costs,” Dr. Chovatiya said. Extrapolating from published data about indirect expenses, he said that the total health cost burden “is absolutely staggering.”

Courtesy Dr. Gary White

Walmart, the nation’s largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company’s workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out to not need those operations. They were either misdiagnosed by their doctor or needed only nonsurgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City–based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy – not price, said employer health experts.

“A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery,” said Ms. Woods. “The goal is to give associates the best chance to get better, and that starts with the right diagnosis.”

Walmart employees are not required to use those 800 centers, but if they don’t use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.

Studies show a 3%-5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

“There’s no question that there are a lot of errors that occur,” said Vijay Rao, MD, chair of radiology at the Jefferson Medical College, Philadelphia.

Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Dr. Rao said. The average radiologist typically has only seconds to read each image. “It’s just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen,” she added.

Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Dr. Rao said.

Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use freestanding outpatient centers, rather than those based in hospitals, which tend to be more expensive.

Ms. Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. “Unfortunately, it is all over the country. It’s everywhere,” she said.

Walmart’s new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants, and certain cancers.

As part of its “Centers of Excellence” program, the Bentonville, Ark.–based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company’s health insurance plan, including a caregiver.

Sampling imaging centers’ work

Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers’ compensation field.

“Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients,” said Dan Elgort, Covera’s chief data science officer.

Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities’ error rates. It uses statistical modeling along with information on each center’s equipment, physicians, and use of industry-accepted patient protocols to determine the facilities’ rates of accuracy.

Covera expects to have about 1,500 imaging centers in the program by year’s end, said CEO Ron Vianu.

There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.

As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients’ images and reports to Covera.

Mr. Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images – like those of the brain or bones – and sometimes radiologists read images from exams they have less experience with, he said.

Mr. Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. “Most people think of diagnostic imaging as a commodity, and that’s a mistake,” he said.

Dr. Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. “I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this,” she said.

Few guides for consumers

Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.

“We would love to have more robust ... measurements” than what is currently available, said Geraldine McGinty, MD, chair of the college’s board of chancellors.

Facilities typically conduct peer reviews of their radiologists’ patient reports, but there is no public reporting of such results, she said.

Covera officials said they have worked with Walmart for nearly 2 years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees’ health records to see where changes in imaging services could have caught potential problems.

Covera said the centers in its network were chosen based on quality and price was not a factor.

In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.

“Walmart is on the leading edge of focusing on quality of diagnostic imaging,” said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group.

But Mark Stolper, executive vice president of Los Angeles–based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. “This would be the first time,” he said, “I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price.”

Ms. Woods said that, even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.

“It’s been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better,” she said.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Walmart, the nation’s largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company’s workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out to not need those operations. They were either misdiagnosed by their doctor or needed only nonsurgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City–based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy – not price, said employer health experts.

“A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery,” said Ms. Woods. “The goal is to give associates the best chance to get better, and that starts with the right diagnosis.”

Walmart employees are not required to use those 800 centers, but if they don’t use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.

Studies show a 3%-5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

“There’s no question that there are a lot of errors that occur,” said Vijay Rao, MD, chair of radiology at the Jefferson Medical College, Philadelphia.

Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Dr. Rao said. The average radiologist typically has only seconds to read each image. “It’s just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen,” she added.

Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Dr. Rao said.

Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use freestanding outpatient centers, rather than those based in hospitals, which tend to be more expensive.

Ms. Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. “Unfortunately, it is all over the country. It’s everywhere,” she said.

Walmart’s new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants, and certain cancers.

As part of its “Centers of Excellence” program, the Bentonville, Ark.–based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company’s health insurance plan, including a caregiver.

Sampling imaging centers’ work

Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers’ compensation field.

“Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients,” said Dan Elgort, Covera’s chief data science officer.

Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities’ error rates. It uses statistical modeling along with information on each center’s equipment, physicians, and use of industry-accepted patient protocols to determine the facilities’ rates of accuracy.

Covera expects to have about 1,500 imaging centers in the program by year’s end, said CEO Ron Vianu.

There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.

As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients’ images and reports to Covera.

Mr. Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images – like those of the brain or bones – and sometimes radiologists read images from exams they have less experience with, he said.

Mr. Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. “Most people think of diagnostic imaging as a commodity, and that’s a mistake,” he said.

Dr. Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. “I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this,” she said.

Few guides for consumers

Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.

“We would love to have more robust ... measurements” than what is currently available, said Geraldine McGinty, MD, chair of the college’s board of chancellors.

Facilities typically conduct peer reviews of their radiologists’ patient reports, but there is no public reporting of such results, she said.

Covera officials said they have worked with Walmart for nearly 2 years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees’ health records to see where changes in imaging services could have caught potential problems.

