Ronald. V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), the Jane and Donald D. Trunkey Endowed Chair in Trauma Surgery; vice-chairman, department of surgery; and professor of surgery, University of Washington School of Medicine, Seattle, was installed as the 99th President of the American College of Surgeons (ACS) at Convocation, October 21, at Clinical Congress 2018 in Boston, MA.

Dr. Maier is highly esteemed for his contributions to trauma surgery, surgical research, and surgical education. In addition to his positions at the University of Washington, he is director, Northwest Regional Trauma Center; and surgeon-in-chief and co-director, surgical intensive care unit (SICU), Harborview Medical Center, Seattle. He also is associate medical staff, University of Washington Medical Center and Seattle Cancer Care Alliance. A Fellow of the College since 1984, Dr. Maier served as First Vice-President of the ACS (2015−2016) and has played an active role on several key committees, most notably the Committee on Trauma (COT).

Ronald. V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), the Jane and Donald D. Trunkey Endowed Chair in Trauma Surgery; vice-chairman, department of surgery; and professor of surgery, University of Washington School of Medicine, Seattle, was installed as the 99th President of the American College of Surgeons (ACS) at Convocation, October 21, at Clinical Congress 2018 in Boston, MA.

Dr. Maier is highly esteemed for his contributions to trauma surgery, surgical research, and surgical education. In addition to his positions at the University of Washington, he is director, Northwest Regional Trauma Center; and surgeon-in-chief and co-director, surgical intensive care unit (SICU), Harborview Medical Center, Seattle. He also is associate medical staff, University of Washington Medical Center and Seattle Cancer Care Alliance. A Fellow of the College since 1984, Dr. Maier served as First Vice-President of the ACS (2015−2016) and has played an active role on several key committees, most notably the Committee on Trauma (COT).

Ronald. V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), the Jane and Donald D. Trunkey Endowed Chair in Trauma Surgery; vice-chairman, department of surgery; and professor of surgery, University of Washington School of Medicine, Seattle, was installed as the 99th President of the American College of Surgeons (ACS) at Convocation, October 21, at Clinical Congress 2018 in Boston, MA.

Dr. Maier is highly esteemed for his contributions to trauma surgery, surgical research, and surgical education. In addition to his positions at the University of Washington, he is director, Northwest Regional Trauma Center; and surgeon-in-chief and co-director, surgical intensive care unit (SICU), Harborview Medical Center, Seattle. He also is associate medical staff, University of Washington Medical Center and Seattle Cancer Care Alliance. A Fellow of the College since 1984, Dr. Maier served as First Vice-President of the ACS (2015−2016) and has played an active role on several key committees, most notably the Committee on Trauma (COT).

In 2016, a staggering 216 million people developed malaria, and 445,000 died—primarily children in sub-Saharan Africa. But a new first-in-human study sponsored by the National Institute of Allergy and Infectious Disease may help reduce the numbers of future victims.

Enrollment has begun in a phase I trial to test the safety of DM1157, an investigational modified form of chloroquine. Many strains of Plasmodium falciparum are now resistant to chloroquine. In fact, the parasites can expel the drug before it can affect them. Like chloroquine, DM1157 interferes with the parasite’s metabolism, but it also inhibits the parasite’s ability to expel the drug.

The study will enroll up to 104 healthy volunteers aged 18-45 years. One group will fast overnight and then receive either a single dose of the experimental drug at 1 of 7 dosage levels or a placebo. A second group also will fast and receive 1 dose at 1 of 4 dosage levels and repeat the routine for 2 more consecutive days. A third group will be given either a single 300-mg dose or placebo after eating a high-fat meal.

The study is expected to be completed by June 2019.

In 2016, a staggering 216 million people developed malaria, and 445,000 died—primarily children in sub-Saharan Africa. But a new first-in-human study sponsored by the National Institute of Allergy and Infectious Disease may help reduce the numbers of future victims.

Enrollment has begun in a phase I trial to test the safety of DM1157, an investigational modified form of chloroquine. Many strains of Plasmodium falciparum are now resistant to chloroquine. In fact, the parasites can expel the drug before it can affect them. Like chloroquine, DM1157 interferes with the parasite’s metabolism, but it also inhibits the parasite’s ability to expel the drug.

The study will enroll up to 104 healthy volunteers aged 18-45 years. One group will fast overnight and then receive either a single dose of the experimental drug at 1 of 7 dosage levels or a placebo. A second group also will fast and receive 1 dose at 1 of 4 dosage levels and repeat the routine for 2 more consecutive days. A third group will be given either a single 300-mg dose or placebo after eating a high-fat meal.

The study is expected to be completed by June 2019.

In 2016, a staggering 216 million people developed malaria, and 445,000 died—primarily children in sub-Saharan Africa. But a new first-in-human study sponsored by the National Institute of Allergy and Infectious Disease may help reduce the numbers of future victims.

Enrollment has begun in a phase I trial to test the safety of DM1157, an investigational modified form of chloroquine. Many strains of Plasmodium falciparum are now resistant to chloroquine. In fact, the parasites can expel the drug before it can affect them. Like chloroquine, DM1157 interferes with the parasite’s metabolism, but it also inhibits the parasite’s ability to expel the drug.

The study will enroll up to 104 healthy volunteers aged 18-45 years. One group will fast overnight and then receive either a single dose of the experimental drug at 1 of 7 dosage levels or a placebo. A second group also will fast and receive 1 dose at 1 of 4 dosage levels and repeat the routine for 2 more consecutive days. A third group will be given either a single 300-mg dose or placebo after eating a high-fat meal.

The study is expected to be completed by June 2019.

Scientists have been warning about climate change for years, but psychiatrists may soon need to follow suit. In this edition of the Psychcast, Lorenzo Norris, MD, welcomes Robin Cooper, MD, to discuss the impacts of global climate change on both patients and communities.

Dr. Cooper “has been in private practice with a focus on both psychotherapy and medical management throughout her 35 years of practice.”

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Scientists have been warning about climate change for years, but psychiatrists may soon need to follow suit. In this edition of the Psychcast, Lorenzo Norris, MD, welcomes Robin Cooper, MD, to discuss the impacts of global climate change on both patients and communities.

Dr. Cooper “has been in private practice with a focus on both psychotherapy and medical management throughout her 35 years of practice.”

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify


 

Scientists have been warning about climate change for years, but psychiatrists may soon need to follow suit. In this edition of the Psychcast, Lorenzo Norris, MD, welcomes Robin Cooper, MD, to discuss the impacts of global climate change on both patients and communities.

Dr. Cooper “has been in private practice with a focus on both psychotherapy and medical management throughout her 35 years of practice.”

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify


 

The daily use of vitamin D3 and omega-3 fatty acid capsules did not result in a lower incidence of invasive cancers or cardiovascular events. Also today, atopic dermatitis can harm both mental health and quality of life, apixaban is the safest effective DOAC for stroke prevention in atrial fibrillation, and a program that is aimed to increase awareness by reduced fetal movement is not effective at preventing stillbirths.
Amazon Alexa
Apple Podcasts
Spotify

The daily use of vitamin D3 and omega-3 fatty acid capsules did not result in a lower incidence of invasive cancers or cardiovascular events. Also today, atopic dermatitis can harm both mental health and quality of life, apixaban is the safest effective DOAC for stroke prevention in atrial fibrillation, and a program that is aimed to increase awareness by reduced fetal movement is not effective at preventing stillbirths.
Amazon Alexa
Apple Podcasts
Spotify

The daily use of vitamin D3 and omega-3 fatty acid capsules did not result in a lower incidence of invasive cancers or cardiovascular events. Also today, atopic dermatitis can harm both mental health and quality of life, apixaban is the safest effective DOAC for stroke prevention in atrial fibrillation, and a program that is aimed to increase awareness by reduced fetal movement is not effective at preventing stillbirths.
Amazon Alexa
Apple Podcasts
Spotify

Photo by Caitlin Kleiboer

New research has revealed markers associated with efficacy of the RTS,S/AS01E malaria vaccine (Mosquirix™).

The study suggests malaria protection depends on the amount and subclass of antibodies generated upon vaccination and on previous exposure levels to the malaria parasite.

Researchers believe these findings, published in BMC Medicine, could aid the development of more effective vaccines and guide efforts to improve the effectiveness of RTS,S.

The RTS,S vaccine demonstrated partial effectiveness in a phase 3 study—31% in infants ages 6 weeks to 12 weeks and 56% in children ages 5 months to 17 months.

Carlota Dobaño Lázaro, PhD, of ISGlobal in Barcelona, Spain, and her colleagues have been working to understand the reasons for this variability and identify vaccine protection correlates.

The team used a quantitative assay to investigate the levels and types of antibodies induced by RTS,S. In particular, they measured total IgM, IgG, and IgG1–4 subclass antibodies to hepatitis B surface antigen (HBsAg) and three constructs of the Plasmodium falciparum circumsporozoite protein (CSP).

The researchers analyzed serum and plasma from 195 infants and children from Kintampo, Ghana (an area with high malaria transmission) and Manhiça, Mozambique (low malaria transmission), who were vaccinated during the phase 3 trial for RTS,S.

The results confirmed that RTS,S induces significant levels of IgG antibodies against both CSP and HBsAg, which are higher in children than in infants.

The researchers found that higher HBsAg antibody levels post-vaccination were associated with protection from malaria.

However, the same could not be said for all subclasses of CSP antibodies. Higher levels of IgG1 and IgG3 antibodies were associated with protection, while higher levels of IgG2 and IgG4 were associated with a greater risk of developing malaria.

“The balance between the different subclasses seems to be more important than the total IgG levels,” said study author Itzi Ubillos Escriche, of ISGlobal.

“This could be because IgG1 and IgG3 antibodies have the capacity to stick to the parasite and give an ‘eat-me’ signal to cells of the immune system.”

The results also showed that subjects with higher pre-vaccine levels of anti-P falciparum and anti-CSP antibodies were less protected against malaria post-vaccination.

“This means that the vaccine will exert a larger benefit to infants who have not been exposed to the parasite in utero or during the first weeks of life,” Dr. Dobaño Lázaro said.

“This study . . . identifies new correlates of vaccine success and failure in African children and provides a basis for designing more efficacious vaccines.”

