Low LDL cholesterol levels and low triglyceride levels are associated with increased risk of hemorrhagic stroke among women, according to research published in Neurology.

“Women with very low LDL cholesterol or low triglycerides should be monitored by their doctors for other stroke risk factors that can be modified, like high blood pressure and smoking, in order to reduce their risk of hemorrhagic stroke,” said Pamela M. Rist, ScD, instructor in epidemiology at Harvard Medical School, Boston. “Additional research is needed to determine how to lower the risk of hemorrhagic stroke in women with very low LDL and low triglycerides.”
 

Several meta-analyses have indicated that LDL cholesterol levels are inversely associated with the risk of hemorrhagic stroke. Because lipid-lowering treatments are used to prevent cardiovascular disease, this potential association has implications for clinical practice. Most of the studies included in these meta-analyses had low numbers of events among women, which prevented researchers from stratifying their results by sex. Because women are at greater risk of stroke than men, Dr. Rist and her colleagues sought to evaluate the association between lipid levels and risk of hemorrhagic stroke.

An analysis of the Women’s Health Study

The investigators examined data from the Women’s Health Study, a randomized, double-blind, placebo-controlled trial of low-dose aspirin and vitamin E for the primary prevention of cardiovascular disease and cancer among female American health professionals aged 45 years or older. The study ended in March 2004, but follow-up is ongoing. At regular intervals, the women complete a questionnaire about disease outcomes, including stroke. Some participants agreed to provide a fasting venous blood sample before randomization. With the subjects’ permission, a committee of physicians examined medical records for women who reported a stroke on a follow-up questionnaire.

Dr. Rist and her colleagues analyzed 27,937 samples for levels of LDL cholesterol, HDL cholesterol, total cholesterol, and triglycerides. They assigned each sample to one of five cholesterol level categories that were based on Adult Treatment Panel III guidelines. Cox proportional hazards models enabled the researchers to calculate the hazard ratio of incident hemorrhagic stroke events. They adjusted their results for covariates such as age, smoking status, menopausal status, body mass index, and alcohol consumption.

A U-shaped association

Women in the lowest category of LDL cholesterol level (less than 70 mg/dL) were younger, less likely to have a history of hypertension, and less likely to use cholesterol-lowering drugs than women in the reference group (100.0-129.9 mg/dL). Women with the lowest LDL cholesterol level were more likely to consume alcohol, have a normal weight, engage in physical activity, and be premenopausal than women in the reference group. The investigators confirmed 137 incident hemorrhagic stroke events during a mean 19.3 years of follow-up.

After data adjustment, the researchers found that women with the lowest level of LDL cholesterol had 2.17 times the risk of hemorrhagic stroke, compared with participants in the reference group. They found a trend toward increased risk among women with an LDL cholesterol level of 160 mg/dL or higher, but the result was not statistically significant. The highest risk for intracerebral hemorrhage (ICH) was among women with an LDL cholesterol level of less than 70 mg/dL (relative risk, 2.32), followed by women with a level of 160 mg/dL or higher (RR, 1.71).

In addition, after multivariable adjustment, women in the lowest quartile of triglycerides (less than or equal to 74 mg/dL for fasting and less than or equal to 85 mg/dL for nonfasting) had a significantly increased risk of hemorrhagic stroke, compared with women in the highest quartile (RR, 2.00). Low triglyceride levels were associated with an increased risk of subarachnoid hemorrhage, but not with an increased risk of ICH. Neither HDL cholesterol nor total cholesterol was associated with risk of hemorrhagic stroke, the researchers wrote.

Mechanism of increased risk unclear

The researchers do not yet know how low triglyceride and LDL cholesterol levels increase the risk of hemorrhagic stroke. One hypothesis is that low cholesterol promotes necrosis of the arterial medial layer’s smooth muscle cells. This impaired endothelium might be more susceptible to microaneurysms, which are common in patients with ICH, said the researchers.

The prospective design and the large sample size were two of the study’s strengths, but the study had important weaknesses as well, the researchers wrote. For example, few women were premenopausal at baseline, so the investigators could not evaluate whether menopausal status modifies the association between lipid levels and risk of hemorrhagic stroke. In addition, lipid levels were measured only at baseline, which prevented an analysis of whether change in lipid levels over time modifies the risk of hemorrhagic stroke.

Dr. Rist reported receiving a grant from the National Institutes of Health.

[email protected]

SOURCE: Rist PM et al. Neurology. 2019 April 10. doi: 10.1212/WNL.0000000000007454.

Low LDL cholesterol levels and low triglyceride levels are associated with increased risk of hemorrhagic stroke among women, according to research published in Neurology.

“Women with very low LDL cholesterol or low triglycerides should be monitored by their doctors for other stroke risk factors that can be modified, like high blood pressure and smoking, in order to reduce their risk of hemorrhagic stroke,” said Pamela M. Rist, ScD, instructor in epidemiology at Harvard Medical School, Boston. “Additional research is needed to determine how to lower the risk of hemorrhagic stroke in women with very low LDL and low triglycerides.”
 

Several meta-analyses have indicated that LDL cholesterol levels are inversely associated with the risk of hemorrhagic stroke. Because lipid-lowering treatments are used to prevent cardiovascular disease, this potential association has implications for clinical practice. Most of the studies included in these meta-analyses had low numbers of events among women, which prevented researchers from stratifying their results by sex. Because women are at greater risk of stroke than men, Dr. Rist and her colleagues sought to evaluate the association between lipid levels and risk of hemorrhagic stroke.

An analysis of the Women’s Health Study

The investigators examined data from the Women’s Health Study, a randomized, double-blind, placebo-controlled trial of low-dose aspirin and vitamin E for the primary prevention of cardiovascular disease and cancer among female American health professionals aged 45 years or older. The study ended in March 2004, but follow-up is ongoing. At regular intervals, the women complete a questionnaire about disease outcomes, including stroke. Some participants agreed to provide a fasting venous blood sample before randomization. With the subjects’ permission, a committee of physicians examined medical records for women who reported a stroke on a follow-up questionnaire.

Dr. Rist and her colleagues analyzed 27,937 samples for levels of LDL cholesterol, HDL cholesterol, total cholesterol, and triglycerides. They assigned each sample to one of five cholesterol level categories that were based on Adult Treatment Panel III guidelines. Cox proportional hazards models enabled the researchers to calculate the hazard ratio of incident hemorrhagic stroke events. They adjusted their results for covariates such as age, smoking status, menopausal status, body mass index, and alcohol consumption.

A U-shaped association

Women in the lowest category of LDL cholesterol level (less than 70 mg/dL) were younger, less likely to have a history of hypertension, and less likely to use cholesterol-lowering drugs than women in the reference group (100.0-129.9 mg/dL). Women with the lowest LDL cholesterol level were more likely to consume alcohol, have a normal weight, engage in physical activity, and be premenopausal than women in the reference group. The investigators confirmed 137 incident hemorrhagic stroke events during a mean 19.3 years of follow-up.

After data adjustment, the researchers found that women with the lowest level of LDL cholesterol had 2.17 times the risk of hemorrhagic stroke, compared with participants in the reference group. They found a trend toward increased risk among women with an LDL cholesterol level of 160 mg/dL or higher, but the result was not statistically significant. The highest risk for intracerebral hemorrhage (ICH) was among women with an LDL cholesterol level of less than 70 mg/dL (relative risk, 2.32), followed by women with a level of 160 mg/dL or higher (RR, 1.71).

In addition, after multivariable adjustment, women in the lowest quartile of triglycerides (less than or equal to 74 mg/dL for fasting and less than or equal to 85 mg/dL for nonfasting) had a significantly increased risk of hemorrhagic stroke, compared with women in the highest quartile (RR, 2.00). Low triglyceride levels were associated with an increased risk of subarachnoid hemorrhage, but not with an increased risk of ICH. Neither HDL cholesterol nor total cholesterol was associated with risk of hemorrhagic stroke, the researchers wrote.

Mechanism of increased risk unclear

The researchers do not yet know how low triglyceride and LDL cholesterol levels increase the risk of hemorrhagic stroke. One hypothesis is that low cholesterol promotes necrosis of the arterial medial layer’s smooth muscle cells. This impaired endothelium might be more susceptible to microaneurysms, which are common in patients with ICH, said the researchers.

The prospective design and the large sample size were two of the study’s strengths, but the study had important weaknesses as well, the researchers wrote. For example, few women were premenopausal at baseline, so the investigators could not evaluate whether menopausal status modifies the association between lipid levels and risk of hemorrhagic stroke. In addition, lipid levels were measured only at baseline, which prevented an analysis of whether change in lipid levels over time modifies the risk of hemorrhagic stroke.

Dr. Rist reported receiving a grant from the National Institutes of Health.

[email protected]

SOURCE: Rist PM et al. Neurology. 2019 April 10. doi: 10.1212/WNL.0000000000007454.

Low LDL cholesterol levels and low triglyceride levels are associated with increased risk of hemorrhagic stroke among women, according to research published in Neurology.