Covera said the centers in its network were chosen based on quality and price was not a factor.

In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.

“Walmart is on the leading edge of focusing on quality of diagnostic imaging,” said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group.

But Mark Stolper, executive vice president of Los Angeles–based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. “This would be the first time,” he said, “I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price.”

Ms. Woods said that, even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.

“It’s been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better,” she said.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Walmart, the nation’s largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company’s workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out to not need those operations. They were either misdiagnosed by their doctor or needed only nonsurgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City–based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy – not price, said employer health experts.

“A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery,” said Ms. Woods. “The goal is to give associates the best chance to get better, and that starts with the right diagnosis.”

Walmart employees are not required to use those 800 centers, but if they don’t use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.

Studies show a 3%-5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

“There’s no question that there are a lot of errors that occur,” said Vijay Rao, MD, chair of radiology at the Jefferson Medical College, Philadelphia.

Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Dr. Rao said. The average radiologist typically has only seconds to read each image. “It’s just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen,” she added.

Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Dr. Rao said.

Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use freestanding outpatient centers, rather than those based in hospitals, which tend to be more expensive.

Ms. Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. “Unfortunately, it is all over the country. It’s everywhere,” she said.

Walmart’s new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants, and certain cancers.

As part of its “Centers of Excellence” program, the Bentonville, Ark.–based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company’s health insurance plan, including a caregiver.

Sampling imaging centers’ work

Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers’ compensation field.

“Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients,” said Dan Elgort, Covera’s chief data science officer.

Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities’ error rates. It uses statistical modeling along with information on each center’s equipment, physicians, and use of industry-accepted patient protocols to determine the facilities’ rates of accuracy.

Covera expects to have about 1,500 imaging centers in the program by year’s end, said CEO Ron Vianu.

There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.

As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients’ images and reports to Covera.

Mr. Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images – like those of the brain or bones – and sometimes radiologists read images from exams they have less experience with, he said.

Mr. Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. “Most people think of diagnostic imaging as a commodity, and that’s a mistake,” he said.

Dr. Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. “I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this,” she said.

Few guides for consumers

Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.

“We would love to have more robust ... measurements” than what is currently available, said Geraldine McGinty, MD, chair of the college’s board of chancellors.

Facilities typically conduct peer reviews of their radiologists’ patient reports, but there is no public reporting of such results, she said.

Covera officials said they have worked with Walmart for nearly 2 years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees’ health records to see where changes in imaging services could have caught potential problems.

Covera said the centers in its network were chosen based on quality and price was not a factor.

In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.

“Walmart is on the leading edge of focusing on quality of diagnostic imaging,” said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group.

But Mark Stolper, executive vice president of Los Angeles–based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. “This would be the first time,” he said, “I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price.”

Ms. Woods said that, even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.

“It’s been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better,” she said.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

BALTIMORE – A large retrospective study found that laparoscopic repair of umbilical hernias in patients with obesity resulted in lower rates of wound complications than open repair even though the laparoscopic group had higher body mass index and rates of other key comorbidities, according to results reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In patients with obesity, even though our laparoscopic umbilical hernia repair [UHR] group had an overall higher BMI; higher rates of diabetes, hypertension, and current smoking status; and longer operative times, they experienced decreased postoperative wound complications, compared to the open-repair group,” said Kristen Williams, MD, of TriHealth in Cincinnati.

The retrospective cohort study evaluated 12,026 adult patients with a BMI of more than 30 kg/m² in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had UHR in 2016. Almost four times as many patients had open rather than laparoscopic surgery (9,695 vs. 2,331, respectively)

Dr. Williams noted that two previous studies reported lower wound infection rates after laparoscopic hernia repair in patients with obesity: an analysis of ventral, not just umbilical, hernia repair based on the NSQIP database from 2009-2012 (Am J Surg. 2015;210:1029-30) and a single-institution retrospective chart review from 2003-2009 of patients who had umbilical hernia repair (Am J Surg. 2013;205:231-6). “In our study we wanted to compare the rate of postoperative complications after laparoscopic vs. open umbilical hernia repairs in patients with obesity based on NSQIP review,” she said.

The rate of composite surgical-site infections in the open group was 1.9% vs. 1.1% in the laparoscopic group (P less than .01), Dr. Williams noted. “SSI was statistically significantly higher in the open-repair group, and there was a trend toward higher deep SSI in the open group [0.3% vs. 0.1%; P = .147],” she said. Laparoscopic patients had significantly higher rates of postoperative pneumonia (0.4% vs 0.1%; P = .012), but Dr. Williams noted this was only significant in the non–elective surgery group. Operative times were significantly longer in the laparoscopic repair group (70 vs. 44 minutes). “The literature shows that longer operative times are associated with higher rates of SSI,” Dr. Williams added. “However our laparoscopic group still had lower rates of composite SSI.”