This research was funded by the National Institutes of Health-National Institute of Allergy and Infectious Diseases, PATH Malaria Vaccine Initiative, Ministerio de Economía y Competitividad, and EVIMalaR and AGAUR-Catalonia. ISGlobal is a member of the CERCA Program, Generalitat de Catalunya.

The authors said they have no competing interests.

The phase 3 trial of RTS,S was supported by GlaxoSmithKline Biologicals SA and the PATH Malaria Vaccine Initiative.

Photo by Caitlin Kleiboer

New research has revealed markers associated with efficacy of the RTS,S/AS01E malaria vaccine (Mosquirix™).

The study suggests malaria protection depends on the amount and subclass of antibodies generated upon vaccination and on previous exposure levels to the malaria parasite.

Researchers believe these findings, published in BMC Medicine, could aid the development of more effective vaccines and guide efforts to improve the effectiveness of RTS,S.

The RTS,S vaccine demonstrated partial effectiveness in a phase 3 study—31% in infants ages 6 weeks to 12 weeks and 56% in children ages 5 months to 17 months.

Carlota Dobaño Lázaro, PhD, of ISGlobal in Barcelona, Spain, and her colleagues have been working to understand the reasons for this variability and identify vaccine protection correlates.

The team used a quantitative assay to investigate the levels and types of antibodies induced by RTS,S. In particular, they measured total IgM, IgG, and IgG1–4 subclass antibodies to hepatitis B surface antigen (HBsAg) and three constructs of the Plasmodium falciparum circumsporozoite protein (CSP).

The researchers analyzed serum and plasma from 195 infants and children from Kintampo, Ghana (an area with high malaria transmission) and Manhiça, Mozambique (low malaria transmission), who were vaccinated during the phase 3 trial for RTS,S.

The results confirmed that RTS,S induces significant levels of IgG antibodies against both CSP and HBsAg, which are higher in children than in infants.

The researchers found that higher HBsAg antibody levels post-vaccination were associated with protection from malaria.

However, the same could not be said for all subclasses of CSP antibodies. Higher levels of IgG1 and IgG3 antibodies were associated with protection, while higher levels of IgG2 and IgG4 were associated with a greater risk of developing malaria.

“The balance between the different subclasses seems to be more important than the total IgG levels,” said study author Itzi Ubillos Escriche, of ISGlobal.

“This could be because IgG1 and IgG3 antibodies have the capacity to stick to the parasite and give an ‘eat-me’ signal to cells of the immune system.”

The results also showed that subjects with higher pre-vaccine levels of anti-P falciparum and anti-CSP antibodies were less protected against malaria post-vaccination.

“This means that the vaccine will exert a larger benefit to infants who have not been exposed to the parasite in utero or during the first weeks of life,” Dr. Dobaño Lázaro said.

“This study . . . identifies new correlates of vaccine success and failure in African children and provides a basis for designing more efficacious vaccines.”

This research was funded by the National Institutes of Health-National Institute of Allergy and Infectious Diseases, PATH Malaria Vaccine Initiative, Ministerio de Economía y Competitividad, and EVIMalaR and AGAUR-Catalonia. ISGlobal is a member of the CERCA Program, Generalitat de Catalunya.

The authors said they have no competing interests.

The phase 3 trial of RTS,S was supported by GlaxoSmithKline Biologicals SA and the PATH Malaria Vaccine Initiative.

Photo by Caitlin Kleiboer

New research has revealed markers associated with efficacy of the RTS,S/AS01E malaria vaccine (Mosquirix™).

The study suggests malaria protection depends on the amount and subclass of antibodies generated upon vaccination and on previous exposure levels to the malaria parasite.

Researchers believe these findings, published in BMC Medicine, could aid the development of more effective vaccines and guide efforts to improve the effectiveness of RTS,S.

The RTS,S vaccine demonstrated partial effectiveness in a phase 3 study—31% in infants ages 6 weeks to 12 weeks and 56% in children ages 5 months to 17 months.

Carlota Dobaño Lázaro, PhD, of ISGlobal in Barcelona, Spain, and her colleagues have been working to understand the reasons for this variability and identify vaccine protection correlates.

The team used a quantitative assay to investigate the levels and types of antibodies induced by RTS,S. In particular, they measured total IgM, IgG, and IgG1–4 subclass antibodies to hepatitis B surface antigen (HBsAg) and three constructs of the Plasmodium falciparum circumsporozoite protein (CSP).

The researchers analyzed serum and plasma from 195 infants and children from Kintampo, Ghana (an area with high malaria transmission) and Manhiça, Mozambique (low malaria transmission), who were vaccinated during the phase 3 trial for RTS,S.

The results confirmed that RTS,S induces significant levels of IgG antibodies against both CSP and HBsAg, which are higher in children than in infants.

The researchers found that higher HBsAg antibody levels post-vaccination were associated with protection from malaria.

However, the same could not be said for all subclasses of CSP antibodies. Higher levels of IgG1 and IgG3 antibodies were associated with protection, while higher levels of IgG2 and IgG4 were associated with a greater risk of developing malaria.

“The balance between the different subclasses seems to be more important than the total IgG levels,” said study author Itzi Ubillos Escriche, of ISGlobal.

“This could be because IgG1 and IgG3 antibodies have the capacity to stick to the parasite and give an ‘eat-me’ signal to cells of the immune system.”

The results also showed that subjects with higher pre-vaccine levels of anti-P falciparum and anti-CSP antibodies were less protected against malaria post-vaccination.

“This means that the vaccine will exert a larger benefit to infants who have not been exposed to the parasite in utero or during the first weeks of life,” Dr. Dobaño Lázaro said.

“This study . . . identifies new correlates of vaccine success and failure in African children and provides a basis for designing more efficacious vaccines.”

This research was funded by the National Institutes of Health-National Institute of Allergy and Infectious Diseases, PATH Malaria Vaccine Initiative, Ministerio de Economía y Competitividad, and EVIMalaR and AGAUR-Catalonia. ISGlobal is a member of the CERCA Program, Generalitat de Catalunya.

The authors said they have no competing interests.

The phase 3 trial of RTS,S was supported by GlaxoSmithKline Biologicals SA and the PATH Malaria Vaccine Initiative.

Obese lab mouse

Switching to a low-fat diet can improve survival in obese mice with acute lymphoblastic leukemia (ALL), according to new research.

Diet-induced obese (DIO) mice with ALL had a survival rate of 17% if they remained on a high-fat diet while treated with vincristine, but survival rose to 92% for mice that were switched to a low-fat diet before treatment.

However, the dietary switch did not impact the survival of DIO mice treated with dexamethasone or L-asparaginase monotherapy.

Researchers reported these findings in Cancer & Metabolism.

“The most exciting thing, to me, about this study is the fact that this shows that a dietary intervention could potentially help us kill leukemia cells in children with acute lymphoblastic leukemia,” said study author Steven Mittelman, MD, PhD, of the University of Southern California, Los Angeles.

“The current treatments for leukemia are very toxic, so finding a way to use a healthy diet, without increasing the toxicity of therapy to treat people with cancer, would be incredible.”

Building on previous research that showed obesity reduced the effectiveness of chemotherapeutic drugs in children with leukemia, the researchers tested whether a dietary intervention could improve ALL outcomes in obese mice.

Methods

The team used NOD/SCID IL2-receptor gamma chain knockout mice raised on either a 60% or 10% fat-calorie diet. Only male mice were studied because female mice do not become as significantly obese on the high-fat diet.

The researchers implanted GFP+ pre-B-cell ALL transgenic mouse cells into DIO and control mice at about 20 weeks old.

Six to seven days after ALL implantation, the researchers randomized the DIO mice to continue their high-fat diet or switch to the control diet (10% calories from fat).

In some experiments, mice received monotherapy with vincristine, and other experiments used L-asparaginase or dexamethasone.

In additional experiments, the researchers implanted DIO and control mice with patient-derived ALL cells with normal karyotype.

After 17 days of engraftment, the researchers switched half the DIO mice to the control diet. The next day, they treated these mice with vincristine, L-asparaginase, or dexamethasone for 4 weeks.

The team monitored the mice daily for food intake, body weight, and onset of progressive leukemia.

Results

Diet had no impact on DIO or control mice that did not receive chemotherapy. Time to progression was the same in these mice.

When vincristine was started on day 7 after ALL implantation, DIO mice switched to the low-fat diet had the best survival, even better than the control mice.

Overall survival was 92% for the DIO mice that switched diets, 42% for the control group, and 17% for the DIO group maintained on the high-fat diet.

Survival experiments performed using L-asparaginase or dexamethasone monotherapy showed no impact of switching diets. The researchers reported there was “no detectable effect on survival in these experiments.”

The team believes this is the first study to test a diet intervention on treatment outcome in hematologic malignancy.

The researchers plan to study dietary intervention further in both obese and non-obese patients.

This study was supported by the National Cancer Institute and funds from the Saban Research Institute, Children’s Hospital of Los Angeles. The researchers had no competing interests to declare.

Obese lab mouse

Switching to a low-fat diet can improve survival in obese mice with acute lymphoblastic leukemia (ALL), according to new research.

Diet-induced obese (DIO) mice with ALL had a survival rate of 17% if they remained on a high-fat diet while treated with vincristine, but survival rose to 92% for mice that were switched to a low-fat diet before treatment.

However, the dietary switch did not impact the survival of DIO mice treated with dexamethasone or L-asparaginase monotherapy.

Researchers reported these findings in Cancer & Metabolism.

“The most exciting thing, to me, about this study is the fact that this shows that a dietary intervention could potentially help us kill leukemia cells in children with acute lymphoblastic leukemia,” said study author Steven Mittelman, MD, PhD, of the University of Southern California, Los Angeles.

“The current treatments for leukemia are very toxic, so finding a way to use a healthy diet, without increasing the toxicity of therapy to treat people with cancer, would be incredible.”

Building on previous research that showed obesity reduced the effectiveness of chemotherapeutic drugs in children with leukemia, the researchers tested whether a dietary intervention could improve ALL outcomes in obese mice.

Methods

The team used NOD/SCID IL2-receptor gamma chain knockout mice raised on either a 60% or 10% fat-calorie diet. Only male mice were studied because female mice do not become as significantly obese on the high-fat diet.