“Women with very low LDL cholesterol or low triglycerides should be monitored by their doctors for other stroke risk factors that can be modified, like high blood pressure and smoking, in order to reduce their risk of hemorrhagic stroke,” said Pamela M. Rist, ScD, instructor in epidemiology at Harvard Medical School, Boston. “Additional research is needed to determine how to lower the risk of hemorrhagic stroke in women with very low LDL and low triglycerides.”
 

Several meta-analyses have indicated that LDL cholesterol levels are inversely associated with the risk of hemorrhagic stroke. Because lipid-lowering treatments are used to prevent cardiovascular disease, this potential association has implications for clinical practice. Most of the studies included in these meta-analyses had low numbers of events among women, which prevented researchers from stratifying their results by sex. Because women are at greater risk of stroke than men, Dr. Rist and her colleagues sought to evaluate the association between lipid levels and risk of hemorrhagic stroke.

An analysis of the Women’s Health Study

The investigators examined data from the Women’s Health Study, a randomized, double-blind, placebo-controlled trial of low-dose aspirin and vitamin E for the primary prevention of cardiovascular disease and cancer among female American health professionals aged 45 years or older. The study ended in March 2004, but follow-up is ongoing. At regular intervals, the women complete a questionnaire about disease outcomes, including stroke. Some participants agreed to provide a fasting venous blood sample before randomization. With the subjects’ permission, a committee of physicians examined medical records for women who reported a stroke on a follow-up questionnaire.

Dr. Rist and her colleagues analyzed 27,937 samples for levels of LDL cholesterol, HDL cholesterol, total cholesterol, and triglycerides. They assigned each sample to one of five cholesterol level categories that were based on Adult Treatment Panel III guidelines. Cox proportional hazards models enabled the researchers to calculate the hazard ratio of incident hemorrhagic stroke events. They adjusted their results for covariates such as age, smoking status, menopausal status, body mass index, and alcohol consumption.

A U-shaped association

Women in the lowest category of LDL cholesterol level (less than 70 mg/dL) were younger, less likely to have a history of hypertension, and less likely to use cholesterol-lowering drugs than women in the reference group (100.0-129.9 mg/dL). Women with the lowest LDL cholesterol level were more likely to consume alcohol, have a normal weight, engage in physical activity, and be premenopausal than women in the reference group. The investigators confirmed 137 incident hemorrhagic stroke events during a mean 19.3 years of follow-up.

After data adjustment, the researchers found that women with the lowest level of LDL cholesterol had 2.17 times the risk of hemorrhagic stroke, compared with participants in the reference group. They found a trend toward increased risk among women with an LDL cholesterol level of 160 mg/dL or higher, but the result was not statistically significant. The highest risk for intracerebral hemorrhage (ICH) was among women with an LDL cholesterol level of less than 70 mg/dL (relative risk, 2.32), followed by women with a level of 160 mg/dL or higher (RR, 1.71).

In addition, after multivariable adjustment, women in the lowest quartile of triglycerides (less than or equal to 74 mg/dL for fasting and less than or equal to 85 mg/dL for nonfasting) had a significantly increased risk of hemorrhagic stroke, compared with women in the highest quartile (RR, 2.00). Low triglyceride levels were associated with an increased risk of subarachnoid hemorrhage, but not with an increased risk of ICH. Neither HDL cholesterol nor total cholesterol was associated with risk of hemorrhagic stroke, the researchers wrote.

Mechanism of increased risk unclear

The researchers do not yet know how low triglyceride and LDL cholesterol levels increase the risk of hemorrhagic stroke. One hypothesis is that low cholesterol promotes necrosis of the arterial medial layer’s smooth muscle cells. This impaired endothelium might be more susceptible to microaneurysms, which are common in patients with ICH, said the researchers.

The prospective design and the large sample size were two of the study’s strengths, but the study had important weaknesses as well, the researchers wrote. For example, few women were premenopausal at baseline, so the investigators could not evaluate whether menopausal status modifies the association between lipid levels and risk of hemorrhagic stroke. In addition, lipid levels were measured only at baseline, which prevented an analysis of whether change in lipid levels over time modifies the risk of hemorrhagic stroke.

Dr. Rist reported receiving a grant from the National Institutes of Health.

[email protected]

SOURCE: Rist PM et al. Neurology. 2019 April 10. doi: 10.1212/WNL.0000000000007454.

The proportion of women speaking at medical conferences in the United States and Canada increased significantly between 2007 and 2017, while the proportion at surgical specialty conferences lagged noticeably behind, according to new research.

“Although female representation at academic meetings has been identified as an important gender equity issue, the proportion of conference speakers who are women has not yet been systematically measured across different medical subspecialties,” wrote Shannon M. Ruzycki, MD, and her colleagues from the University of Calgary (Alta.). The report is in JAMA Network Open.

Using the Web of Science Conference database, the investigators identified 181 conferences and 701 unique meetings (40 in 2007, 104 in 2013, 115 in 2014, 124 in 2015, 137 in 2016, and 181 in 2017). The list of names from each meeting program was analyzed by the Gender Balance Assessment Tool to identify the likely proportion of female speakers by assigning a probability of each name belonging to a gender, based on social media data.

In 2007, the proportion of female speakers was 24.6% , which increased to 34.1% by 2017, an average increase of 0.97% per year. The range of female speakers at each meeting ranged from 0% to 82.6%, with 82 (12%) of the 701 meetings having more than 50% female speakers. The proportion of female speakers was slightly less than the proportion of female doctors in the United States and Canada in 2007 (26.1%), but was slightly greater than the proportion of female doctors in 2015 (32.4%).

During the study period, the proportion of female speakers at surgical specialty conferences was significantly lower than that for medical specialty conferences (20.1% in 2007 and 28.4% in 2017 vs. 29.9% in 2007 and 38.8% in 2017). While the number of speakers at medical meetings in 2015 matched the proportion of doctors in the United States and Canada in that year, the proportion of speakers at surgical meetings was noticeably higher than the number of female surgeons.

“We hypothesize that the low proportion of female speakers at medical conferences reflects broader gender inequity within the medical profession, particularly in subspecialties where the majority of physicians are men. It has been shown that the presence of female role models in male-dominated career streams can increase engagement of young women,” the investigators wrote. “Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated. Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine,” they concluded.

The University of Calgary funded the study. The authors reported no conflicts of interest.

[email protected]

SOURCE: Ruzycki SM et al. JAMA Netw Open. 2019 Apr 12. doi: 10.1001/jamanetworkopen.2019.2103.

The proportion of women speaking at medical conferences in the United States and Canada increased significantly between 2007 and 2017, while the proportion at surgical specialty conferences lagged noticeably behind, according to new research.

“Although female representation at academic meetings has been identified as an important gender equity issue, the proportion of conference speakers who are women has not yet been systematically measured across different medical subspecialties,” wrote Shannon M. Ruzycki, MD, and her colleagues from the University of Calgary (Alta.). The report is in JAMA Network Open.

Using the Web of Science Conference database, the investigators identified 181 conferences and 701 unique meetings (40 in 2007, 104 in 2013, 115 in 2014, 124 in 2015, 137 in 2016, and 181 in 2017). The list of names from each meeting program was analyzed by the Gender Balance Assessment Tool to identify the likely proportion of female speakers by assigning a probability of each name belonging to a gender, based on social media data.

In 2007, the proportion of female speakers was 24.6% , which increased to 34.1% by 2017, an average increase of 0.97% per year. The range of female speakers at each meeting ranged from 0% to 82.6%, with 82 (12%) of the 701 meetings having more than 50% female speakers. The proportion of female speakers was slightly less than the proportion of female doctors in the United States and Canada in 2007 (26.1%), but was slightly greater than the proportion of female doctors in 2015 (32.4%).

During the study period, the proportion of female speakers at surgical specialty conferences was significantly lower than that for medical specialty conferences (20.1% in 2007 and 28.4% in 2017 vs. 29.9% in 2007 and 38.8% in 2017). While the number of speakers at medical meetings in 2015 matched the proportion of doctors in the United States and Canada in that year, the proportion of speakers at surgical meetings was noticeably higher than the number of female surgeons.

“We hypothesize that the low proportion of female speakers at medical conferences reflects broader gender inequity within the medical profession, particularly in subspecialties where the majority of physicians are men. It has been shown that the presence of female role models in male-dominated career streams can increase engagement of young women,” the investigators wrote. “Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated. Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine,” they concluded.

The University of Calgary funded the study. The authors reported no conflicts of interest.

[email protected]

SOURCE: Ruzycki SM et al. JAMA Netw Open. 2019 Apr 12. doi: 10.1001/jamanetworkopen.2019.2103.

The proportion of women speaking at medical conferences in the United States and Canada increased significantly between 2007 and 2017, while the proportion at surgical specialty conferences lagged noticeably behind, according to new research.

“Although female representation at academic meetings has been identified as an important gender equity issue, the proportion of conference speakers who are women has not yet been systematically measured across different medical subspecialties,” wrote Shannon M. Ruzycki, MD, and her colleagues from the University of Calgary (Alta.). The report is in JAMA Network Open.