“Logistic regression was utilized and found that morbidity, defined as superficial, deep, and organ-space SSIs, was significantly increased in the open-repair group,” Dr. Williams said.

A higher percentage of patients in the laparoscopic group were women than in the open group (29.4% vs. 24.4%; P less than .001). The laparoscopic group had statistically significant higher average BMI (37.5 vs. 36.1; P less than .001) and higher rates of smoking (18.6% vs. 16.5%; P = .018), diabetes (18.4% vs. 15.8%; P = .002), and hypertension (47.5% vs. 43.8%; P = .001) than the open group.

The study also analyzed outcomes by BMI class. “As BMI class increased, superficial SSI, deep SSI, return-to-OR rates, postoperative pneumonia rates, and composite SSI increased in the open-repair group, indicating that higher BMI is associated with higher rates of complications in the open-repair group,” Dr. Williams said. Likewise, as obesity class increased, so did operative times in both the open and laparoscopic groups, she added.

She also noted that this study reported a significant increase in the proportion of laparoscopic UHRs than did a retrospective cohort study of 2009 and 2010 NSQIP files of UHR (Surg Endosc. 2014;28:741-6), 19.4% in this study versus 10.5% in that one.

Dr. Williams had no financial relationships to disclose.

SOURCE: Williams K et al. SAGES 2019, Abstract S099.

BALTIMORE – A large retrospective study found that laparoscopic repair of umbilical hernias in patients with obesity resulted in lower rates of wound complications than open repair even though the laparoscopic group had higher body mass index and rates of other key comorbidities, according to results reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In patients with obesity, even though our laparoscopic umbilical hernia repair [UHR] group had an overall higher BMI; higher rates of diabetes, hypertension, and current smoking status; and longer operative times, they experienced decreased postoperative wound complications, compared to the open-repair group,” said Kristen Williams, MD, of TriHealth in Cincinnati.

The retrospective cohort study evaluated 12,026 adult patients with a BMI of more than 30 kg/m² in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had UHR in 2016. Almost four times as many patients had open rather than laparoscopic surgery (9,695 vs. 2,331, respectively)

Dr. Williams noted that two previous studies reported lower wound infection rates after laparoscopic hernia repair in patients with obesity: an analysis of ventral, not just umbilical, hernia repair based on the NSQIP database from 2009-2012 (Am J Surg. 2015;210:1029-30) and a single-institution retrospective chart review from 2003-2009 of patients who had umbilical hernia repair (Am J Surg. 2013;205:231-6). “In our study we wanted to compare the rate of postoperative complications after laparoscopic vs. open umbilical hernia repairs in patients with obesity based on NSQIP review,” she said.

The rate of composite surgical-site infections in the open group was 1.9% vs. 1.1% in the laparoscopic group (P less than .01), Dr. Williams noted. “SSI was statistically significantly higher in the open-repair group, and there was a trend toward higher deep SSI in the open group [0.3% vs. 0.1%; P = .147],” she said. Laparoscopic patients had significantly higher rates of postoperative pneumonia (0.4% vs 0.1%; P = .012), but Dr. Williams noted this was only significant in the non–elective surgery group. Operative times were significantly longer in the laparoscopic repair group (70 vs. 44 minutes). “The literature shows that longer operative times are associated with higher rates of SSI,” Dr. Williams added. “However our laparoscopic group still had lower rates of composite SSI.”

“Logistic regression was utilized and found that morbidity, defined as superficial, deep, and organ-space SSIs, was significantly increased in the open-repair group,” Dr. Williams said.

A higher percentage of patients in the laparoscopic group were women than in the open group (29.4% vs. 24.4%; P less than .001). The laparoscopic group had statistically significant higher average BMI (37.5 vs. 36.1; P less than .001) and higher rates of smoking (18.6% vs. 16.5%; P = .018), diabetes (18.4% vs. 15.8%; P = .002), and hypertension (47.5% vs. 43.8%; P = .001) than the open group.

The study also analyzed outcomes by BMI class. “As BMI class increased, superficial SSI, deep SSI, return-to-OR rates, postoperative pneumonia rates, and composite SSI increased in the open-repair group, indicating that higher BMI is associated with higher rates of complications in the open-repair group,” Dr. Williams said. Likewise, as obesity class increased, so did operative times in both the open and laparoscopic groups, she added.

She also noted that this study reported a significant increase in the proportion of laparoscopic UHRs than did a retrospective cohort study of 2009 and 2010 NSQIP files of UHR (Surg Endosc. 2014;28:741-6), 19.4% in this study versus 10.5% in that one.