The researchers implanted GFP+ pre-B-cell ALL transgenic mouse cells into DIO and control mice at about 20 weeks old.

Six to seven days after ALL implantation, the researchers randomized the DIO mice to continue their high-fat diet or switch to the control diet (10% calories from fat).

In some experiments, mice received monotherapy with vincristine, and other experiments used L-asparaginase or dexamethasone.

In additional experiments, the researchers implanted DIO and control mice with patient-derived ALL cells with normal karyotype.

After 17 days of engraftment, the researchers switched half the DIO mice to the control diet. The next day, they treated these mice with vincristine, L-asparaginase, or dexamethasone for 4 weeks.

The team monitored the mice daily for food intake, body weight, and onset of progressive leukemia.

Results

Diet had no impact on DIO or control mice that did not receive chemotherapy. Time to progression was the same in these mice.

When vincristine was started on day 7 after ALL implantation, DIO mice switched to the low-fat diet had the best survival, even better than the control mice.

Overall survival was 92% for the DIO mice that switched diets, 42% for the control group, and 17% for the DIO group maintained on the high-fat diet.

Survival experiments performed using L-asparaginase or dexamethasone monotherapy showed no impact of switching diets. The researchers reported there was “no detectable effect on survival in these experiments.”

The team believes this is the first study to test a diet intervention on treatment outcome in hematologic malignancy.

The researchers plan to study dietary intervention further in both obese and non-obese patients.

This study was supported by the National Cancer Institute and funds from the Saban Research Institute, Children’s Hospital of Los Angeles. The researchers had no competing interests to declare.

Obese lab mouse

Switching to a low-fat diet can improve survival in obese mice with acute lymphoblastic leukemia (ALL), according to new research.

Diet-induced obese (DIO) mice with ALL had a survival rate of 17% if they remained on a high-fat diet while treated with vincristine, but survival rose to 92% for mice that were switched to a low-fat diet before treatment.

However, the dietary switch did not impact the survival of DIO mice treated with dexamethasone or L-asparaginase monotherapy.

Researchers reported these findings in Cancer & Metabolism.

“The most exciting thing, to me, about this study is the fact that this shows that a dietary intervention could potentially help us kill leukemia cells in children with acute lymphoblastic leukemia,” said study author Steven Mittelman, MD, PhD, of the University of Southern California, Los Angeles.

“The current treatments for leukemia are very toxic, so finding a way to use a healthy diet, without increasing the toxicity of therapy to treat people with cancer, would be incredible.”

Building on previous research that showed obesity reduced the effectiveness of chemotherapeutic drugs in children with leukemia, the researchers tested whether a dietary intervention could improve ALL outcomes in obese mice.

Methods

The team used NOD/SCID IL2-receptor gamma chain knockout mice raised on either a 60% or 10% fat-calorie diet. Only male mice were studied because female mice do not become as significantly obese on the high-fat diet.

The researchers implanted GFP+ pre-B-cell ALL transgenic mouse cells into DIO and control mice at about 20 weeks old.

Six to seven days after ALL implantation, the researchers randomized the DIO mice to continue their high-fat diet or switch to the control diet (10% calories from fat).

In some experiments, mice received monotherapy with vincristine, and other experiments used L-asparaginase or dexamethasone.

In additional experiments, the researchers implanted DIO and control mice with patient-derived ALL cells with normal karyotype.

After 17 days of engraftment, the researchers switched half the DIO mice to the control diet. The next day, they treated these mice with vincristine, L-asparaginase, or dexamethasone for 4 weeks.

The team monitored the mice daily for food intake, body weight, and onset of progressive leukemia.

Results

Diet had no impact on DIO or control mice that did not receive chemotherapy. Time to progression was the same in these mice.

When vincristine was started on day 7 after ALL implantation, DIO mice switched to the low-fat diet had the best survival, even better than the control mice.

Overall survival was 92% for the DIO mice that switched diets, 42% for the control group, and 17% for the DIO group maintained on the high-fat diet.

Survival experiments performed using L-asparaginase or dexamethasone monotherapy showed no impact of switching diets. The researchers reported there was “no detectable effect on survival in these experiments.”

The team believes this is the first study to test a diet intervention on treatment outcome in hematologic malignancy.

The researchers plan to study dietary intervention further in both obese and non-obese patients.

This study was supported by the National Cancer Institute and funds from the Saban Research Institute, Children’s Hospital of Los Angeles. The researchers had no competing interests to declare.

Micrograph showing MM

Overly zealous editing of messenger RNA in multiple myeloma (MM) cells contributes to MM pathogenesis and is associated with poor outcomes after certain treatments, investigators contend.

The team found evidence to suggest that overexpression of the RNA editing enzyme ADAR1 leads to hyperediting of the MM transcriptome that appears related to a drug-resistant disease phenotype and worse prognosis.

Phaik Ju Teoh, PhD, of the Cancer Science Institute of Singapore, and colleagues reported these findings in Blood.

The investigators implicate aberrant editing of adenosine (A) to inosine (I) in malignant plasma cells and its effects on NEIL1, a gene that encodes proteins involved in base-excision repair of DNA, as important mechanisms in MM pathogenesis.

A to I editing is the most prevalent form of RNA editing in humans, and aberrant editing mediated by ADAR1 has recently been linked to the development of several cancer types, the investigators noted.

To see whether this process may also be involved in MM, the investigators examined whole blood or bone marrow samples from healthy volunteers and MM patients.

The team found that ADAR1 was overexpressed in MM cells compared to nonmalignant plasma cells.

Furthermore, ADAR1 was expressed at higher levels in patients with newly diagnosed or relapsed MM compared to patients who had smoldering myeloma or monoclonal gammopathy of undetermined significance.

Response to treatment

The investigators also assessed ADAR1 expression in relation to MM patients’ responsiveness to treatment using data from the CoMMpass study.

The team found that patients with poor responses (stable or progressive disease) to bortezomib-based and immunomodulatory-based therapies had high ADAR1 mRNA.

There was no correlation between ADAR1 and responsiveness to carfilzomib-based treatments, but the investigators said this may be because of the relatively lower number of patients who received carfilzomib in this study.

The investigators also found that bortezomib was more effective in inhibiting the growth of MM cells with low ADAR1, and bortezomib-treated cells showed downregulation of ADAR1 expression in a dose- and time-dependent manner.

ADAR1-mediated editing

The investigators determined that ADAR1 directly regulates hyperediting of the MM transcriptome. This was evidenced by a significant increase in A to guanosine (G) editing in newly diagnosed and relapsed MM samples, compared with normal plasma cells.

The team confirmed this finding by observing the effects of ADAR1 levels on editing events across the transcriptome.

The investigators followed this observation with experiments to see whether ADAR1-mediated editing contributes to oncogenesis in MM cells. The MM growth rate slowed when the team silenced ADAR1, and introducing wild-type ADAR1 into cells promoted growth and proliferation.

The investigators also identified NEIL1 as an important ADAR1 editing target in MM. The editing compromised NEIL1’s ability to accurately repair DNA damage.

This study was supported by the National Research Foundation Singapore, the Singapore Ministry of Education, and the National University of Singapore. The investigators reported no competing financial interests.

Micrograph showing MM

Overly zealous editing of messenger RNA in multiple myeloma (MM) cells contributes to MM pathogenesis and is associated with poor outcomes after certain treatments, investigators contend.

The team found evidence to suggest that overexpression of the RNA editing enzyme ADAR1 leads to hyperediting of the MM transcriptome that appears related to a drug-resistant disease phenotype and worse prognosis.

Phaik Ju Teoh, PhD, of the Cancer Science Institute of Singapore, and colleagues reported these findings in Blood.

The investigators implicate aberrant editing of adenosine (A) to inosine (I) in malignant plasma cells and its effects on NEIL1, a gene that encodes proteins involved in base-excision repair of DNA, as important mechanisms in MM pathogenesis.

A to I editing is the most prevalent form of RNA editing in humans, and aberrant editing mediated by ADAR1 has recently been linked to the development of several cancer types, the investigators noted.

To see whether this process may also be involved in MM, the investigators examined whole blood or bone marrow samples from healthy volunteers and MM patients.

The team found that ADAR1 was overexpressed in MM cells compared to nonmalignant plasma cells.

Furthermore, ADAR1 was expressed at higher levels in patients with newly diagnosed or relapsed MM compared to patients who had smoldering myeloma or monoclonal gammopathy of undetermined significance.

Response to treatment

The investigators also assessed ADAR1 expression in relation to MM patients’ responsiveness to treatment using data from the CoMMpass study.

The team found that patients with poor responses (stable or progressive disease) to bortezomib-based and immunomodulatory-based therapies had high ADAR1 mRNA.

There was no correlation between ADAR1 and responsiveness to carfilzomib-based treatments, but the investigators said this may be because of the relatively lower number of patients who received carfilzomib in this study.

The investigators also found that bortezomib was more effective in inhibiting the growth of MM cells with low ADAR1, and bortezomib-treated cells showed downregulation of ADAR1 expression in a dose- and time-dependent manner.

ADAR1-mediated editing

The investigators determined that ADAR1 directly regulates hyperediting of the MM transcriptome. This was evidenced by a significant increase in A to guanosine (G) editing in newly diagnosed and relapsed MM samples, compared with normal plasma cells.

The team confirmed this finding by observing the effects of ADAR1 levels on editing events across the transcriptome.

The investigators followed this observation with experiments to see whether ADAR1-mediated editing contributes to oncogenesis in MM cells. The MM growth rate slowed when the team silenced ADAR1, and introducing wild-type ADAR1 into cells promoted growth and proliferation.

The investigators also identified NEIL1 as an important ADAR1 editing target in MM. The editing compromised NEIL1’s ability to accurately repair DNA damage.

This study was supported by the National Research Foundation Singapore, the Singapore Ministry of Education, and the National University of Singapore. The investigators reported no competing financial interests.

Micrograph showing MM

Overly zealous editing of messenger RNA in multiple myeloma (MM) cells contributes to MM pathogenesis and is associated with poor outcomes after certain treatments, investigators contend.