Using the Web of Science Conference database, the investigators identified 181 conferences and 701 unique meetings (40 in 2007, 104 in 2013, 115 in 2014, 124 in 2015, 137 in 2016, and 181 in 2017). The list of names from each meeting program was analyzed by the Gender Balance Assessment Tool to identify the likely proportion of female speakers by assigning a probability of each name belonging to a gender, based on social media data.

In 2007, the proportion of female speakers was 24.6% , which increased to 34.1% by 2017, an average increase of 0.97% per year. The range of female speakers at each meeting ranged from 0% to 82.6%, with 82 (12%) of the 701 meetings having more than 50% female speakers. The proportion of female speakers was slightly less than the proportion of female doctors in the United States and Canada in 2007 (26.1%), but was slightly greater than the proportion of female doctors in 2015 (32.4%).

During the study period, the proportion of female speakers at surgical specialty conferences was significantly lower than that for medical specialty conferences (20.1% in 2007 and 28.4% in 2017 vs. 29.9% in 2007 and 38.8% in 2017). While the number of speakers at medical meetings in 2015 matched the proportion of doctors in the United States and Canada in that year, the proportion of speakers at surgical meetings was noticeably higher than the number of female surgeons.

“We hypothesize that the low proportion of female speakers at medical conferences reflects broader gender inequity within the medical profession, particularly in subspecialties where the majority of physicians are men. It has been shown that the presence of female role models in male-dominated career streams can increase engagement of young women,” the investigators wrote. “Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated. Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine,” they concluded.

The University of Calgary funded the study. The authors reported no conflicts of interest.

[email protected]

SOURCE: Ruzycki SM et al. JAMA Netw Open. 2019 Apr 12. doi: 10.1001/jamanetworkopen.2019.2103.

PHILADELPHIA – Preparing to enter into employment contract negotiations? Lawyer up, Michael Sinha, MD, advised in a presentation at the annual meeting of the American College of Physicians.

Gregory Twachtman/MDedge News

In a presentation that outlined the essentials of reviewing an employment contract, Dr. Sinha of Harvard Medical School, Boston, advised hiring a lawyer with expertise in health care law and health care employment contracts once the letter of intent has been received. Understanding the contract process is helpful, “but ultimately the lawyer is going to be the one helping you with regional expertise. Perhaps they have already interacted with this employer and have a long-standing relationship. They are going to know state laws that are relevant to you. They are going to have a lot of insights that you are just not going to be able to bring to the table very easily.”

A lawyer also will have expertise in negotiation. “If you can form an alliance and negotiate as a team, you are much more likely to get the things you want out of a negotiation,” he said.

Dr. Sinha advised going into a contract knowing exactly what you want. He recommended coming up with six or seven things that matter to you, such as base pay and bonus structure, fringe benefits, relocation expenses, work hours and locations, terms, employee versus independent contractor, and no compete clauses. Even if you have only three key things you’re looking for out of the negotiations, still try to come up with six or seven items.

To get the best results, you need to do your homework. Find out starting salaries and use salary scales when available. Get a sense of who the prospective employer is, what their needs are, and who is competing with you for that contract. Talk to the staff to get a sense of what the work environment is like.

“And then, really speak to people in the community. ... I think this [factor] gets overlooked,” he said. “You can get a lot of valuable information, get a sense of public perception about a physician group, a hospital, a medical school. Those are important considerations as well.”

He also stressed understanding the economic viability of the organization and the growth opportunities for the organization, and recommended reading the contract multiple times. “Understanding the contract is the key to being able to negotiate the provisions.”

Finally, he emphasized that there is no need to accept the first offer made.

“There is always room for negotiating and the bottom line is both sides have to be happy with the contract they negotiated,” he said.

[email protected]

PHILADELPHIA – Preparing to enter into employment contract negotiations? Lawyer up, Michael Sinha, MD, advised in a presentation at the annual meeting of the American College of Physicians.

Gregory Twachtman/MDedge News

In a presentation that outlined the essentials of reviewing an employment contract, Dr. Sinha of Harvard Medical School, Boston, advised hiring a lawyer with expertise in health care law and health care employment contracts once the letter of intent has been received. Understanding the contract process is helpful, “but ultimately the lawyer is going to be the one helping you with regional expertise. Perhaps they have already interacted with this employer and have a long-standing relationship. They are going to know state laws that are relevant to you. They are going to have a lot of insights that you are just not going to be able to bring to the table very easily.”

A lawyer also will have expertise in negotiation. “If you can form an alliance and negotiate as a team, you are much more likely to get the things you want out of a negotiation,” he said.

Dr. Sinha advised going into a contract knowing exactly what you want. He recommended coming up with six or seven things that matter to you, such as base pay and bonus structure, fringe benefits, relocation expenses, work hours and locations, terms, employee versus independent contractor, and no compete clauses. Even if you have only three key things you’re looking for out of the negotiations, still try to come up with six or seven items.

To get the best results, you need to do your homework. Find out starting salaries and use salary scales when available. Get a sense of who the prospective employer is, what their needs are, and who is competing with you for that contract. Talk to the staff to get a sense of what the work environment is like.

“And then, really speak to people in the community. ... I think this [factor] gets overlooked,” he said. “You can get a lot of valuable information, get a sense of public perception about a physician group, a hospital, a medical school. Those are important considerations as well.”

He also stressed understanding the economic viability of the organization and the growth opportunities for the organization, and recommended reading the contract multiple times. “Understanding the contract is the key to being able to negotiate the provisions.”

Finally, he emphasized that there is no need to accept the first offer made.

“There is always room for negotiating and the bottom line is both sides have to be happy with the contract they negotiated,” he said.

[email protected]

PHILADELPHIA – Preparing to enter into employment contract negotiations? Lawyer up, Michael Sinha, MD, advised in a presentation at the annual meeting of the American College of Physicians.

Gregory Twachtman/MDedge News

In a presentation that outlined the essentials of reviewing an employment contract, Dr. Sinha of Harvard Medical School, Boston, advised hiring a lawyer with expertise in health care law and health care employment contracts once the letter of intent has been received. Understanding the contract process is helpful, “but ultimately the lawyer is going to be the one helping you with regional expertise. Perhaps they have already interacted with this employer and have a long-standing relationship. They are going to know state laws that are relevant to you. They are going to have a lot of insights that you are just not going to be able to bring to the table very easily.”

A lawyer also will have expertise in negotiation. “If you can form an alliance and negotiate as a team, you are much more likely to get the things you want out of a negotiation,” he said.

Dr. Sinha advised going into a contract knowing exactly what you want. He recommended coming up with six or seven things that matter to you, such as base pay and bonus structure, fringe benefits, relocation expenses, work hours and locations, terms, employee versus independent contractor, and no compete clauses. Even if you have only three key things you’re looking for out of the negotiations, still try to come up with six or seven items.

To get the best results, you need to do your homework. Find out starting salaries and use salary scales when available. Get a sense of who the prospective employer is, what their needs are, and who is competing with you for that contract. Talk to the staff to get a sense of what the work environment is like.

“And then, really speak to people in the community. ... I think this [factor] gets overlooked,” he said. “You can get a lot of valuable information, get a sense of public perception about a physician group, a hospital, a medical school. Those are important considerations as well.”

He also stressed understanding the economic viability of the organization and the growth opportunities for the organization, and recommended reading the contract multiple times. “Understanding the contract is the key to being able to negotiate the provisions.”

Finally, he emphasized that there is no need to accept the first offer made.

“There is always room for negotiating and the bottom line is both sides have to be happy with the contract they negotiated,” he said.

[email protected]

Read more.

This supplement to Neurology Reviews compiles news briefs from the 2018 ECTRIMS annual meeting in Berlin and the 2019 annual ACTRIMS meeting in Dallas.

Read more.

Read more.

This supplement to Neurology Reviews compiles news briefs from the 2018 ECTRIMS annual meeting in Berlin and the 2019 annual ACTRIMS meeting in Dallas.

Read more.

Read more.

This supplement to Neurology Reviews compiles news briefs from the 2018 ECTRIMS annual meeting in Berlin and the 2019 annual ACTRIMS meeting in Dallas.

Read more.

Is America coming apart at the seams? According to the press, there are more things that divide us than bind us together. It’s red state versus blue state, it’s the privileged versus the disadvantaged, people of color versus the white majority. Could the great melting pot have cooled and its contents settled out into a dozen stratified layers?

Sean Locke/iStockphoto

Despite the image of a divided America that we see portrayed in the newspapers and on television, I continue to believe that there is more that we share in common than separate us, but it’s a struggle. The media operate on the assumption that conflict draws more readers than good news about cooperation and compromise. The situation is compounded by the apparent absence of a leader from either party who wants to unite us.

However, when one scratches the surface, there is surprising amount of agreement among Americans. For example, according to John Gramlich (“7 facts about guns in the U.S.,” Pew Research Center, Dec. 27, 2018), 89% of both Republicans and Democrats feel that people with mental illness should not be allowed to purchase a gun. And 79% of Republicans and 91% of Democrats favor background checks at gun shows and for private sales for purchase of a gun. As of 2018, 58% of Americans feel that abortion should be legal in all or most cases, and only 37% feel it should be illegal in all or most cases. (“Public Opinion on Abortion,” Pew Research Center, Oct. 15, 2018).