Dr. Williams had no financial relationships to disclose.

SOURCE: Williams K et al. SAGES 2019, Abstract S099.

BALTIMORE – A large retrospective study found that laparoscopic repair of umbilical hernias in patients with obesity resulted in lower rates of wound complications than open repair even though the laparoscopic group had higher body mass index and rates of other key comorbidities, according to results reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In patients with obesity, even though our laparoscopic umbilical hernia repair [UHR] group had an overall higher BMI; higher rates of diabetes, hypertension, and current smoking status; and longer operative times, they experienced decreased postoperative wound complications, compared to the open-repair group,” said Kristen Williams, MD, of TriHealth in Cincinnati.

The retrospective cohort study evaluated 12,026 adult patients with a BMI of more than 30 kg/m² in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had UHR in 2016. Almost four times as many patients had open rather than laparoscopic surgery (9,695 vs. 2,331, respectively)

Dr. Williams noted that two previous studies reported lower wound infection rates after laparoscopic hernia repair in patients with obesity: an analysis of ventral, not just umbilical, hernia repair based on the NSQIP database from 2009-2012 (Am J Surg. 2015;210:1029-30) and a single-institution retrospective chart review from 2003-2009 of patients who had umbilical hernia repair (Am J Surg. 2013;205:231-6). “In our study we wanted to compare the rate of postoperative complications after laparoscopic vs. open umbilical hernia repairs in patients with obesity based on NSQIP review,” she said.

The rate of composite surgical-site infections in the open group was 1.9% vs. 1.1% in the laparoscopic group (P less than .01), Dr. Williams noted. “SSI was statistically significantly higher in the open-repair group, and there was a trend toward higher deep SSI in the open group [0.3% vs. 0.1%; P = .147],” she said. Laparoscopic patients had significantly higher rates of postoperative pneumonia (0.4% vs 0.1%; P = .012), but Dr. Williams noted this was only significant in the non–elective surgery group. Operative times were significantly longer in the laparoscopic repair group (70 vs. 44 minutes). “The literature shows that longer operative times are associated with higher rates of SSI,” Dr. Williams added. “However our laparoscopic group still had lower rates of composite SSI.”

“Logistic regression was utilized and found that morbidity, defined as superficial, deep, and organ-space SSIs, was significantly increased in the open-repair group,” Dr. Williams said.

A higher percentage of patients in the laparoscopic group were women than in the open group (29.4% vs. 24.4%; P less than .001). The laparoscopic group had statistically significant higher average BMI (37.5 vs. 36.1; P less than .001) and higher rates of smoking (18.6% vs. 16.5%; P = .018), diabetes (18.4% vs. 15.8%; P = .002), and hypertension (47.5% vs. 43.8%; P = .001) than the open group.

The study also analyzed outcomes by BMI class. “As BMI class increased, superficial SSI, deep SSI, return-to-OR rates, postoperative pneumonia rates, and composite SSI increased in the open-repair group, indicating that higher BMI is associated with higher rates of complications in the open-repair group,” Dr. Williams said. Likewise, as obesity class increased, so did operative times in both the open and laparoscopic groups, she added.

She also noted that this study reported a significant increase in the proportion of laparoscopic UHRs than did a retrospective cohort study of 2009 and 2010 NSQIP files of UHR (Surg Endosc. 2014;28:741-6), 19.4% in this study versus 10.5% in that one.

Dr. Williams had no financial relationships to disclose.

SOURCE: Williams K et al. SAGES 2019, Abstract S099.

In my last column, I gave you some options for handling those inevitable negative online reviews without violating patient confidentiality or pouring fuel on the fire. Your options in such cases are limited by HIPAA rules (among others) and by the patient’s right to free expression under the First Amendment.

juststock/Getty Images

When a review contains false or defamatory content, however, the game changes – as do your options – although you need to carefully consider the situation before going to war with a critic.

Critics have legislative protection in many states, called anti-SLAPP (Strategic Lawsuit Against Public Participation) laws, which allow judges to summarily dismiss lawsuits that they consider retaliatory or intended to intimidate and silence citizens speaking out on issues of public interest – such as health care. Federal courts recently nullified anti-SLAPP laws in Washington and Minnesota as unconstitutional; but as I write this, similar laws remain on the books in 28 other states, plus Washington, D.C., and Guam.

There is also a federal law – the Consumer Review Freedom Act of 2016 – which prohibits any attempt to prevent consumers from giving “honest” reviews about products or services. No law protects demonstrably false statements, of course.