The team found evidence to suggest that overexpression of the RNA editing enzyme ADAR1 leads to hyperediting of the MM transcriptome that appears related to a drug-resistant disease phenotype and worse prognosis.

Phaik Ju Teoh, PhD, of the Cancer Science Institute of Singapore, and colleagues reported these findings in Blood.

The investigators implicate aberrant editing of adenosine (A) to inosine (I) in malignant plasma cells and its effects on NEIL1, a gene that encodes proteins involved in base-excision repair of DNA, as important mechanisms in MM pathogenesis.

A to I editing is the most prevalent form of RNA editing in humans, and aberrant editing mediated by ADAR1 has recently been linked to the development of several cancer types, the investigators noted.

To see whether this process may also be involved in MM, the investigators examined whole blood or bone marrow samples from healthy volunteers and MM patients.

The team found that ADAR1 was overexpressed in MM cells compared to nonmalignant plasma cells.

Furthermore, ADAR1 was expressed at higher levels in patients with newly diagnosed or relapsed MM compared to patients who had smoldering myeloma or monoclonal gammopathy of undetermined significance.

Response to treatment

The investigators also assessed ADAR1 expression in relation to MM patients’ responsiveness to treatment using data from the CoMMpass study.

The team found that patients with poor responses (stable or progressive disease) to bortezomib-based and immunomodulatory-based therapies had high ADAR1 mRNA.

There was no correlation between ADAR1 and responsiveness to carfilzomib-based treatments, but the investigators said this may be because of the relatively lower number of patients who received carfilzomib in this study.

The investigators also found that bortezomib was more effective in inhibiting the growth of MM cells with low ADAR1, and bortezomib-treated cells showed downregulation of ADAR1 expression in a dose- and time-dependent manner.

ADAR1-mediated editing

The investigators determined that ADAR1 directly regulates hyperediting of the MM transcriptome. This was evidenced by a significant increase in A to guanosine (G) editing in newly diagnosed and relapsed MM samples, compared with normal plasma cells.

The team confirmed this finding by observing the effects of ADAR1 levels on editing events across the transcriptome.

The investigators followed this observation with experiments to see whether ADAR1-mediated editing contributes to oncogenesis in MM cells. The MM growth rate slowed when the team silenced ADAR1, and introducing wild-type ADAR1 into cells promoted growth and proliferation.

The investigators also identified NEIL1 as an important ADAR1 editing target in MM. The editing compromised NEIL1’s ability to accurately repair DNA damage.

This study was supported by the National Research Foundation Singapore, the Singapore Ministry of Education, and the National University of Singapore. The investigators reported no competing financial interests.

CHICAGO – Asymptomatic chronic lymphocytic leukemia (CLL) patients should be observed, but consider therapy when symptoms develop, said Paul M. Barr, MD.

Courtesy Matt Wittmeyer/University of Rochester Medical Center

He described a patient who had been observed for 7 years when he began to complain of increasing fatigue and lost work time. A complete blood count (CBC) showed thrombocytopenia.

The recently updated International Workshop on Chronic Lymphocytic Leukemia (iwCLL) guidelines state that assessments before treatment in this type of patient should include history and physical, evaluation of infectious disease status, and routine laboratory testing – including CBC and differential, chemistry, serum immunoglobulin, and direct antiglobulin test.

“Bone marrow biopsies and [computed tomography] scans are listed as ‘not necessarily required,’ ” Dr. Barr, medical director of the Clinical Trials Office for Wilmot Cancer Institute at the University of Rochester (N.Y.) said during a presentation at the American Society of Hematology Meeting on Hematologic Malignancies.

He added that he opts for CT scans prior to therapy “to understand the patient’s disease burden and potentially to compare to later” and that bone marrow biopsy is “still very reasonable” for understanding the source of a patient’s cytopenias.

“Is it marrow failure or [immune thrombocytopenia]? Could the patient have [myelodysplastic syndrome]? All important considerations,” he said.

Positron emission tomography (PET) scans, however, are only considered when there is concern about transformation, he noted.

Predictive tests that should be conducted before initiating therapy, and that could help in guiding therapy decisions, include TP53 mutation testing and immunoglobulin heavy chain variable region gene (IGHV) mutational status testing (although this doesn’t need to be repeated if it was done at diagnosis because mutational status doesn’t change). Another helpful test is molecular cytogenetics using fluorescence in situ hybridization (FISH) for del(13q), del(17p), and trisomy 12 in peripheral blood lymphocytes. This should be repeated even it was done at diagnosis because patients can acquire additional molecular aberrations over time, Dr. Barr said.

Among the data that justify this advice for predictive testing are studies showing the curative potential of fludarabine/cyclophosphamide/rituximab (FCR) in mutated IGHV CLL, the progression-free survival (PFS) benefits of ibrutinib for patients with del(17p), and the activity of idelalisib in relapsed/refractory CLL patients, including those with TP53 dysfunction.

“The IGHV mutation status is useful to know what to expect from chemoimmunotherapy over time,” Dr. Barr said, explaining that several analyses demonstrate that patients with mutated IGHV genes (patients with low-risk disease) respond exceptionally well to chemoimmunotherapy, especially FCR.

In fact, studies, including a 2016 study by Philip A. Thompson and his colleagues and another by Kirsten Fischer and her colleagues, show that nearly 60% of patients with IGHV mutation remain in remission 10 years after FCR treatment, he said. However, the same is not necessarily true for bendamustine/rituximab (BR); the CLL10 study showed a significantly greater PFS with FCR, compared with that seen with BR.

Unmutated patients in that study had lower PFS, but the outcomes were still better with FCR than with BR, he said.

Studies of novel agents, including ibrutinib and idelalisib, suggest they may have particular benefit in higher-risk patients.

Ibrutinib was shown in a phase 2 study to be of benefit regardless of IGHV status, and this was replicated in the first-line RESONATE 2 study, which compared ibrutinib with chlorambucil and showed it had better PFS than that seen in unmutated patients treated with FCR in other studies, said Dr. Barr, the first author on that study.

“So you can see how the treatment paradigms are starting to evolve. It does look like ... comparing across trials, that ibrutinib leads to better remission durations, compared to chemoimmunotherapy, so far,” he said.

Ibrutinib has also been shown to be of benefit for patients with del(17p). A single-arm phase 2 study showed 79% PFS in relapsed, high-risk patients, which is much better than has been seen with chemoimmunotherapy, he noted.

“Venetoclax is also a very good option for this patient population in the relapse setting,” he said, adding that the PFS with venetoclax has been shown to be very similar to that with ibrutinib.

Similarly, idelalisib has been shown to provide comparable benefit in relapsed/refractory CLL patients, with and without del(17p)/TP53 mutation, he said.

Dr. Barr is a consultant for Pharmacyclics, AbbVie, Celgene, Gilead, Infinity, Novartis, and Seattle Genetics and has received research funding from Pharmacyclics and AbbVie.

[email protected]

CHICAGO – Asymptomatic chronic lymphocytic leukemia (CLL) patients should be observed, but consider therapy when symptoms develop, said Paul M. Barr, MD.

Courtesy Matt Wittmeyer/University of Rochester Medical Center

He described a patient who had been observed for 7 years when he began to complain of increasing fatigue and lost work time. A complete blood count (CBC) showed thrombocytopenia.

The recently updated International Workshop on Chronic Lymphocytic Leukemia (iwCLL) guidelines state that assessments before treatment in this type of patient should include history and physical, evaluation of infectious disease status, and routine laboratory testing – including CBC and differential, chemistry, serum immunoglobulin, and direct antiglobulin test.

“Bone marrow biopsies and [computed tomography] scans are listed as ‘not necessarily required,’ ” Dr. Barr, medical director of the Clinical Trials Office for Wilmot Cancer Institute at the University of Rochester (N.Y.) said during a presentation at the American Society of Hematology Meeting on Hematologic Malignancies.

He added that he opts for CT scans prior to therapy “to understand the patient’s disease burden and potentially to compare to later” and that bone marrow biopsy is “still very reasonable” for understanding the source of a patient’s cytopenias.

“Is it marrow failure or [immune thrombocytopenia]? Could the patient have [myelodysplastic syndrome]? All important considerations,” he said.

Positron emission tomography (PET) scans, however, are only considered when there is concern about transformation, he noted.

Predictive tests that should be conducted before initiating therapy, and that could help in guiding therapy decisions, include TP53 mutation testing and immunoglobulin heavy chain variable region gene (IGHV) mutational status testing (although this doesn’t need to be repeated if it was done at diagnosis because mutational status doesn’t change). Another helpful test is molecular cytogenetics using fluorescence in situ hybridization (FISH) for del(13q), del(17p), and trisomy 12 in peripheral blood lymphocytes. This should be repeated even it was done at diagnosis because patients can acquire additional molecular aberrations over time, Dr. Barr said.

Among the data that justify this advice for predictive testing are studies showing the curative potential of fludarabine/cyclophosphamide/rituximab (FCR) in mutated IGHV CLL, the progression-free survival (PFS) benefits of ibrutinib for patients with del(17p), and the activity of idelalisib in relapsed/refractory CLL patients, including those with TP53 dysfunction.

“The IGHV mutation status is useful to know what to expect from chemoimmunotherapy over time,” Dr. Barr said, explaining that several analyses demonstrate that patients with mutated IGHV genes (patients with low-risk disease) respond exceptionally well to chemoimmunotherapy, especially FCR.

In fact, studies, including a 2016 study by Philip A. Thompson and his colleagues and another by Kirsten Fischer and her colleagues, show that nearly 60% of patients with IGHV mutation remain in remission 10 years after FCR treatment, he said. However, the same is not necessarily true for bendamustine/rituximab (BR); the CLL10 study showed a significantly greater PFS with FCR, compared with that seen with BR.

Unmutated patients in that study had lower PFS, but the outcomes were still better with FCR than with BR, he said.

Studies of novel agents, including ibrutinib and idelalisib, suggest they may have particular benefit in higher-risk patients.

Ibrutinib was shown in a phase 2 study to be of benefit regardless of IGHV status, and this was replicated in the first-line RESONATE 2 study, which compared ibrutinib with chlorambucil and showed it had better PFS than that seen in unmutated patients treated with FCR in other studies, said Dr. Barr, the first author on that study.