At the core of many of our struggles to unite is a question that has bedeviled democracies for millennia: How does one balance a citizen’s freedom of choice with the health and safety of the society in which that person lives? While resolutions on gun control and abortion seem unlikely in the foreseeable future, the current outbreaks of measles offer America a rare opportunity to unite on an issue that pits personal freedom against societal safety.

According to Virginia Villa (“5 facts about vaccines in the U.S.,” Pew Research Center, Mar. 19, 2019), 82% of adults in the United States believe that the MMR vaccine should be required for public school attendance, while only 17% believe that parents should be allowed to leave their child unvaccinated even if their decision creates a health risk for other children and adults.

Why should we expect the government to respond to protect the population from the risk posed by the unvaccinated minority when it has done very little to further gun control? Obviously a key difference is that the antivaccination minority lacks the financial resources and political muscle of a large organization such as the National Rifle Association. While we must never underestimate the power of social media, the publicity surfacing from the mainstream media as the measles outbreaks in the United States have continued has prompted several states to rethink their policies regarding vaccination requirements and school attendance. Here in Maine, there has been strong support among the legislature for eliminating exemptions for philosophic or religious exemptions.

It is probably unrealistic to expect the federal government to act on the health threat caused by the antivaccine movement. However, it is encouraging that, at least at the local level, there is hope for closing one of the wounds that divide us. As providers who care for children, we should seize this opportunity created by the measles outbreaks to promote legislation and policies that strike a sensible balance between the right of the individual and the safety of the society at large.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Is America coming apart at the seams? According to the press, there are more things that divide us than bind us together. It’s red state versus blue state, it’s the privileged versus the disadvantaged, people of color versus the white majority. Could the great melting pot have cooled and its contents settled out into a dozen stratified layers?

Sean Locke/iStockphoto

Despite the image of a divided America that we see portrayed in the newspapers and on television, I continue to believe that there is more that we share in common than separate us, but it’s a struggle. The media operate on the assumption that conflict draws more readers than good news about cooperation and compromise. The situation is compounded by the apparent absence of a leader from either party who wants to unite us.

However, when one scratches the surface, there is surprising amount of agreement among Americans. For example, according to John Gramlich (“7 facts about guns in the U.S.,” Pew Research Center, Dec. 27, 2018), 89% of both Republicans and Democrats feel that people with mental illness should not be allowed to purchase a gun. And 79% of Republicans and 91% of Democrats favor background checks at gun shows and for private sales for purchase of a gun. As of 2018, 58% of Americans feel that abortion should be legal in all or most cases, and only 37% feel it should be illegal in all or most cases. (“Public Opinion on Abortion,” Pew Research Center, Oct. 15, 2018).

At the core of many of our struggles to unite is a question that has bedeviled democracies for millennia: How does one balance a citizen’s freedom of choice with the health and safety of the society in which that person lives? While resolutions on gun control and abortion seem unlikely in the foreseeable future, the current outbreaks of measles offer America a rare opportunity to unite on an issue that pits personal freedom against societal safety.

According to Virginia Villa (“5 facts about vaccines in the U.S.,” Pew Research Center, Mar. 19, 2019), 82% of adults in the United States believe that the MMR vaccine should be required for public school attendance, while only 17% believe that parents should be allowed to leave their child unvaccinated even if their decision creates a health risk for other children and adults.

Why should we expect the government to respond to protect the population from the risk posed by the unvaccinated minority when it has done very little to further gun control? Obviously a key difference is that the antivaccination minority lacks the financial resources and political muscle of a large organization such as the National Rifle Association. While we must never underestimate the power of social media, the publicity surfacing from the mainstream media as the measles outbreaks in the United States have continued has prompted several states to rethink their policies regarding vaccination requirements and school attendance. Here in Maine, there has been strong support among the legislature for eliminating exemptions for philosophic or religious exemptions.

It is probably unrealistic to expect the federal government to act on the health threat caused by the antivaccine movement. However, it is encouraging that, at least at the local level, there is hope for closing one of the wounds that divide us. As providers who care for children, we should seize this opportunity created by the measles outbreaks to promote legislation and policies that strike a sensible balance between the right of the individual and the safety of the society at large.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Is America coming apart at the seams? According to the press, there are more things that divide us than bind us together. It’s red state versus blue state, it’s the privileged versus the disadvantaged, people of color versus the white majority. Could the great melting pot have cooled and its contents settled out into a dozen stratified layers?

Sean Locke/iStockphoto

Despite the image of a divided America that we see portrayed in the newspapers and on television, I continue to believe that there is more that we share in common than separate us, but it’s a struggle. The media operate on the assumption that conflict draws more readers than good news about cooperation and compromise. The situation is compounded by the apparent absence of a leader from either party who wants to unite us.

However, when one scratches the surface, there is surprising amount of agreement among Americans. For example, according to John Gramlich (“7 facts about guns in the U.S.,” Pew Research Center, Dec. 27, 2018), 89% of both Republicans and Democrats feel that people with mental illness should not be allowed to purchase a gun. And 79% of Republicans and 91% of Democrats favor background checks at gun shows and for private sales for purchase of a gun. As of 2018, 58% of Americans feel that abortion should be legal in all or most cases, and only 37% feel it should be illegal in all or most cases. (“Public Opinion on Abortion,” Pew Research Center, Oct. 15, 2018).

At the core of many of our struggles to unite is a question that has bedeviled democracies for millennia: How does one balance a citizen’s freedom of choice with the health and safety of the society in which that person lives? While resolutions on gun control and abortion seem unlikely in the foreseeable future, the current outbreaks of measles offer America a rare opportunity to unite on an issue that pits personal freedom against societal safety.

According to Virginia Villa (“5 facts about vaccines in the U.S.,” Pew Research Center, Mar. 19, 2019), 82% of adults in the United States believe that the MMR vaccine should be required for public school attendance, while only 17% believe that parents should be allowed to leave their child unvaccinated even if their decision creates a health risk for other children and adults.

Why should we expect the government to respond to protect the population from the risk posed by the unvaccinated minority when it has done very little to further gun control? Obviously a key difference is that the antivaccination minority lacks the financial resources and political muscle of a large organization such as the National Rifle Association. While we must never underestimate the power of social media, the publicity surfacing from the mainstream media as the measles outbreaks in the United States have continued has prompted several states to rethink their policies regarding vaccination requirements and school attendance. Here in Maine, there has been strong support among the legislature for eliminating exemptions for philosophic or religious exemptions.

It is probably unrealistic to expect the federal government to act on the health threat caused by the antivaccine movement. However, it is encouraging that, at least at the local level, there is hope for closing one of the wounds that divide us. As providers who care for children, we should seize this opportunity created by the measles outbreaks to promote legislation and policies that strike a sensible balance between the right of the individual and the safety of the society at large.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

PHILADELPHIA – The American College of Physicians has launched a program – ACP Advance – to help organizations better implement quality improvement (QI) projects .

Vidyard Video

The program includes 12 months of virtual coaching for a cost, and free online module training, according to Daisy Smith, MD, FACP, who spoke at a press conference at the annual meeting of the American College of Physicians.

Dr. Smith, the ACP’s vice president of clinical programs, discussed additional aspects of ACP Advance with Selam Wubu, director of the ACP’s Center for Quality, in a video interview.

“We launched ACP Advance to engage physicians and their teams [and] empower them to engage and implement quality improvement that results in meaningful improvement for them and their patients,” Ms. Wubu said.

Dr. Smith and Ms. Wubu have no relevant disclosures.

[email protected]

PHILADELPHIA – The American College of Physicians has launched a program – ACP Advance – to help organizations better implement quality improvement (QI) projects .

Vidyard Video

The program includes 12 months of virtual coaching for a cost, and free online module training, according to Daisy Smith, MD, FACP, who spoke at a press conference at the annual meeting of the American College of Physicians.

Dr. Smith, the ACP’s vice president of clinical programs, discussed additional aspects of ACP Advance with Selam Wubu, director of the ACP’s Center for Quality, in a video interview.

“We launched ACP Advance to engage physicians and their teams [and] empower them to engage and implement quality improvement that results in meaningful improvement for them and their patients,” Ms. Wubu said.

Dr. Smith and Ms. Wubu have no relevant disclosures.

[email protected]

PHILADELPHIA – The American College of Physicians has launched a program – ACP Advance – to help organizations better implement quality improvement (QI) projects .

Vidyard Video

The program includes 12 months of virtual coaching for a cost, and free online module training, according to Daisy Smith, MD, FACP, who spoke at a press conference at the annual meeting of the American College of Physicians.

Dr. Smith, the ACP’s vice president of clinical programs, discussed additional aspects of ACP Advance with Selam Wubu, director of the ACP’s Center for Quality, in a video interview.

“We launched ACP Advance to engage physicians and their teams [and] empower them to engage and implement quality improvement that results in meaningful improvement for them and their patients,” Ms. Wubu said.

Dr. Smith and Ms. Wubu have no relevant disclosures.