The first thing to do before taking any action is to determine whether that defamatory review is, in fact, defamatory. Defamation is generally defined as the act of making false statements “with malice” – that is, in a deliberate attempt to damage someone’s reputation. The main issue in most defamation cases is whether the statements in question are merely strong opinions, which are protected by the First Amendment; or “assertions of verifiable fact”, which are not.

For example, “Dr. ____’s office does not clean its instruments properly” is a statement that can be proven true or false. Therefore, it is an assertion of fact, not an opinion, and if false, vulnerable to a defamation suit. The only unimpeachable defense in such a suit would be to prove that the assertion is true.

It is worth noting that attempting to disguise assertions of fact as opinions, simply by calling them opinions – for example, “In my opinion, Dr. ____’s office does not clean its instruments properly” – does not make them unverifiable or immunize them from litigation.

Once you have determined that the review fits the legal definition of defamation, the usual first step is to contact the website where the review is posted. Most rating sites are loath to intercede in arguments. (for example, Yelp’s official position: “We don’t typically take sides in factual disputes, and generally allow Yelpers to stand behind their reviews.”) They also have their own legal shield: The U.S. Communications Decency Act, which prohibits lawsuits against websites for publishing reviews, comments, and other third-party content, unless the site itself changes or somehow alters the meaning of the original post.

Even so, websites have their own reputations to protect; they don’t want to be used as venues for acts of defamation, nor be seen as perpetuating false or misleading information, and can sometimes be persuaded to take down really egregious hatchet jobs. It is certainly worth a try – but it may take a lawyer’s letter to get their attention.

If the site won’t remove it, you’ll have to try to persuade the patient to do so. Most attorneys recommend sending a “cease-and-desist” letter, explaining why the review is defamatory and demanding its removal. You should carefully consider the situation before sending such a letter; it may fuel the patient’s anger and trigger additional online attacks.

If a cease-and-desist letter is ineffective, your only further option is to file a lawsuit. Such cases are rare, and success even rarer: Of the 29 health care–related defamation cases that I was able to find in the public record, 19 were summarily dismissed; in 6 of those cases, the plaintiff was ordered to pay the defendant’s court costs. The other 10 were settled on undisclosed terms; only one, apparently, involved a cash payment to the plaintiff.

If you believe that the defamation is causing you real, monetary damage – enough to outweigh the costs of litigation – and you can prove that the allegations against you are false, it might be worth the considerable time, money, and emotional energy that litigation demands to pursue it.

As always, never venture into the litigation jungle without the support and guidance of an experienced attorney.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

In my last column, I gave you some options for handling those inevitable negative online reviews without violating patient confidentiality or pouring fuel on the fire. Your options in such cases are limited by HIPAA rules (among others) and by the patient’s right to free expression under the First Amendment.

juststock/Getty Images

When a review contains false or defamatory content, however, the game changes – as do your options – although you need to carefully consider the situation before going to war with a critic.

Critics have legislative protection in many states, called anti-SLAPP (Strategic Lawsuit Against Public Participation) laws, which allow judges to summarily dismiss lawsuits that they consider retaliatory or intended to intimidate and silence citizens speaking out on issues of public interest – such as health care. Federal courts recently nullified anti-SLAPP laws in Washington and Minnesota as unconstitutional; but as I write this, similar laws remain on the books in 28 other states, plus Washington, D.C., and Guam.

There is also a federal law – the Consumer Review Freedom Act of 2016 – which prohibits any attempt to prevent consumers from giving “honest” reviews about products or services. No law protects demonstrably false statements, of course.

The first thing to do before taking any action is to determine whether that defamatory review is, in fact, defamatory. Defamation is generally defined as the act of making false statements “with malice” – that is, in a deliberate attempt to damage someone’s reputation. The main issue in most defamation cases is whether the statements in question are merely strong opinions, which are protected by the First Amendment; or “assertions of verifiable fact”, which are not.

For example, “Dr. ____’s office does not clean its instruments properly” is a statement that can be proven true or false. Therefore, it is an assertion of fact, not an opinion, and if false, vulnerable to a defamation suit. The only unimpeachable defense in such a suit would be to prove that the assertion is true.

It is worth noting that attempting to disguise assertions of fact as opinions, simply by calling them opinions – for example, “In my opinion, Dr. ____’s office does not clean its instruments properly” – does not make them unverifiable or immunize them from litigation.

Once you have determined that the review fits the legal definition of defamation, the usual first step is to contact the website where the review is posted. Most rating sites are loath to intercede in arguments. (for example, Yelp’s official position: “We don’t typically take sides in factual disputes, and generally allow Yelpers to stand behind their reviews.”) They also have their own legal shield: The U.S. Communications Decency Act, which prohibits lawsuits against websites for publishing reviews, comments, and other third-party content, unless the site itself changes or somehow alters the meaning of the original post.