“So you can see how the treatment paradigms are starting to evolve. It does look like ... comparing across trials, that ibrutinib leads to better remission durations, compared to chemoimmunotherapy, so far,” he said.

Ibrutinib has also been shown to be of benefit for patients with del(17p). A single-arm phase 2 study showed 79% PFS in relapsed, high-risk patients, which is much better than has been seen with chemoimmunotherapy, he noted.

“Venetoclax is also a very good option for this patient population in the relapse setting,” he said, adding that the PFS with venetoclax has been shown to be very similar to that with ibrutinib.

Similarly, idelalisib has been shown to provide comparable benefit in relapsed/refractory CLL patients, with and without del(17p)/TP53 mutation, he said.

Dr. Barr is a consultant for Pharmacyclics, AbbVie, Celgene, Gilead, Infinity, Novartis, and Seattle Genetics and has received research funding from Pharmacyclics and AbbVie.

[email protected]

CHICAGO – Asymptomatic chronic lymphocytic leukemia (CLL) patients should be observed, but consider therapy when symptoms develop, said Paul M. Barr, MD.

Courtesy Matt Wittmeyer/University of Rochester Medical Center

He described a patient who had been observed for 7 years when he began to complain of increasing fatigue and lost work time. A complete blood count (CBC) showed thrombocytopenia.

The recently updated International Workshop on Chronic Lymphocytic Leukemia (iwCLL) guidelines state that assessments before treatment in this type of patient should include history and physical, evaluation of infectious disease status, and routine laboratory testing – including CBC and differential, chemistry, serum immunoglobulin, and direct antiglobulin test.

“Bone marrow biopsies and [computed tomography] scans are listed as ‘not necessarily required,’ ” Dr. Barr, medical director of the Clinical Trials Office for Wilmot Cancer Institute at the University of Rochester (N.Y.) said during a presentation at the American Society of Hematology Meeting on Hematologic Malignancies.

He added that he opts for CT scans prior to therapy “to understand the patient’s disease burden and potentially to compare to later” and that bone marrow biopsy is “still very reasonable” for understanding the source of a patient’s cytopenias.

“Is it marrow failure or [immune thrombocytopenia]? Could the patient have [myelodysplastic syndrome]? All important considerations,” he said.

Positron emission tomography (PET) scans, however, are only considered when there is concern about transformation, he noted.

Predictive tests that should be conducted before initiating therapy, and that could help in guiding therapy decisions, include TP53 mutation testing and immunoglobulin heavy chain variable region gene (IGHV) mutational status testing (although this doesn’t need to be repeated if it was done at diagnosis because mutational status doesn’t change). Another helpful test is molecular cytogenetics using fluorescence in situ hybridization (FISH) for del(13q), del(17p), and trisomy 12 in peripheral blood lymphocytes. This should be repeated even it was done at diagnosis because patients can acquire additional molecular aberrations over time, Dr. Barr said.

Among the data that justify this advice for predictive testing are studies showing the curative potential of fludarabine/cyclophosphamide/rituximab (FCR) in mutated IGHV CLL, the progression-free survival (PFS) benefits of ibrutinib for patients with del(17p), and the activity of idelalisib in relapsed/refractory CLL patients, including those with TP53 dysfunction.

“The IGHV mutation status is useful to know what to expect from chemoimmunotherapy over time,” Dr. Barr said, explaining that several analyses demonstrate that patients with mutated IGHV genes (patients with low-risk disease) respond exceptionally well to chemoimmunotherapy, especially FCR.

In fact, studies, including a 2016 study by Philip A. Thompson and his colleagues and another by Kirsten Fischer and her colleagues, show that nearly 60% of patients with IGHV mutation remain in remission 10 years after FCR treatment, he said. However, the same is not necessarily true for bendamustine/rituximab (BR); the CLL10 study showed a significantly greater PFS with FCR, compared with that seen with BR.

Unmutated patients in that study had lower PFS, but the outcomes were still better with FCR than with BR, he said.

Studies of novel agents, including ibrutinib and idelalisib, suggest they may have particular benefit in higher-risk patients.

Ibrutinib was shown in a phase 2 study to be of benefit regardless of IGHV status, and this was replicated in the first-line RESONATE 2 study, which compared ibrutinib with chlorambucil and showed it had better PFS than that seen in unmutated patients treated with FCR in other studies, said Dr. Barr, the first author on that study.

“So you can see how the treatment paradigms are starting to evolve. It does look like ... comparing across trials, that ibrutinib leads to better remission durations, compared to chemoimmunotherapy, so far,” he said.

Ibrutinib has also been shown to be of benefit for patients with del(17p). A single-arm phase 2 study showed 79% PFS in relapsed, high-risk patients, which is much better than has been seen with chemoimmunotherapy, he noted.

“Venetoclax is also a very good option for this patient population in the relapse setting,” he said, adding that the PFS with venetoclax has been shown to be very similar to that with ibrutinib.

Similarly, idelalisib has been shown to provide comparable benefit in relapsed/refractory CLL patients, with and without del(17p)/TP53 mutation, he said.

Dr. Barr is a consultant for Pharmacyclics, AbbVie, Celgene, Gilead, Infinity, Novartis, and Seattle Genetics and has received research funding from Pharmacyclics and AbbVie.

[email protected]

In patients with a new diagnosis of advanced cancer, an intervention that combined palliative care with rehabilitation helped improve quality of life, results of a randomized, single-center study suggest.

Patients had a significant improvement in their most pressing quality-of-life issues after participating in the intervention, which included individualized palliative care consultations and a patient/caregiver “school” of lectures, discussion, and physical exercise, investigators said.

These findings suggest that every patient facing an advanced cancer diagnosis should at least have an initial exploratory consultation with a specialized palliative care team, and should be offered not only the usual components of palliative care, but also cancer rehabilitation, said Lise Nottelmann, MD, of the department of oncology at Vejle Hospital in Denmark.

“We should be active as a health care system in approaching these patients and offering them this intervention, or at least a consultation exploring these aspects of quality of life,” Dr. Nottelmann said in an interview at the 2018 Palliative and Supportive Care in Oncology Symposium.

The study by Dr. Nottelmann and her colleagues, presented at the symposium, comprised 301 patients with nonresectable solid tumors, including lung, gastrointestinal, prostate, and others. Those patients were randomly allocated to the palliative rehabilitation intervention or to standard care only.

Every patient participated in two consultations with a specialized palliative care team, and then had the opportunity for individualized contact with the team in a 12-week open contact period. They were also invited to participate in the school sessions, each of which included a 20-minute lecture on topics such as physical activity and good nutrition plus a 40-minute discussion period, followed by an exercise session.

Of the patients randomized to the palliative rehabilitation intervention, 26 participated only in the initial consultations, while 59 participated in the group program, and 47 had individual consultations, Dr. Nottelmann reported.

To measure quality of life, the investigators asked patients to identify a “primary problem” that corresponded to one of 12 scales in the EORTC QLQ-C30 questionnaire related to physical and role functioning, emotional and cognitive functioning, or symptoms.

The primary endpoint of the analysis was improvement in QLQ-C30 scores at 12 weeks. The analysis was done on specific scales in the patients who identified a primary problem, combined with global QLQ-C30 scores for the remaining one-quarter of the patients who did not, Dr. Nottelmann said.

After 12 weeks, the patients in the intervention arm had a significant improvement versus the no-intervention arm as measured by a version of the EORTC QLQ-C30 questionnaire. The absolute between-group difference in scores was 3.0 (95% confidence interval, 0.0-6.0; P less than .047), according to researchers.

Starting palliative care earlier in the course of cancer, as done in this intervention, is an increasingly accepted practice, supported by large studies and recent clinical practice guidelines that recommend early integration of palliative care into the seriously ill patient’s care plan.

What was different about this intervention was the integration of rehabilitation aspects into palliative care, Dr. Nottelmann said in the interview. While not traditionally thought of as a component of palliative care, the concept of palliative rehabilitation is gaining ground, she said.

The goal of rehabilitative palliative care is to help individuals with life-limiting or terminal conditions actively self-manage their conditions so they can “live fully” and enjoy the best quality of life possible, according to Hospice UK, a national charity for hospice care in the United Kingdom.

The symposium was cosponsored by AAHPM, ASCO, ASTRO, and MASCC. Dr. Nottelmann and her colleagues reported research funding from the Danish Cancer Society. Dr. Nottelmann had no disclosures related to the presentation. One coauthor provided disclosures related to Roche, Amgen, Bayer, and Merck Sharp & Dohme.

SOURCE: Nottelmann L et al. PallOnc 2018, Abstract 75.

In patients with a new diagnosis of advanced cancer, an intervention that combined palliative care with rehabilitation helped improve quality of life, results of a randomized, single-center study suggest.

Patients had a significant improvement in their most pressing quality-of-life issues after participating in the intervention, which included individualized palliative care consultations and a patient/caregiver “school” of lectures, discussion, and physical exercise, investigators said.

These findings suggest that every patient facing an advanced cancer diagnosis should at least have an initial exploratory consultation with a specialized palliative care team, and should be offered not only the usual components of palliative care, but also cancer rehabilitation, said Lise Nottelmann, MD, of the department of oncology at Vejle Hospital in Denmark.

“We should be active as a health care system in approaching these patients and offering them this intervention, or at least a consultation exploring these aspects of quality of life,” Dr. Nottelmann said in an interview at the 2018 Palliative and Supportive Care in Oncology Symposium.

The study by Dr. Nottelmann and her colleagues, presented at the symposium, comprised 301 patients with nonresectable solid tumors, including lung, gastrointestinal, prostate, and others. Those patients were randomly allocated to the palliative rehabilitation intervention or to standard care only.

Every patient participated in two consultations with a specialized palliative care team, and then had the opportunity for individualized contact with the team in a 12-week open contact period. They were also invited to participate in the school sessions, each of which included a 20-minute lecture on topics such as physical activity and good nutrition plus a 40-minute discussion period, followed by an exercise session.

Of the patients randomized to the palliative rehabilitation intervention, 26 participated only in the initial consultations, while 59 participated in the group program, and 47 had individual consultations, Dr. Nottelmann reported.