[email protected]

Are you happy with your current situation? Do you enjoy your job and look forward to getting home at the end of the day? Or, do you find your work unrewarding? Do you consider your home simply a place to wait impatiently until you can hop on a plane for your next getaway vacation?

wellesenterprises/Getty Images

Maybe you should consider relocating to Montana. According to the headline in an article by Richard Franki in Pediatric News (“Montana named ‘best state to practice medicine’ in 2019,” Mar. 28, 2019) the Treasure State is currently the best state to practice medicine. Big Sky Country earned this distinction by outdistancing 49 states and Washington, D.C., in a ranking by WalletHub. The personal finance website used 18 metrics ranging from average annual wage adjusted for cost of living to malpractice award payment per capita. One category of metrics grouped data related to “competition and opportunity” and the other “medical environment.”

I suspect that you are as skeptical as I am of surveys that claim to rank complex entities across broad geographic landscapes. I hope you are neither depressed or elated when your alma mater moves three positions on U.S. News and World Report’s ranking of colleges and universities. However, there are a few pearls hidden in this WalletHub attempt at choosing the most physician-friendly states.

New York was again ranked the worst state to practice medicine, a distinction it had “earned” in 2017 with a highest cost of malpractice insurance. This consistency suggests that there is a litigious atmosphere, at least in some parts of New York, that could make forging a trusting doctor-patient relationship difficult. Heading off to work each morning under the dark cloud of malpractice must take a lot of the fun out of practicing medicine.

The other interesting association buried in the ranking is that Montana is at the top of the list because it also was the state with the highest percentage of “medical residents retained.” This concurrence suggests that living and working in Big Sky Country provided a balance that young physicians found not just tolerable but so enjoyable they wanted to stay. I have been unable to find a complete listing of the raw data, but I suspect that Maine also could boast a high percentage of medical residents who choose to remain at the end of their training. It has been and continues to be a wonderful place to live and raise a family.

While there may be days when you feel as though the practice of medicine has consumed your every waking moment, the truth is that there is more to life than being a physician. Of course, one must be able to earn enough to support oneself and family, but this survey that purports to rank the best place to practice is too heavily weighted to the financial side of the equation and ignores the more difficult to quantify lifestyle qualities.

You may have found a position that pays well enough but requires a time-gobbling and stress-inducing commute to a place you feel comfortable living. Or, you may like your work, but find the community where you have settled lacks the suite of recreational and/or cultural opportunities you enjoy. Finding a place that offers the best mix of lifestyle and professional rewards that fits your wants and needs can be a matter of luck. Not everyone gets it right the first time. Sometimes it is a matter of making compromises and then continuing to reassess whether these compromises have been the best ones.

Regardless of its ranking on any survey, every state has multiple communities in which a physician can have a satisfying career and a lifestyle he or she enjoys. However, achieving this balanced mix may require the physician to invest something of him or herself into making that community one that feels like home.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Are you happy with your current situation? Do you enjoy your job and look forward to getting home at the end of the day? Or, do you find your work unrewarding? Do you consider your home simply a place to wait impatiently until you can hop on a plane for your next getaway vacation?

wellesenterprises/Getty Images

Maybe you should consider relocating to Montana. According to the headline in an article by Richard Franki in Pediatric News (“Montana named ‘best state to practice medicine’ in 2019,” Mar. 28, 2019) the Treasure State is currently the best state to practice medicine. Big Sky Country earned this distinction by outdistancing 49 states and Washington, D.C., in a ranking by WalletHub. The personal finance website used 18 metrics ranging from average annual wage adjusted for cost of living to malpractice award payment per capita. One category of metrics grouped data related to “competition and opportunity” and the other “medical environment.”

I suspect that you are as skeptical as I am of surveys that claim to rank complex entities across broad geographic landscapes. I hope you are neither depressed or elated when your alma mater moves three positions on U.S. News and World Report’s ranking of colleges and universities. However, there are a few pearls hidden in this WalletHub attempt at choosing the most physician-friendly states.

New York was again ranked the worst state to practice medicine, a distinction it had “earned” in 2017 with a highest cost of malpractice insurance. This consistency suggests that there is a litigious atmosphere, at least in some parts of New York, that could make forging a trusting doctor-patient relationship difficult. Heading off to work each morning under the dark cloud of malpractice must take a lot of the fun out of practicing medicine.

The other interesting association buried in the ranking is that Montana is at the top of the list because it also was the state with the highest percentage of “medical residents retained.” This concurrence suggests that living and working in Big Sky Country provided a balance that young physicians found not just tolerable but so enjoyable they wanted to stay. I have been unable to find a complete listing of the raw data, but I suspect that Maine also could boast a high percentage of medical residents who choose to remain at the end of their training. It has been and continues to be a wonderful place to live and raise a family.

While there may be days when you feel as though the practice of medicine has consumed your every waking moment, the truth is that there is more to life than being a physician. Of course, one must be able to earn enough to support oneself and family, but this survey that purports to rank the best place to practice is too heavily weighted to the financial side of the equation and ignores the more difficult to quantify lifestyle qualities.

You may have found a position that pays well enough but requires a time-gobbling and stress-inducing commute to a place you feel comfortable living. Or, you may like your work, but find the community where you have settled lacks the suite of recreational and/or cultural opportunities you enjoy. Finding a place that offers the best mix of lifestyle and professional rewards that fits your wants and needs can be a matter of luck. Not everyone gets it right the first time. Sometimes it is a matter of making compromises and then continuing to reassess whether these compromises have been the best ones.

Regardless of its ranking on any survey, every state has multiple communities in which a physician can have a satisfying career and a lifestyle he or she enjoys. However, achieving this balanced mix may require the physician to invest something of him or herself into making that community one that feels like home.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Are you happy with your current situation? Do you enjoy your job and look forward to getting home at the end of the day? Or, do you find your work unrewarding? Do you consider your home simply a place to wait impatiently until you can hop on a plane for your next getaway vacation?

wellesenterprises/Getty Images

Maybe you should consider relocating to Montana. According to the headline in an article by Richard Franki in Pediatric News (“Montana named ‘best state to practice medicine’ in 2019,” Mar. 28, 2019) the Treasure State is currently the best state to practice medicine. Big Sky Country earned this distinction by outdistancing 49 states and Washington, D.C., in a ranking by WalletHub. The personal finance website used 18 metrics ranging from average annual wage adjusted for cost of living to malpractice award payment per capita. One category of metrics grouped data related to “competition and opportunity” and the other “medical environment.”

I suspect that you are as skeptical as I am of surveys that claim to rank complex entities across broad geographic landscapes. I hope you are neither depressed or elated when your alma mater moves three positions on U.S. News and World Report’s ranking of colleges and universities. However, there are a few pearls hidden in this WalletHub attempt at choosing the most physician-friendly states.

New York was again ranked the worst state to practice medicine, a distinction it had “earned” in 2017 with a highest cost of malpractice insurance. This consistency suggests that there is a litigious atmosphere, at least in some parts of New York, that could make forging a trusting doctor-patient relationship difficult. Heading off to work each morning under the dark cloud of malpractice must take a lot of the fun out of practicing medicine.

The other interesting association buried in the ranking is that Montana is at the top of the list because it also was the state with the highest percentage of “medical residents retained.” This concurrence suggests that living and working in Big Sky Country provided a balance that young physicians found not just tolerable but so enjoyable they wanted to stay. I have been unable to find a complete listing of the raw data, but I suspect that Maine also could boast a high percentage of medical residents who choose to remain at the end of their training. It has been and continues to be a wonderful place to live and raise a family.

While there may be days when you feel as though the practice of medicine has consumed your every waking moment, the truth is that there is more to life than being a physician. Of course, one must be able to earn enough to support oneself and family, but this survey that purports to rank the best place to practice is too heavily weighted to the financial side of the equation and ignores the more difficult to quantify lifestyle qualities.

You may have found a position that pays well enough but requires a time-gobbling and stress-inducing commute to a place you feel comfortable living. Or, you may like your work, but find the community where you have settled lacks the suite of recreational and/or cultural opportunities you enjoy. Finding a place that offers the best mix of lifestyle and professional rewards that fits your wants and needs can be a matter of luck. Not everyone gets it right the first time. Sometimes it is a matter of making compromises and then continuing to reassess whether these compromises have been the best ones.

Regardless of its ranking on any survey, every state has multiple communities in which a physician can have a satisfying career and a lifestyle he or she enjoys. However, achieving this balanced mix may require the physician to invest something of him or herself into making that community one that feels like home.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

SAN FRANCISCO – The potential power of machine learning to improve therapeutic choices in inflammatory bowel disease (IBD) is at the threshold of clinical applications, according to data presented at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

Joel Austell/MDedge News

This type of work is relevant to many fields of medicine, but studies conducted in IBD have provided particularly compelling evidence that predictive analytics will improve outcomes and lead to more cost-effective delivery of care, according to Akbar K. Waljee, MD, MSc, an associate professor in the division of gastroenterology, University of Michigan, Ann Arbor, and a staff physician and researcher at the VA Ann Arbor Healthcare System.