Even so, websites have their own reputations to protect; they don’t want to be used as venues for acts of defamation, nor be seen as perpetuating false or misleading information, and can sometimes be persuaded to take down really egregious hatchet jobs. It is certainly worth a try – but it may take a lawyer’s letter to get their attention.

If the site won’t remove it, you’ll have to try to persuade the patient to do so. Most attorneys recommend sending a “cease-and-desist” letter, explaining why the review is defamatory and demanding its removal. You should carefully consider the situation before sending such a letter; it may fuel the patient’s anger and trigger additional online attacks.

If a cease-and-desist letter is ineffective, your only further option is to file a lawsuit. Such cases are rare, and success even rarer: Of the 29 health care–related defamation cases that I was able to find in the public record, 19 were summarily dismissed; in 6 of those cases, the plaintiff was ordered to pay the defendant’s court costs. The other 10 were settled on undisclosed terms; only one, apparently, involved a cash payment to the plaintiff.

If you believe that the defamation is causing you real, monetary damage – enough to outweigh the costs of litigation – and you can prove that the allegations against you are false, it might be worth the considerable time, money, and emotional energy that litigation demands to pursue it.

As always, never venture into the litigation jungle without the support and guidance of an experienced attorney.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

In my last column, I gave you some options for handling those inevitable negative online reviews without violating patient confidentiality or pouring fuel on the fire. Your options in such cases are limited by HIPAA rules (among others) and by the patient’s right to free expression under the First Amendment.

juststock/Getty Images

When a review contains false or defamatory content, however, the game changes – as do your options – although you need to carefully consider the situation before going to war with a critic.

Critics have legislative protection in many states, called anti-SLAPP (Strategic Lawsuit Against Public Participation) laws, which allow judges to summarily dismiss lawsuits that they consider retaliatory or intended to intimidate and silence citizens speaking out on issues of public interest – such as health care. Federal courts recently nullified anti-SLAPP laws in Washington and Minnesota as unconstitutional; but as I write this, similar laws remain on the books in 28 other states, plus Washington, D.C., and Guam.

There is also a federal law – the Consumer Review Freedom Act of 2016 – which prohibits any attempt to prevent consumers from giving “honest” reviews about products or services. No law protects demonstrably false statements, of course.

The first thing to do before taking any action is to determine whether that defamatory review is, in fact, defamatory. Defamation is generally defined as the act of making false statements “with malice” – that is, in a deliberate attempt to damage someone’s reputation. The main issue in most defamation cases is whether the statements in question are merely strong opinions, which are protected by the First Amendment; or “assertions of verifiable fact”, which are not.

For example, “Dr. ____’s office does not clean its instruments properly” is a statement that can be proven true or false. Therefore, it is an assertion of fact, not an opinion, and if false, vulnerable to a defamation suit. The only unimpeachable defense in such a suit would be to prove that the assertion is true.

It is worth noting that attempting to disguise assertions of fact as opinions, simply by calling them opinions – for example, “In my opinion, Dr. ____’s office does not clean its instruments properly” – does not make them unverifiable or immunize them from litigation.

Once you have determined that the review fits the legal definition of defamation, the usual first step is to contact the website where the review is posted. Most rating sites are loath to intercede in arguments. (for example, Yelp’s official position: “We don’t typically take sides in factual disputes, and generally allow Yelpers to stand behind their reviews.”) They also have their own legal shield: The U.S. Communications Decency Act, which prohibits lawsuits against websites for publishing reviews, comments, and other third-party content, unless the site itself changes or somehow alters the meaning of the original post.

Even so, websites have their own reputations to protect; they don’t want to be used as venues for acts of defamation, nor be seen as perpetuating false or misleading information, and can sometimes be persuaded to take down really egregious hatchet jobs. It is certainly worth a try – but it may take a lawyer’s letter to get their attention.

If the site won’t remove it, you’ll have to try to persuade the patient to do so. Most attorneys recommend sending a “cease-and-desist” letter, explaining why the review is defamatory and demanding its removal. You should carefully consider the situation before sending such a letter; it may fuel the patient’s anger and trigger additional online attacks.

If a cease-and-desist letter is ineffective, your only further option is to file a lawsuit. Such cases are rare, and success even rarer: Of the 29 health care–related defamation cases that I was able to find in the public record, 19 were summarily dismissed; in 6 of those cases, the plaintiff was ordered to pay the defendant’s court costs. The other 10 were settled on undisclosed terms; only one, apparently, involved a cash payment to the plaintiff.