To measure quality of life, the investigators asked patients to identify a “primary problem” that corresponded to one of 12 scales in the EORTC QLQ-C30 questionnaire related to physical and role functioning, emotional and cognitive functioning, or symptoms.

The primary endpoint of the analysis was improvement in QLQ-C30 scores at 12 weeks. The analysis was done on specific scales in the patients who identified a primary problem, combined with global QLQ-C30 scores for the remaining one-quarter of the patients who did not, Dr. Nottelmann said.

After 12 weeks, the patients in the intervention arm had a significant improvement versus the no-intervention arm as measured by a version of the EORTC QLQ-C30 questionnaire. The absolute between-group difference in scores was 3.0 (95% confidence interval, 0.0-6.0; P less than .047), according to researchers.

Starting palliative care earlier in the course of cancer, as done in this intervention, is an increasingly accepted practice, supported by large studies and recent clinical practice guidelines that recommend early integration of palliative care into the seriously ill patient’s care plan.

What was different about this intervention was the integration of rehabilitation aspects into palliative care, Dr. Nottelmann said in the interview. While not traditionally thought of as a component of palliative care, the concept of palliative rehabilitation is gaining ground, she said.

The goal of rehabilitative palliative care is to help individuals with life-limiting or terminal conditions actively self-manage their conditions so they can “live fully” and enjoy the best quality of life possible, according to Hospice UK, a national charity for hospice care in the United Kingdom.

The symposium was cosponsored by AAHPM, ASCO, ASTRO, and MASCC. Dr. Nottelmann and her colleagues reported research funding from the Danish Cancer Society. Dr. Nottelmann had no disclosures related to the presentation. One coauthor provided disclosures related to Roche, Amgen, Bayer, and Merck Sharp & Dohme.

SOURCE: Nottelmann L et al. PallOnc 2018, Abstract 75.

In patients with a new diagnosis of advanced cancer, an intervention that combined palliative care with rehabilitation helped improve quality of life, results of a randomized, single-center study suggest.

Patients had a significant improvement in their most pressing quality-of-life issues after participating in the intervention, which included individualized palliative care consultations and a patient/caregiver “school” of lectures, discussion, and physical exercise, investigators said.

These findings suggest that every patient facing an advanced cancer diagnosis should at least have an initial exploratory consultation with a specialized palliative care team, and should be offered not only the usual components of palliative care, but also cancer rehabilitation, said Lise Nottelmann, MD, of the department of oncology at Vejle Hospital in Denmark.

“We should be active as a health care system in approaching these patients and offering them this intervention, or at least a consultation exploring these aspects of quality of life,” Dr. Nottelmann said in an interview at the 2018 Palliative and Supportive Care in Oncology Symposium.

The study by Dr. Nottelmann and her colleagues, presented at the symposium, comprised 301 patients with nonresectable solid tumors, including lung, gastrointestinal, prostate, and others. Those patients were randomly allocated to the palliative rehabilitation intervention or to standard care only.

Every patient participated in two consultations with a specialized palliative care team, and then had the opportunity for individualized contact with the team in a 12-week open contact period. They were also invited to participate in the school sessions, each of which included a 20-minute lecture on topics such as physical activity and good nutrition plus a 40-minute discussion period, followed by an exercise session.

Of the patients randomized to the palliative rehabilitation intervention, 26 participated only in the initial consultations, while 59 participated in the group program, and 47 had individual consultations, Dr. Nottelmann reported.

To measure quality of life, the investigators asked patients to identify a “primary problem” that corresponded to one of 12 scales in the EORTC QLQ-C30 questionnaire related to physical and role functioning, emotional and cognitive functioning, or symptoms.

The primary endpoint of the analysis was improvement in QLQ-C30 scores at 12 weeks. The analysis was done on specific scales in the patients who identified a primary problem, combined with global QLQ-C30 scores for the remaining one-quarter of the patients who did not, Dr. Nottelmann said.

After 12 weeks, the patients in the intervention arm had a significant improvement versus the no-intervention arm as measured by a version of the EORTC QLQ-C30 questionnaire. The absolute between-group difference in scores was 3.0 (95% confidence interval, 0.0-6.0; P less than .047), according to researchers.

Starting palliative care earlier in the course of cancer, as done in this intervention, is an increasingly accepted practice, supported by large studies and recent clinical practice guidelines that recommend early integration of palliative care into the seriously ill patient’s care plan.

What was different about this intervention was the integration of rehabilitation aspects into palliative care, Dr. Nottelmann said in the interview. While not traditionally thought of as a component of palliative care, the concept of palliative rehabilitation is gaining ground, she said.

The goal of rehabilitative palliative care is to help individuals with life-limiting or terminal conditions actively self-manage their conditions so they can “live fully” and enjoy the best quality of life possible, according to Hospice UK, a national charity for hospice care in the United Kingdom.

The symposium was cosponsored by AAHPM, ASCO, ASTRO, and MASCC. Dr. Nottelmann and her colleagues reported research funding from the Danish Cancer Society. Dr. Nottelmann had no disclosures related to the presentation. One coauthor provided disclosures related to Roche, Amgen, Bayer, and Merck Sharp & Dohme.

SOURCE: Nottelmann L et al. PallOnc 2018, Abstract 75.

Physician stress and burnout remain major concerns for the U.S. health care system, with frustrations over the electronic health record (EHR) driving much of the dissatisfaction experienced by hospitalists and other physicians in the hospital.¹ Underlying the EHR conundrum is a deeper question: Is entering clinical data on a computer the best use of a doctor’s time and professional skills? Or could a portion of that clerical function be delegated to nonphysicians?

Trained medical scribes, charting specialists who input EHR data for physicians on rounds, have been offered as a solution to potentially affect job stress for physicians and shorten their work days. But while scribes have been used and tested by different hospitalist groups around the country, the concept has not taken off in hospital medicine the way it has in certain other settings, such as emergency departments.

“The demand for scribes doesn’t seem to have materialized in a big way for hospital medicine,” said John Nelson, MD, MHM, a hospitalist and consultant in Bellevue, Wash., and a cofounder of the Society of Hospital Medicine. “I’m not convinced that scribes have had a big impact on hospitalist burnout.” It’s difficult to share scribes between doctors on a shift, and it’s a problem if the scribe and doctor get physically separated in the hospital. There’s also the question of who should pay the scribe’s salary, Dr. Nelson said.

Frustrations with the EHR can be a major factor in the experience of physician burnout, but Dr. Nelson said hospitalists can get proficient more quickly because they’re using the same computer system all day. “The bigger problem is that other doctors like surgeons don’t learn how to use the EHR and dump their routine tasks involving the EHR on the hospitalist, which means more work that is less satisfying.”

Could pairing a scribe with a hospitalist improve efficiency and decrease costs relative to the expense of employing the scribe? Are there specific settings, applications, and caseloads in hospital medicine where it makes more sense to use a scribe to support and assist doctors while they’re meeting with patients, with the doctor reviewing and editing the scribe’s work for accuracy? Could the scribe even help with physician staffing shortages by making doctors more productive?

TeamHealth, a national physician services company based in Knoxville, Tenn., has used scribes in emergency departments for years but had concluded that they made less sense for its hospitalist groups after a failure to document significant net increases in productivity, according to a 2015 report in The Hospitalist.² Michael Corvini, MD, FACP, FACEP, TeamHealth’s new regional medical director for acute care services, said he brought extensive positive experience with scribes to his new job and is quite excited about their potential for hospital medicine. “When I came to TeamHealth in July, I began to suggest that there was unrealized potential for scribes,” he said.

Dr. Corvini noted that a potential benefit of scribes for patients is that their presence may allow for more face time with the doctor. Providers, relieved of worrying about completing the chart in its entirety would be more able to focus on the patient and critical thinking. There are even benefits for scribes themselves. Often scribes are medical students, and those who are interested in pursuing a future in the health professions gain invaluable experience in the workings of medicine. “They are making a real contribution to patient care. They are a member of the health care team,” he said.

Dr. Corvini sees two primary areas in which scribes can contribute to hospital medicine. The first is shadowing the physician who is admitting patients during a high-volume admissions shift. Regular tasks like capturing the patient’s medication list and populating the History and Physical document lend themselves well to data entry by scribes, in contrast to completing more routine daily progress notes, which does not.

“They can also be helpful when there is a major transition from paper charting to the EHR or from one EHR system to another, when there is a lot of stress on the physician and risk for lost billing revenue,” Dr. Corvini said. “If scribes are trained in a particular EHR, they could help teach the physician how to use it.” TeamHealth is now in the process of running a trial of scribes at one of its sites, and the organization plans to measure productivity, provider satisfaction, and HCAHPS patient satisfaction scores.


 

A workaround – or a problem solver?

In a 2015 Viewpoint article in JAMA,³ George Gellert, MD, MPH, MPA, former chief medical information officer for the CHRISTUS Santa Rosa health system in San Antonio, Texas, and his coauthors labeled the use of scribes as a “workaround” that could curtail efforts to make EHRs more functionally operational because their use allows physicians to be satisfied with inferior EHR products.

In an interview, Dr. Gellert stated that he hasn’t changed his views about the negative consequences of scribes on EHR improvement. “The work of clinicians in using and advancing EHR technology is presently the only method we have for massively distributing and ensuring the use of evidence-based medicine,” he said. “That in turn is a critical strategy for reducing high rates of medical errors through a variety of decision-support applications.”

For better or worse, EHRs are an essential part of the solution to the epidemic of preventable, medical error–caused patient deaths, Dr. Gellert said. He also believes that substantial progress has already been made in advancing EHR usability, as reflected in the most recent product releases by leading EHR companies. However, considerable evolution is still needed in both usability and optimization of clinical decision support.

“With respect to your readers, my recommendation is to not use medical scribes, or else delimit their use to only where absolutely required. Instead, develop systematic processes to regularly capture specific physician concerns with the EHR being used, and transmit that critical information to their EHR vendor with a clear expectation that the manufacturer will address the issue in the near term, or at least in their next major product iteration or generation,” Dr. Gellert said.