Having now published several papers on the role of precision analytics and big data to improve treatment choices in IBD as well as other diseases, Dr. Waljee said, “We collect large amounts of clinical data every day in the delivery of health care but we are now only just beginning to leverage [these] data to guide treatment.”

Based on the experience in IBD, these analyses are relevant for selecting who to treat and not to treat with a given drug.

In one study of how this technology can be applied, data from 1,080 IBD patients taking thiopurines were used to develop a machine learning algorithm that analyzed multiple readily available variables, such as a complete blood count with differential and a chemistry panel, to predict if the patient was in remission. The area under the receiver operating characteristics curve (AuROC) was 0.79 or much higher than previous prediction using drug metabolites, according to Dr. Waljee.

The mean yearly rate of clinical events (new steroid prescriptions, hospitalizations, and abdominal surgeries) was then compared between those who did and those who did not have an algorithm-predicted remission. The lower mean rate in those predicted to be in remission (1.08 vs. 3.95 events) provided support for the conclusions that the algorithm is clinically viable.

“The heterogeneity of response to therapies for IBD is well established. If machine learning predicts effective choices, there will be an opportunity to accelerate the time to disease control as well as save costs by avoiding therapies not likely to be effective,” Dr. Waljee explained.

In another example, the focus was on predicting response to vedolizumab, a monoclonal antibody targeted at a gut-specific mediator of inflammation. In this case, machine learning was applied to predicting corticosteroid-free remission at 1 year in patients with Crohn’s disease patients evaluated 6 weeks after initiating therapy. The machine-learning algorithm was based on an analysis of numerous variables, including laboratory data, sex, and race. Based on the model drawn from the analysis of 472 patients, 35.8% of the patients predicted to be in corticosteroid-free biologic remission at 1 year achieved this endpoint, whereas only 6.7% of the patients predicted to fail achieved the endpoint.

“This suggests that we can use an algorithm relatively early in the course of this biologic to predict who is going to respond,” reported Dr. Waljee. Again, patients with a low likelihood of response at 6 weeks can be started on an alternative therapy, potentially accelerating the time to disease control and avoiding the costs of ineffective and expensive treatments.

IBD is a particularly attractive focus of precision analytics with big data. IBD has a relatively unpredictable relapsing-remitting course and a variable heterogeneous response to available therapies. Algorithms predictive of response circumvent the inherent delays from evaluating disease control over an extended period.

“With ever increasing concern about costs of care and access to care, these treatment algorithms promise to use resources more efficiently,” Dr. Waljee said.

SAN FRANCISCO – The potential power of machine learning to improve therapeutic choices in inflammatory bowel disease (IBD) is at the threshold of clinical applications, according to data presented at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

Joel Austell/MDedge News

This type of work is relevant to many fields of medicine, but studies conducted in IBD have provided particularly compelling evidence that predictive analytics will improve outcomes and lead to more cost-effective delivery of care, according to Akbar K. Waljee, MD, MSc, an associate professor in the division of gastroenterology, University of Michigan, Ann Arbor, and a staff physician and researcher at the VA Ann Arbor Healthcare System.

Having now published several papers on the role of precision analytics and big data to improve treatment choices in IBD as well as other diseases, Dr. Waljee said, “We collect large amounts of clinical data every day in the delivery of health care but we are now only just beginning to leverage [these] data to guide treatment.”

Based on the experience in IBD, these analyses are relevant for selecting who to treat and not to treat with a given drug.

In one study of how this technology can be applied, data from 1,080 IBD patients taking thiopurines were used to develop a machine learning algorithm that analyzed multiple readily available variables, such as a complete blood count with differential and a chemistry panel, to predict if the patient was in remission. The area under the receiver operating characteristics curve (AuROC) was 0.79 or much higher than previous prediction using drug metabolites, according to Dr. Waljee.

The mean yearly rate of clinical events (new steroid prescriptions, hospitalizations, and abdominal surgeries) was then compared between those who did and those who did not have an algorithm-predicted remission. The lower mean rate in those predicted to be in remission (1.08 vs. 3.95 events) provided support for the conclusions that the algorithm is clinically viable.

“The heterogeneity of response to therapies for IBD is well established. If machine learning predicts effective choices, there will be an opportunity to accelerate the time to disease control as well as save costs by avoiding therapies not likely to be effective,” Dr. Waljee explained.

In another example, the focus was on predicting response to vedolizumab, a monoclonal antibody targeted at a gut-specific mediator of inflammation. In this case, machine learning was applied to predicting corticosteroid-free remission at 1 year in patients with Crohn’s disease patients evaluated 6 weeks after initiating therapy. The machine-learning algorithm was based on an analysis of numerous variables, including laboratory data, sex, and race. Based on the model drawn from the analysis of 472 patients, 35.8% of the patients predicted to be in corticosteroid-free biologic remission at 1 year achieved this endpoint, whereas only 6.7% of the patients predicted to fail achieved the endpoint.

“This suggests that we can use an algorithm relatively early in the course of this biologic to predict who is going to respond,” reported Dr. Waljee. Again, patients with a low likelihood of response at 6 weeks can be started on an alternative therapy, potentially accelerating the time to disease control and avoiding the costs of ineffective and expensive treatments.

IBD is a particularly attractive focus of precision analytics with big data. IBD has a relatively unpredictable relapsing-remitting course and a variable heterogeneous response to available therapies. Algorithms predictive of response circumvent the inherent delays from evaluating disease control over an extended period.

“With ever increasing concern about costs of care and access to care, these treatment algorithms promise to use resources more efficiently,” Dr. Waljee said.

SAN FRANCISCO – The potential power of machine learning to improve therapeutic choices in inflammatory bowel disease (IBD) is at the threshold of clinical applications, according to data presented at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

Joel Austell/MDedge News

This type of work is relevant to many fields of medicine, but studies conducted in IBD have provided particularly compelling evidence that predictive analytics will improve outcomes and lead to more cost-effective delivery of care, according to Akbar K. Waljee, MD, MSc, an associate professor in the division of gastroenterology, University of Michigan, Ann Arbor, and a staff physician and researcher at the VA Ann Arbor Healthcare System.

Having now published several papers on the role of precision analytics and big data to improve treatment choices in IBD as well as other diseases, Dr. Waljee said, “We collect large amounts of clinical data every day in the delivery of health care but we are now only just beginning to leverage [these] data to guide treatment.”

Based on the experience in IBD, these analyses are relevant for selecting who to treat and not to treat with a given drug.

In one study of how this technology can be applied, data from 1,080 IBD patients taking thiopurines were used to develop a machine learning algorithm that analyzed multiple readily available variables, such as a complete blood count with differential and a chemistry panel, to predict if the patient was in remission. The area under the receiver operating characteristics curve (AuROC) was 0.79 or much higher than previous prediction using drug metabolites, according to Dr. Waljee.

The mean yearly rate of clinical events (new steroid prescriptions, hospitalizations, and abdominal surgeries) was then compared between those who did and those who did not have an algorithm-predicted remission. The lower mean rate in those predicted to be in remission (1.08 vs. 3.95 events) provided support for the conclusions that the algorithm is clinically viable.

“The heterogeneity of response to therapies for IBD is well established. If machine learning predicts effective choices, there will be an opportunity to accelerate the time to disease control as well as save costs by avoiding therapies not likely to be effective,” Dr. Waljee explained.

In another example, the focus was on predicting response to vedolizumab, a monoclonal antibody targeted at a gut-specific mediator of inflammation. In this case, machine learning was applied to predicting corticosteroid-free remission at 1 year in patients with Crohn’s disease patients evaluated 6 weeks after initiating therapy. The machine-learning algorithm was based on an analysis of numerous variables, including laboratory data, sex, and race. Based on the model drawn from the analysis of 472 patients, 35.8% of the patients predicted to be in corticosteroid-free biologic remission at 1 year achieved this endpoint, whereas only 6.7% of the patients predicted to fail achieved the endpoint.

“This suggests that we can use an algorithm relatively early in the course of this biologic to predict who is going to respond,” reported Dr. Waljee. Again, patients with a low likelihood of response at 6 weeks can be started on an alternative therapy, potentially accelerating the time to disease control and avoiding the costs of ineffective and expensive treatments.

IBD is a particularly attractive focus of precision analytics with big data. IBD has a relatively unpredictable relapsing-remitting course and a variable heterogeneous response to available therapies. Algorithms predictive of response circumvent the inherent delays from evaluating disease control over an extended period.

“With ever increasing concern about costs of care and access to care, these treatment algorithms promise to use resources more efficiently,” Dr. Waljee said.

ORLANDO – Cognitive-behavioral therapy (CBT) should be more widely offered to patients with psychosis, and a growing body of evidence is demonstrating why, an expert said at the annual congress of the Schizophrenia International Research Society.

Tony Morrison, ClinPsyD, said that, while antipsychotic medications are appropriate for many patients with disorders such as schizophrenia, they are not offered cognitive therapy nearly often enough.