If you believe that the defamation is causing you real, monetary damage – enough to outweigh the costs of litigation – and you can prove that the allegations against you are false, it might be worth the considerable time, money, and emotional energy that litigation demands to pursue it.

As always, never venture into the litigation jungle without the support and guidance of an experienced attorney.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

BALTIMORE – Even in a public health system like Canada’s, almost one-quarter of patients who get referrals for bariatric surgery from their primary care provider drop out before going through with the operation, and researchers have identified patient characteristics that could be predictive of dropout risk that would potentially have implications in a nonuniversal system, such as that of the United States, according to a study of almost 18,000 patients reported at the annual meeting Society of American Gastrointestinal and Endoscopic Surgeons.

“Even in a universal health care system, clear disparities exist among patient populations having bariatric surgery,” said Aristithes Doumouras, MD, of McMaster University in Hamilton, Ont. “Extensive work-ups and long wait times can have an impact on the delivery of bariatric care.”

Dr. Doumouras reported on results of a retrospective, population-based study of 17,703 patients referred for surgery during 2009-2015 in the Ontario Bariatric Network, a province-wide network of 11 hospitals credentialed to perform bariatric surgery. The study found that 23.2% of patients referred for bariatric surgery did not go through with it and that overall average wait times between referral and the operation were just short of a year – 362.2 days to be precise.

The goal of the study was to identify any factors associated with attrition, Dr. Doumouras said.

“Predictors of interest included patient demographics – age, sex, income quintile, immigration status, employment status, smoking status – and comorbidities, such as diabetes, heart failure, hypertension, sleep apnea, and renal disease,” he said. “The study also evaluated health services factors, such as overall wait time to bariatric surgery, presence of centers of excellence, and health care utilization.”

The study found that demographics with more than twice the odds of attrition were male gender and presence of a disability (P less than .01). Smokers were 60% more likely to drop out (P less than .01), he said. “To receive bariatric surgery in Ontario, smokers must go through a smoking cessation program.”

Unemployed individuals and immigrants also had higher rates of attrition, at 55% and 39%, respectively, and were more likely to not go through with the operation (P less than .01). Health factors associated with attrition, but to a lesser extent, were diabetes (odds ratio, 1.23) and heart failure (OR, 1.35; P less than .01).

“Low socioeconomic status actually had a very low impact in our system on attrition after adjustment for other demographic factors such as disability and unemployment,” Dr. Doumouras said, noting a 16% greater risk of attrition in this group (P = .02).

“Interestingly,” he noted, “there was one factor associated with less dropout – obstructive sleep apnea – probably because people hate using the CPAP machines every single night.” People with OSA were 47% less likely to drop out than were people without the disease (P less than .001).

When asked if the findings would be applicable in the United States, Dr. Doumouras said they would to an extent.

“I think we can say confidently that they would apply to most universal health care systems,” he said. “In nonuniversal health care systems, the interplay between insurance status, socioeconomic status, and the like makes it more of a complex relationship, but if you were to take any kind of health care system, even in the United States, you would probably see very similar trends in terms of who can get bariatric surgery.”

He added, “I think also the length of work-up matters. Only a 3- or 4-week work-up probably affects attrition as well. These are relatively universal things.”

Dr. Doumouras has no financial relationships to disclose.

SOURCE: Doumouras A et al. SAGES 2019, Abstract S118.

BALTIMORE – Even in a public health system like Canada’s, almost one-quarter of patients who get referrals for bariatric surgery from their primary care provider drop out before going through with the operation, and researchers have identified patient characteristics that could be predictive of dropout risk that would potentially have implications in a nonuniversal system, such as that of the United States, according to a study of almost 18,000 patients reported at the annual meeting Society of American Gastrointestinal and Endoscopic Surgeons.

“Even in a universal health care system, clear disparities exist among patient populations having bariatric surgery,” said Aristithes Doumouras, MD, of McMaster University in Hamilton, Ont. “Extensive work-ups and long wait times can have an impact on the delivery of bariatric care.”

Dr. Doumouras reported on results of a retrospective, population-based study of 17,703 patients referred for surgery during 2009-2015 in the Ontario Bariatric Network, a province-wide network of 11 hospitals credentialed to perform bariatric surgery. The study found that 23.2% of patients referred for bariatric surgery did not go through with it and that overall average wait times between referral and the operation were just short of a year – 362.2 days to be precise.

The goal of the study was to identify any factors associated with attrition, Dr. Doumouras said.

“Predictors of interest included patient demographics – age, sex, income quintile, immigration status, employment status, smoking status – and comorbidities, such as diabetes, heart failure, hypertension, sleep apnea, and renal disease,” he said. “The study also evaluated health services factors, such as overall wait time to bariatric surgery, presence of centers of excellence, and health care utilization.”