By contrast, at the Management of the Hospitalized Patient conference in San Francisco in October 2015, Christine Sinsky, MD, FACP, vice president for professional satisfaction at the American Medical Association, identified documentation assistance as a helpful intervention for physician stress and burnout.⁴ In a recent email, Dr. Sinsky called documentation assistance “the most powerful intervention to give patients the time, attention, and care they need from their physicians. The data entry and data retrieval work of health care has grown over the last decade. Sharing this work with nonphysicians allows society to get the most value for its investment in physicians’ training.”

Dr. Sinsky calls documentation assistance – such as that provided by medical scribes – “a logical and strategic delegation of work according to ability for greater value,” not a workaround. She said it makes patient care safer by allowing physicians to focus on medical decision making and relationship building – rather than record keeping.
 

Experience from the front lines

Eric Edwards, MD, FAAP, FHM, of the division of hospital medicine at the University of North Carolina’s Hillsborough Hospital campus, recently presented a poster on his group’s experience with medical scribes at a meeting of the North Carolina Triangle Chapter of SHM. Their research concluded that scribes can be successfully incorporated into an inpatient hospital medicine practice and thus increase provider satisfaction and decrease the time clinicians spend charting.

“We were able to get the support of the hospital administration to pilot the use of scribes 3 days per week, which we’ve now done for almost a year,” Dr. Edwards said. Scribes are employed through a local company, MedScribes, and they work alongside admitting hospitalists during their 10-hour shifts. The hospitalists have been overwhelmingly positive about their experience, he said. “We established that it saves the physician 15 minutes per patient encounter by helping with documentation.”

It’s important that the scribe gets to know an individual provider’s personal preferences, Dr. Edwards said. Some hospitalists create their own charting templates. There’s also a need to train the clinician in how to use the medical scribe. For example, physicians are instructed to call out physical findings during their exam, which simultaneously informs the patient while allowing the scribe to document the exam.

“We are working on getting more formal data about the scribe experience,” he added. “But we have found that our providers love it, and it improves their efficiency and productivity. The danger is if the physician becomes too reliant on the scribe and fails to exercise due diligence in reviewing the scribe’s notes to ensure that all relevant information is in the chart and irrelevant information is not. We need to make sure we are carefully reviewing and signing off on the scribe’s notes,” he explained.

“I think we’re years away from improving the EHR to the point that would allow us to call it doctor friendly,” Dr. Edwards said. “For now, the scribe is a great way to alleviate some of the physician’s burden. But for hospitalist groups to use scribes successfully, it can’t be done haphazardly. We are lucky to have an experienced local scribe company to partner with. They provide systematic training and orientation. It’s also important that scribes are trained in the specific EHR that they will be using.”

Christine Lum Lung, MD, SFHM, CEO and medical director of Northern Colorado Hospitalists, a hospital medicine group at the University of Colorado’s North Campus hospitals in Fort Collins, has been studying the use of scribes since 2014. “We had a gap in bringing on new doctors fast enough for our group’s needs, so I looked into the return on investment from scribes and pitched it to our group,” she said. “It’s difficult to say what has been the actual impact on caseload, but we all think it has reduced physician workdays by an hour or greater.”

The 32-member hospitalist group, which covers two facilities, has a designated director of scribes who periodically surveys the hospitalists’ satisfaction with the scribes. “Now we all embrace the use of scribes. Satisfaction is high, and quality of life has improved,” Dr. Lum Lung said. “It’s hard to quantify, but we feel like it helps with burnout for us to be able to leave work earlier, and it alleviates some of the other stresses in our workday.”

She said scribes are important to the medical team not just with managing the EHR but also with other burdens such as documenting compliance with code status, VTEs, and other quality requirements, and to help with other regulatory issues. Scribes can look up lab values and radiology reports. When there are downtimes, they can prepare discharge plans.

Typically, there are five scribes on duty for 18 hours a day at each hospital, Dr. Lum Lung said. But only those doctors primarily doing admissions are assured of having a scribe to round with them. “Most doctors in the group would say the greatest efficiency of scribes is with admitting,” she said. The company that provides scribes to the UC hospitals, ScribeAmerica, handles administration, training, and human resource issues, and the scribe team has a designated Lead Scribe and Quality Scribe at their facility.


 

Studying the benefits

Andrew Friedson, PhD, a health care economist at the University of Colorado in Denver, recently conducted a 9-month randomized experiment in three hospital emergency rooms in the Denver area to determine the effects of scribes on measures of emergency physician productivity.⁵ He found that scribes reduced patient wait times in the emergency department by about 13 minutes per patient, while greatly decreasing the amount of time physicians spent after a shift completing their charting, which thus lowered overtime costs for ED physicians.

“This is one of the first times medical scribes have been studied with a randomized, controlled trial,” Dr. Friedson said. “I tracked the amount of overtime, patient waiting, and charge capture for each encounter. These were hospitals where the emergency doctors weren’t allowed to go home until their charting was done.” He discovered that there was a large drop in the time between when patients arrived at the ED and when a decision was made regarding whether to admit them. Additionally, charge capture increased significantly, and physicians had more time to perform medical procedures. Dr. Friedson believes that his findings hold implications for other settings and medical groups, including hospital medicine. To the extent that scribes free up hospitalists to perform tasks other than charting, they should provide an efficiency benefit.

So why hasn’t the medical scribe caught on in a bigger way for hospitalists, compared with ED physicians? For Dr. Corvini, the ED is an obvious, high-pressure, high-volume setting where the cost of the scribe can be easily recouped. “That doesn’t exist in such an obvious fashion in hospital medicine, except where high-volume admissions are concentrated in a single physician’s caseload,” he said. Not all hospitalist groups will fit that model. Some may divide admissions between hospitalists on a shift, and others may not be large enough to experience significant caseload pressures.

“EDs are obviously time pressured, and once scribes demonstrate the ability to produce documentation in a high-quality fashion, they are quickly accepted. In hospital medicine, the time pressures are different – not necessarily less, but different,” Dr. Corvini said. There are also differences in physician responsibilities between the ED and hospital medicine, as well as in physicians’ willingness to let go of documentation responsibilities. “My prediction, if the scribe test is rolled out successfully in TeamHealth, with measurable benefits, it will be adopted in other settings where it fits.”
 

References

1. Shanafelt TD et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48.

2. Collins TR. Use of medical scribes spurs debate about costs, difficulties of electronic health records. The Hospitalist; 2015 Oct.

3. Gellert GA et al. The rise of the medical scribe industry: Implications for the advancement of electronic health records. JAMA; 2015;313(13):1315-6.

4. Beresford L. Electronic Health Records Key Driver of Physician Burnout. The Hospitalist; 2015 Dec.

5. Friedson AI. Medical scribes as an input in healthcare production: Evidence from a randomized experiment. Am J Health Econ. 2017 Oct 2. doi: /10.1162/ajhe_a_00103.






 

Physician stress and burnout remain major concerns for the U.S. health care system, with frustrations over the electronic health record (EHR) driving much of the dissatisfaction experienced by hospitalists and other physicians in the hospital.¹ Underlying the EHR conundrum is a deeper question: Is entering clinical data on a computer the best use of a doctor’s time and professional skills? Or could a portion of that clerical function be delegated to nonphysicians?

Trained medical scribes, charting specialists who input EHR data for physicians on rounds, have been offered as a solution to potentially affect job stress for physicians and shorten their work days. But while scribes have been used and tested by different hospitalist groups around the country, the concept has not taken off in hospital medicine the way it has in certain other settings, such as emergency departments.

“The demand for scribes doesn’t seem to have materialized in a big way for hospital medicine,” said John Nelson, MD, MHM, a hospitalist and consultant in Bellevue, Wash., and a cofounder of the Society of Hospital Medicine. “I’m not convinced that scribes have had a big impact on hospitalist burnout.” It’s difficult to share scribes between doctors on a shift, and it’s a problem if the scribe and doctor get physically separated in the hospital. There’s also the question of who should pay the scribe’s salary, Dr. Nelson said.

Frustrations with the EHR can be a major factor in the experience of physician burnout, but Dr. Nelson said hospitalists can get proficient more quickly because they’re using the same computer system all day. “The bigger problem is that other doctors like surgeons don’t learn how to use the EHR and dump their routine tasks involving the EHR on the hospitalist, which means more work that is less satisfying.”

Could pairing a scribe with a hospitalist improve efficiency and decrease costs relative to the expense of employing the scribe? Are there specific settings, applications, and caseloads in hospital medicine where it makes more sense to use a scribe to support and assist doctors while they’re meeting with patients, with the doctor reviewing and editing the scribe’s work for accuracy? Could the scribe even help with physician staffing shortages by making doctors more productive?

TeamHealth, a national physician services company based in Knoxville, Tenn., has used scribes in emergency departments for years but had concluded that they made less sense for its hospitalist groups after a failure to document significant net increases in productivity, according to a 2015 report in The Hospitalist.² Michael Corvini, MD, FACP, FACEP, TeamHealth’s new regional medical director for acute care services, said he brought extensive positive experience with scribes to his new job and is quite excited about their potential for hospital medicine. “When I came to TeamHealth in July, I began to suggest that there was unrealized potential for scribes,” he said.

Dr. Corvini noted that a potential benefit of scribes for patients is that their presence may allow for more face time with the doctor. Providers, relieved of worrying about completing the chart in its entirety would be more able to focus on the patient and critical thinking. There are even benefits for scribes themselves. Often scribes are medical students, and those who are interested in pursuing a future in the health professions gain invaluable experience in the workings of medicine. “They are making a real contribution to patient care. They are a member of the health care team,” he said.

Dr. Corvini sees two primary areas in which scribes can contribute to hospital medicine. The first is shadowing the physician who is admitting patients during a high-volume admissions shift. Regular tasks like capturing the patient’s medication list and populating the History and Physical document lend themselves well to data entry by scribes, in contrast to completing more routine daily progress notes, which does not.

“They can also be helpful when there is a major transition from paper charting to the EHR or from one EHR system to another, when there is a lot of stress on the physician and risk for lost billing revenue,” Dr. Corvini said. “If scribes are trained in a particular EHR, they could help teach the physician how to use it.” TeamHealth is now in the process of running a trial of scribes at one of its sites, and the organization plans to measure productivity, provider satisfaction, and HCAHPS patient satisfaction scores.


 

A workaround – or a problem solver?