“What I am against is the sole reliance on antipsychotics,” said Dr. Morrison, professor of clinical psychology at the University of Manchester (England). “Putting all of our eggs in that basket is not particularly sensible.” That’s because so many patients who are started on antipsychotic medications discontinue them, either because they are ineffective or because they conclude that the risk of side effects – weight gain, cardiovascular problems, and sexual dysfunction among them – are not worth it.

In a trial published last year, 75 patients with psychosis who were not taking antipsychotic medication were randomized to receive up to 26 sessions of CBT over 6 months, antipsychotic medication, or both. After a year, no difference was found in Positive and Negative Symptom Scale (PANSS) scores between the three groups, researchers found, although the combination group saw an improvement in PANSS scores at 24 weeks before later falling in line with the other groups (Lancet Psychiatry. 2018 May;5[5]:411-23).

Patients in the medical treatment arm mostly received aripiprazole, olanzapine, or quetiapine. Patients received an average of 14 sessions of CBT, with 80% attending at least 6 sessions. Researchers did not see any significant level adverse events in the CBT group.

The findings show that this is fertile ground to explore further, Dr. Morrison said. “It is safe to conduct trials in which people with psychosis are not taking antipsychotics,” he said. “It is clear that people significantly improve across all measures of symptoms and recovery [and] function regardless of intervention.”

A larger, more definitive trial is needed in this area.

Treatment of patients for whom antipsychotic medication has already been shown not to work is a bigger challenge, but a recent study Dr. Morrison led shows that CBT could work in these patients as well (Health Technol Assess. 2019 Feb;23[7]:1-144).

In that study, 487 patients with schizophrenia who were resistant to treatment with clozapine were randomized to CBT – up to 30 sessions over 9 months – or treatment as usual, without CBT. Researchers saw a slight benefit in PANSS scores for CBT at 9 months (P = .049). But this benefit was not maintained after patients stopped their cognitive therapy, and no difference in PANSS scores was seen at 21 months, the study’s primary endpoint.

Nonetheless, the findings were encouraging, Dr. Morrison said, showing that CBT “compares favorably with augmenting treatment with a second antipsychotic.” Researchers, however, were not able to determine which patients were likely to benefit most from CBT, despite “lots of subanalyses” in an effort to do so.

Patients resistant to initial medical therapy will need their illness tackled from a variety of fronts – subsequent antipsychotic therapy, psychological therapy, social-activity based therapy, and peer support.

“I think we probably need lots of things in combination – a much more rich package of care,” Dr. Morrison said.

Dr. Morrison reported no disclosures.

ORLANDO – Cognitive-behavioral therapy (CBT) should be more widely offered to patients with psychosis, and a growing body of evidence is demonstrating why, an expert said at the annual congress of the Schizophrenia International Research Society.

Tony Morrison, ClinPsyD, said that, while antipsychotic medications are appropriate for many patients with disorders such as schizophrenia, they are not offered cognitive therapy nearly often enough.

“What I am against is the sole reliance on antipsychotics,” said Dr. Morrison, professor of clinical psychology at the University of Manchester (England). “Putting all of our eggs in that basket is not particularly sensible.” That’s because so many patients who are started on antipsychotic medications discontinue them, either because they are ineffective or because they conclude that the risk of side effects – weight gain, cardiovascular problems, and sexual dysfunction among them – are not worth it.

In a trial published last year, 75 patients with psychosis who were not taking antipsychotic medication were randomized to receive up to 26 sessions of CBT over 6 months, antipsychotic medication, or both. After a year, no difference was found in Positive and Negative Symptom Scale (PANSS) scores between the three groups, researchers found, although the combination group saw an improvement in PANSS scores at 24 weeks before later falling in line with the other groups (Lancet Psychiatry. 2018 May;5[5]:411-23).

Patients in the medical treatment arm mostly received aripiprazole, olanzapine, or quetiapine. Patients received an average of 14 sessions of CBT, with 80% attending at least 6 sessions. Researchers did not see any significant level adverse events in the CBT group.

The findings show that this is fertile ground to explore further, Dr. Morrison said. “It is safe to conduct trials in which people with psychosis are not taking antipsychotics,” he said. “It is clear that people significantly improve across all measures of symptoms and recovery [and] function regardless of intervention.”

A larger, more definitive trial is needed in this area.

Treatment of patients for whom antipsychotic medication has already been shown not to work is a bigger challenge, but a recent study Dr. Morrison led shows that CBT could work in these patients as well (Health Technol Assess. 2019 Feb;23[7]:1-144).

In that study, 487 patients with schizophrenia who were resistant to treatment with clozapine were randomized to CBT – up to 30 sessions over 9 months – or treatment as usual, without CBT. Researchers saw a slight benefit in PANSS scores for CBT at 9 months (P = .049). But this benefit was not maintained after patients stopped their cognitive therapy, and no difference in PANSS scores was seen at 21 months, the study’s primary endpoint.

Nonetheless, the findings were encouraging, Dr. Morrison said, showing that CBT “compares favorably with augmenting treatment with a second antipsychotic.” Researchers, however, were not able to determine which patients were likely to benefit most from CBT, despite “lots of subanalyses” in an effort to do so.

Patients resistant to initial medical therapy will need their illness tackled from a variety of fronts – subsequent antipsychotic therapy, psychological therapy, social-activity based therapy, and peer support.

“I think we probably need lots of things in combination – a much more rich package of care,” Dr. Morrison said.

Dr. Morrison reported no disclosures.

ORLANDO – Cognitive-behavioral therapy (CBT) should be more widely offered to patients with psychosis, and a growing body of evidence is demonstrating why, an expert said at the annual congress of the Schizophrenia International Research Society.

Tony Morrison, ClinPsyD, said that, while antipsychotic medications are appropriate for many patients with disorders such as schizophrenia, they are not offered cognitive therapy nearly often enough.

“What I am against is the sole reliance on antipsychotics,” said Dr. Morrison, professor of clinical psychology at the University of Manchester (England). “Putting all of our eggs in that basket is not particularly sensible.” That’s because so many patients who are started on antipsychotic medications discontinue them, either because they are ineffective or because they conclude that the risk of side effects – weight gain, cardiovascular problems, and sexual dysfunction among them – are not worth it.

In a trial published last year, 75 patients with psychosis who were not taking antipsychotic medication were randomized to receive up to 26 sessions of CBT over 6 months, antipsychotic medication, or both. After a year, no difference was found in Positive and Negative Symptom Scale (PANSS) scores between the three groups, researchers found, although the combination group saw an improvement in PANSS scores at 24 weeks before later falling in line with the other groups (Lancet Psychiatry. 2018 May;5[5]:411-23).

Patients in the medical treatment arm mostly received aripiprazole, olanzapine, or quetiapine. Patients received an average of 14 sessions of CBT, with 80% attending at least 6 sessions. Researchers did not see any significant level adverse events in the CBT group.

The findings show that this is fertile ground to explore further, Dr. Morrison said. “It is safe to conduct trials in which people with psychosis are not taking antipsychotics,” he said. “It is clear that people significantly improve across all measures of symptoms and recovery [and] function regardless of intervention.”

A larger, more definitive trial is needed in this area.

Treatment of patients for whom antipsychotic medication has already been shown not to work is a bigger challenge, but a recent study Dr. Morrison led shows that CBT could work in these patients as well (Health Technol Assess. 2019 Feb;23[7]:1-144).

In that study, 487 patients with schizophrenia who were resistant to treatment with clozapine were randomized to CBT – up to 30 sessions over 9 months – or treatment as usual, without CBT. Researchers saw a slight benefit in PANSS scores for CBT at 9 months (P = .049). But this benefit was not maintained after patients stopped their cognitive therapy, and no difference in PANSS scores was seen at 21 months, the study’s primary endpoint.

Nonetheless, the findings were encouraging, Dr. Morrison said, showing that CBT “compares favorably with augmenting treatment with a second antipsychotic.” Researchers, however, were not able to determine which patients were likely to benefit most from CBT, despite “lots of subanalyses” in an effort to do so.

Patients resistant to initial medical therapy will need their illness tackled from a variety of fronts – subsequent antipsychotic therapy, psychological therapy, social-activity based therapy, and peer support.

“I think we probably need lots of things in combination – a much more rich package of care,” Dr. Morrison said.

Dr. Morrison reported no disclosures.

SAN FRANCISCO – The growing sophistication of simulation technology has the potential to improve training and assessment of skills in gastrointestinal endoscopy, but there are gaps between the promise and evidence, according to an overview of this form of training at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

For endoscopy, the term simulator encompasses a broad expanse of tools that can range from a simple physical model with holes used to practice endoscope navigation skills to a complex virtual world that challenges technical skills as well as decision-making processes. In 2012, the American Society of Gastrointestinal Endoscopy (ASGE) issued a statement encouraging endoscopy simulation-based training in the context of other strategies to gain skills, but Catharine Walsh, MD, MEd, PhD, of the University of Toronto, warned of the current limits as well as the advantages of simulation training.