The study found that demographics with more than twice the odds of attrition were male gender and presence of a disability (P less than .01). Smokers were 60% more likely to drop out (P less than .01), he said. “To receive bariatric surgery in Ontario, smokers must go through a smoking cessation program.”

Unemployed individuals and immigrants also had higher rates of attrition, at 55% and 39%, respectively, and were more likely to not go through with the operation (P less than .01). Health factors associated with attrition, but to a lesser extent, were diabetes (odds ratio, 1.23) and heart failure (OR, 1.35; P less than .01).

“Low socioeconomic status actually had a very low impact in our system on attrition after adjustment for other demographic factors such as disability and unemployment,” Dr. Doumouras said, noting a 16% greater risk of attrition in this group (P = .02).

“Interestingly,” he noted, “there was one factor associated with less dropout – obstructive sleep apnea – probably because people hate using the CPAP machines every single night.” People with OSA were 47% less likely to drop out than were people without the disease (P less than .001).

When asked if the findings would be applicable in the United States, Dr. Doumouras said they would to an extent.

“I think we can say confidently that they would apply to most universal health care systems,” he said. “In nonuniversal health care systems, the interplay between insurance status, socioeconomic status, and the like makes it more of a complex relationship, but if you were to take any kind of health care system, even in the United States, you would probably see very similar trends in terms of who can get bariatric surgery.”

He added, “I think also the length of work-up matters. Only a 3- or 4-week work-up probably affects attrition as well. These are relatively universal things.”

Dr. Doumouras has no financial relationships to disclose.

SOURCE: Doumouras A et al. SAGES 2019, Abstract S118.

BALTIMORE – Even in a public health system like Canada’s, almost one-quarter of patients who get referrals for bariatric surgery from their primary care provider drop out before going through with the operation, and researchers have identified patient characteristics that could be predictive of dropout risk that would potentially have implications in a nonuniversal system, such as that of the United States, according to a study of almost 18,000 patients reported at the annual meeting Society of American Gastrointestinal and Endoscopic Surgeons.

“Even in a universal health care system, clear disparities exist among patient populations having bariatric surgery,” said Aristithes Doumouras, MD, of McMaster University in Hamilton, Ont. “Extensive work-ups and long wait times can have an impact on the delivery of bariatric care.”

Dr. Doumouras reported on results of a retrospective, population-based study of 17,703 patients referred for surgery during 2009-2015 in the Ontario Bariatric Network, a province-wide network of 11 hospitals credentialed to perform bariatric surgery. The study found that 23.2% of patients referred for bariatric surgery did not go through with it and that overall average wait times between referral and the operation were just short of a year – 362.2 days to be precise.

The goal of the study was to identify any factors associated with attrition, Dr. Doumouras said.

“Predictors of interest included patient demographics – age, sex, income quintile, immigration status, employment status, smoking status – and comorbidities, such as diabetes, heart failure, hypertension, sleep apnea, and renal disease,” he said. “The study also evaluated health services factors, such as overall wait time to bariatric surgery, presence of centers of excellence, and health care utilization.”

The study found that demographics with more than twice the odds of attrition were male gender and presence of a disability (P less than .01). Smokers were 60% more likely to drop out (P less than .01), he said. “To receive bariatric surgery in Ontario, smokers must go through a smoking cessation program.”

Unemployed individuals and immigrants also had higher rates of attrition, at 55% and 39%, respectively, and were more likely to not go through with the operation (P less than .01). Health factors associated with attrition, but to a lesser extent, were diabetes (odds ratio, 1.23) and heart failure (OR, 1.35; P less than .01).

“Low socioeconomic status actually had a very low impact in our system on attrition after adjustment for other demographic factors such as disability and unemployment,” Dr. Doumouras said, noting a 16% greater risk of attrition in this group (P = .02).

“Interestingly,” he noted, “there was one factor associated with less dropout – obstructive sleep apnea – probably because people hate using the CPAP machines every single night.” People with OSA were 47% less likely to drop out than were people without the disease (P less than .001).

When asked if the findings would be applicable in the United States, Dr. Doumouras said they would to an extent.

“I think we can say confidently that they would apply to most universal health care systems,” he said. “In nonuniversal health care systems, the interplay between insurance status, socioeconomic status, and the like makes it more of a complex relationship, but if you were to take any kind of health care system, even in the United States, you would probably see very similar trends in terms of who can get bariatric surgery.”

He added, “I think also the length of work-up matters. Only a 3- or 4-week work-up probably affects attrition as well. These are relatively universal things.”

Dr. Doumouras has no financial relationships to disclose.

SOURCE: Doumouras A et al. SAGES 2019, Abstract S118.