“There are many companies making simulators of varying price and complexity. For early skill acquisition, more expensive devices may not necessarily be better,” Dr. Walsh said. She highlighted that “one’s choice of simulator should be based on the educational goals as opposed to technology, as the effectiveness of simulation depends highly on a close match between the training goals and the simulation tool.” A longstanding issue in the field of simulation relates to cost and access. Simulation will not have widespread impact unless it is accessible. “There is a need for future development of inexpensive, portable simulators targeting specific skills to help facilitate uptake of simulation across endoscopy units and training programs,” said Dr. Walsh. Other strategies to increase uptake include specific learning modules designed to complement simulators.

Although simulators are increasingly being used during training to help endoscopists develop basic endoscopic skills, Dr. Walsh focused on the gap in development of simulator devices targeting practicing endoscopists and research examining their use for training new skills within practice, preventing skills decay, and remediating performance deficits. She explained that “currently, there is a lack of evidence that simulation adoption by practicing endoscopists leads to better patient outcomes. This remains a priority area for simulation education, research, and development.” It also remains to be seen how cost-effective simulators are compared with other reaching modalities, she said. 

“The potential is certainly there, but it is essential to develop simulators targeting training for low-volume, higher stakes therapeutic techniques, emerging procedures, and techniques and advanced endoscopic procedures, and perform well-controlled studies to demonstrate their effectiveness in practice,” Dr. Walsh said. “Embedding assessments within emerging simulation technology is key as it permits identification of skills requiring further practice and can form the basis of virtual coaching employing endoscopic simulation to improve skills and outcomes.”

Simulators offer the very important advantage of giving the physician the chance to acquire skills before participating in a clinical case and allowing errors to occur in a risk-free environment, suggesting that this type of training will only grow. For example, Dr. Walsh described emerging simulation-based team training that allows endoscopy teams to practice both technical skills as well as nontechnical skills, such as communication and decision making, which may be particularly important in the event of a crisis. Gamification is also being pursued as a potential adjunct strategy to help improve engagement and skill acquisition.

Current simulators are limited in their ability to train and assess cognitive and nontechnical skills. Development of simulation-based cognitive training tools for key areas such as lesion recognition, classification, and management decision-making skills is also a promising area to pursue. Such education could be delivered via portable electronic devices and incorporate assessment and feedback to facilitate skills acquisition.

“There remains a substantial gap between the promise of many types of simulation training and objective evidence that these are helping endoscopists gain skills,” Dr. Walsh said. This in no way diminishes the enormous promise of new simulation technology to be an effective and safe approach for clinicians to learn and maintain performance of endoscopic skills, but Dr. Walsh focused on the need for the development of new simulation technologies and controlled studies that will render these approaches evidence based.

SAN FRANCISCO – The growing sophistication of simulation technology has the potential to improve training and assessment of skills in gastrointestinal endoscopy, but there are gaps between the promise and evidence, according to an overview of this form of training at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

For endoscopy, the term simulator encompasses a broad expanse of tools that can range from a simple physical model with holes used to practice endoscope navigation skills to a complex virtual world that challenges technical skills as well as decision-making processes. In 2012, the American Society of Gastrointestinal Endoscopy (ASGE) issued a statement encouraging endoscopy simulation-based training in the context of other strategies to gain skills, but Catharine Walsh, MD, MEd, PhD, of the University of Toronto, warned of the current limits as well as the advantages of simulation training.

“There are many companies making simulators of varying price and complexity. For early skill acquisition, more expensive devices may not necessarily be better,” Dr. Walsh said. She highlighted that “one’s choice of simulator should be based on the educational goals as opposed to technology, as the effectiveness of simulation depends highly on a close match between the training goals and the simulation tool.” A longstanding issue in the field of simulation relates to cost and access. Simulation will not have widespread impact unless it is accessible. “There is a need for future development of inexpensive, portable simulators targeting specific skills to help facilitate uptake of simulation across endoscopy units and training programs,” said Dr. Walsh. Other strategies to increase uptake include specific learning modules designed to complement simulators.

Although simulators are increasingly being used during training to help endoscopists develop basic endoscopic skills, Dr. Walsh focused on the gap in development of simulator devices targeting practicing endoscopists and research examining their use for training new skills within practice, preventing skills decay, and remediating performance deficits. She explained that “currently, there is a lack of evidence that simulation adoption by practicing endoscopists leads to better patient outcomes. This remains a priority area for simulation education, research, and development.” It also remains to be seen how cost-effective simulators are compared with other reaching modalities, she said. 

“The potential is certainly there, but it is essential to develop simulators targeting training for low-volume, higher stakes therapeutic techniques, emerging procedures, and techniques and advanced endoscopic procedures, and perform well-controlled studies to demonstrate their effectiveness in practice,” Dr. Walsh said. “Embedding assessments within emerging simulation technology is key as it permits identification of skills requiring further practice and can form the basis of virtual coaching employing endoscopic simulation to improve skills and outcomes.”

Simulators offer the very important advantage of giving the physician the chance to acquire skills before participating in a clinical case and allowing errors to occur in a risk-free environment, suggesting that this type of training will only grow. For example, Dr. Walsh described emerging simulation-based team training that allows endoscopy teams to practice both technical skills as well as nontechnical skills, such as communication and decision making, which may be particularly important in the event of a crisis. Gamification is also being pursued as a potential adjunct strategy to help improve engagement and skill acquisition.

Current simulators are limited in their ability to train and assess cognitive and nontechnical skills. Development of simulation-based cognitive training tools for key areas such as lesion recognition, classification, and management decision-making skills is also a promising area to pursue. Such education could be delivered via portable electronic devices and incorporate assessment and feedback to facilitate skills acquisition.

“There remains a substantial gap between the promise of many types of simulation training and objective evidence that these are helping endoscopists gain skills,” Dr. Walsh said. This in no way diminishes the enormous promise of new simulation technology to be an effective and safe approach for clinicians to learn and maintain performance of endoscopic skills, but Dr. Walsh focused on the need for the development of new simulation technologies and controlled studies that will render these approaches evidence based.

SAN FRANCISCO – The growing sophistication of simulation technology has the potential to improve training and assessment of skills in gastrointestinal endoscopy, but there are gaps between the promise and evidence, according to an overview of this form of training at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

For endoscopy, the term simulator encompasses a broad expanse of tools that can range from a simple physical model with holes used to practice endoscope navigation skills to a complex virtual world that challenges technical skills as well as decision-making processes. In 2012, the American Society of Gastrointestinal Endoscopy (ASGE) issued a statement encouraging endoscopy simulation-based training in the context of other strategies to gain skills, but Catharine Walsh, MD, MEd, PhD, of the University of Toronto, warned of the current limits as well as the advantages of simulation training.

“There are many companies making simulators of varying price and complexity. For early skill acquisition, more expensive devices may not necessarily be better,” Dr. Walsh said. She highlighted that “one’s choice of simulator should be based on the educational goals as opposed to technology, as the effectiveness of simulation depends highly on a close match between the training goals and the simulation tool.” A longstanding issue in the field of simulation relates to cost and access. Simulation will not have widespread impact unless it is accessible. “There is a need for future development of inexpensive, portable simulators targeting specific skills to help facilitate uptake of simulation across endoscopy units and training programs,” said Dr. Walsh. Other strategies to increase uptake include specific learning modules designed to complement simulators.

Although simulators are increasingly being used during training to help endoscopists develop basic endoscopic skills, Dr. Walsh focused on the gap in development of simulator devices targeting practicing endoscopists and research examining their use for training new skills within practice, preventing skills decay, and remediating performance deficits. She explained that “currently, there is a lack of evidence that simulation adoption by practicing endoscopists leads to better patient outcomes. This remains a priority area for simulation education, research, and development.” It also remains to be seen how cost-effective simulators are compared with other reaching modalities, she said. 

“The potential is certainly there, but it is essential to develop simulators targeting training for low-volume, higher stakes therapeutic techniques, emerging procedures, and techniques and advanced endoscopic procedures, and perform well-controlled studies to demonstrate their effectiveness in practice,” Dr. Walsh said. “Embedding assessments within emerging simulation technology is key as it permits identification of skills requiring further practice and can form the basis of virtual coaching employing endoscopic simulation to improve skills and outcomes.”

Simulators offer the very important advantage of giving the physician the chance to acquire skills before participating in a clinical case and allowing errors to occur in a risk-free environment, suggesting that this type of training will only grow. For example, Dr. Walsh described emerging simulation-based team training that allows endoscopy teams to practice both technical skills as well as nontechnical skills, such as communication and decision making, which may be particularly important in the event of a crisis. Gamification is also being pursued as a potential adjunct strategy to help improve engagement and skill acquisition.

Current simulators are limited in their ability to train and assess cognitive and nontechnical skills. Development of simulation-based cognitive training tools for key areas such as lesion recognition, classification, and management decision-making skills is also a promising area to pursue. Such education could be delivered via portable electronic devices and incorporate assessment and feedback to facilitate skills acquisition.

“There remains a substantial gap between the promise of many types of simulation training and objective evidence that these are helping endoscopists gain skills,” Dr. Walsh said. This in no way diminishes the enormous promise of new simulation technology to be an effective and safe approach for clinicians to learn and maintain performance of endoscopic skills, but Dr. Walsh focused on the need for the development of new simulation technologies and controlled studies that will render these approaches evidence based.