In a 2015 Viewpoint article in JAMA,³ George Gellert, MD, MPH, MPA, former chief medical information officer for the CHRISTUS Santa Rosa health system in San Antonio, Texas, and his coauthors labeled the use of scribes as a “workaround” that could curtail efforts to make EHRs more functionally operational because their use allows physicians to be satisfied with inferior EHR products.

In an interview, Dr. Gellert stated that he hasn’t changed his views about the negative consequences of scribes on EHR improvement. “The work of clinicians in using and advancing EHR technology is presently the only method we have for massively distributing and ensuring the use of evidence-based medicine,” he said. “That in turn is a critical strategy for reducing high rates of medical errors through a variety of decision-support applications.”

For better or worse, EHRs are an essential part of the solution to the epidemic of preventable, medical error–caused patient deaths, Dr. Gellert said. He also believes that substantial progress has already been made in advancing EHR usability, as reflected in the most recent product releases by leading EHR companies. However, considerable evolution is still needed in both usability and optimization of clinical decision support.

“With respect to your readers, my recommendation is to not use medical scribes, or else delimit their use to only where absolutely required. Instead, develop systematic processes to regularly capture specific physician concerns with the EHR being used, and transmit that critical information to their EHR vendor with a clear expectation that the manufacturer will address the issue in the near term, or at least in their next major product iteration or generation,” Dr. Gellert said.

By contrast, at the Management of the Hospitalized Patient conference in San Francisco in October 2015, Christine Sinsky, MD, FACP, vice president for professional satisfaction at the American Medical Association, identified documentation assistance as a helpful intervention for physician stress and burnout.⁴ In a recent email, Dr. Sinsky called documentation assistance “the most powerful intervention to give patients the time, attention, and care they need from their physicians. The data entry and data retrieval work of health care has grown over the last decade. Sharing this work with nonphysicians allows society to get the most value for its investment in physicians’ training.”

Dr. Sinsky calls documentation assistance – such as that provided by medical scribes – “a logical and strategic delegation of work according to ability for greater value,” not a workaround. She said it makes patient care safer by allowing physicians to focus on medical decision making and relationship building – rather than record keeping.
 

Experience from the front lines

Eric Edwards, MD, FAAP, FHM, of the division of hospital medicine at the University of North Carolina’s Hillsborough Hospital campus, recently presented a poster on his group’s experience with medical scribes at a meeting of the North Carolina Triangle Chapter of SHM. Their research concluded that scribes can be successfully incorporated into an inpatient hospital medicine practice and thus increase provider satisfaction and decrease the time clinicians spend charting.

“We were able to get the support of the hospital administration to pilot the use of scribes 3 days per week, which we’ve now done for almost a year,” Dr. Edwards said. Scribes are employed through a local company, MedScribes, and they work alongside admitting hospitalists during their 10-hour shifts. The hospitalists have been overwhelmingly positive about their experience, he said. “We established that it saves the physician 15 minutes per patient encounter by helping with documentation.”

It’s important that the scribe gets to know an individual provider’s personal preferences, Dr. Edwards said. Some hospitalists create their own charting templates. There’s also a need to train the clinician in how to use the medical scribe. For example, physicians are instructed to call out physical findings during their exam, which simultaneously informs the patient while allowing the scribe to document the exam.

“We are working on getting more formal data about the scribe experience,” he added. “But we have found that our providers love it, and it improves their efficiency and productivity. The danger is if the physician becomes too reliant on the scribe and fails to exercise due diligence in reviewing the scribe’s notes to ensure that all relevant information is in the chart and irrelevant information is not. We need to make sure we are carefully reviewing and signing off on the scribe’s notes,” he explained.

“I think we’re years away from improving the EHR to the point that would allow us to call it doctor friendly,” Dr. Edwards said. “For now, the scribe is a great way to alleviate some of the physician’s burden. But for hospitalist groups to use scribes successfully, it can’t be done haphazardly. We are lucky to have an experienced local scribe company to partner with. They provide systematic training and orientation. It’s also important that scribes are trained in the specific EHR that they will be using.”

Christine Lum Lung, MD, SFHM, CEO and medical director of Northern Colorado Hospitalists, a hospital medicine group at the University of Colorado’s North Campus hospitals in Fort Collins, has been studying the use of scribes since 2014. “We had a gap in bringing on new doctors fast enough for our group’s needs, so I looked into the return on investment from scribes and pitched it to our group,” she said. “It’s difficult to say what has been the actual impact on caseload, but we all think it has reduced physician workdays by an hour or greater.”

The 32-member hospitalist group, which covers two facilities, has a designated director of scribes who periodically surveys the hospitalists’ satisfaction with the scribes. “Now we all embrace the use of scribes. Satisfaction is high, and quality of life has improved,” Dr. Lum Lung said. “It’s hard to quantify, but we feel like it helps with burnout for us to be able to leave work earlier, and it alleviates some of the other stresses in our workday.”

She said scribes are important to the medical team not just with managing the EHR but also with other burdens such as documenting compliance with code status, VTEs, and other quality requirements, and to help with other regulatory issues. Scribes can look up lab values and radiology reports. When there are downtimes, they can prepare discharge plans.

Typically, there are five scribes on duty for 18 hours a day at each hospital, Dr. Lum Lung said. But only those doctors primarily doing admissions are assured of having a scribe to round with them. “Most doctors in the group would say the greatest efficiency of scribes is with admitting,” she said. The company that provides scribes to the UC hospitals, ScribeAmerica, handles administration, training, and human resource issues, and the scribe team has a designated Lead Scribe and Quality Scribe at their facility.


 

Studying the benefits

Andrew Friedson, PhD, a health care economist at the University of Colorado in Denver, recently conducted a 9-month randomized experiment in three hospital emergency rooms in the Denver area to determine the effects of scribes on measures of emergency physician productivity.⁵ He found that scribes reduced patient wait times in the emergency department by about 13 minutes per patient, while greatly decreasing the amount of time physicians spent after a shift completing their charting, which thus lowered overtime costs for ED physicians.

“This is one of the first times medical scribes have been studied with a randomized, controlled trial,” Dr. Friedson said. “I tracked the amount of overtime, patient waiting, and charge capture for each encounter. These were hospitals where the emergency doctors weren’t allowed to go home until their charting was done.” He discovered that there was a large drop in the time between when patients arrived at the ED and when a decision was made regarding whether to admit them. Additionally, charge capture increased significantly, and physicians had more time to perform medical procedures. Dr. Friedson believes that his findings hold implications for other settings and medical groups, including hospital medicine. To the extent that scribes free up hospitalists to perform tasks other than charting, they should provide an efficiency benefit.

So why hasn’t the medical scribe caught on in a bigger way for hospitalists, compared with ED physicians? For Dr. Corvini, the ED is an obvious, high-pressure, high-volume setting where the cost of the scribe can be easily recouped. “That doesn’t exist in such an obvious fashion in hospital medicine, except where high-volume admissions are concentrated in a single physician’s caseload,” he said. Not all hospitalist groups will fit that model. Some may divide admissions between hospitalists on a shift, and others may not be large enough to experience significant caseload pressures.

“EDs are obviously time pressured, and once scribes demonstrate the ability to produce documentation in a high-quality fashion, they are quickly accepted. In hospital medicine, the time pressures are different – not necessarily less, but different,” Dr. Corvini said. There are also differences in physician responsibilities between the ED and hospital medicine, as well as in physicians’ willingness to let go of documentation responsibilities. “My prediction, if the scribe test is rolled out successfully in TeamHealth, with measurable benefits, it will be adopted in other settings where it fits.”
 

References

1. Shanafelt TD et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48.

2. Collins TR. Use of medical scribes spurs debate about costs, difficulties of electronic health records. The Hospitalist; 2015 Oct.

3. Gellert GA et al. The rise of the medical scribe industry: Implications for the advancement of electronic health records. JAMA; 2015;313(13):1315-6.

4. Beresford L. Electronic Health Records Key Driver of Physician Burnout. The Hospitalist; 2015 Dec.

5. Friedson AI. Medical scribes as an input in healthcare production: Evidence from a randomized experiment. Am J Health Econ. 2017 Oct 2. doi: /10.1162/ajhe_a_00103.






 

Physician stress and burnout remain major concerns for the U.S. health care system, with frustrations over the electronic health record (EHR) driving much of the dissatisfaction experienced by hospitalists and other physicians in the hospital.¹ Underlying the EHR conundrum is a deeper question: Is entering clinical data on a computer the best use of a doctor’s time and professional skills? Or could a portion of that clerical function be delegated to nonphysicians?

Trained medical scribes, charting specialists who input EHR data for physicians on rounds, have been offered as a solution to potentially affect job stress for physicians and shorten their work days. But while scribes have been used and tested by different hospitalist groups around the country, the concept has not taken off in hospital medicine the way it has in certain other settings, such as emergency departments.

“The demand for scribes doesn’t seem to have materialized in a big way for hospital medicine,” said John Nelson, MD, MHM, a hospitalist and consultant in Bellevue, Wash., and a cofounder of the Society of Hospital Medicine. “I’m not convinced that scribes have had a big impact on hospitalist burnout.” It’s difficult to share scribes between doctors on a shift, and it’s a problem if the scribe and doctor get physically separated in the hospital. There’s also the question of who should pay the scribe’s salary, Dr. Nelson said.

Frustrations with the EHR can be a major factor in the experience of physician burnout, but Dr. Nelson said hospitalists can get proficient more quickly because they’re using the same computer system all day. “The bigger problem is that other doctors like surgeons don’t learn how to use the EHR and dump their routine tasks involving the EHR on the hospitalist, which means more work that is less satisfying.”

Could pairing a scribe with a hospitalist improve efficiency and decrease costs relative to the expense of employing the scribe? Are there specific settings, applications, and caseloads in hospital medicine where it makes more sense to use a scribe to support and assist doctors while they’re meeting with patients, with the doctor reviewing and editing the scribe’s work for accuracy? Could the scribe even help with physician staffing shortages by making doctors more productive?

TeamHealth, a national physician services company based in Knoxville, Tenn., has used scribes in emergency departments for years but had concluded that they made less sense for its hospitalist groups after a failure to document significant net increases in productivity, according to a 2015 report in The Hospitalist.² Michael Corvini, MD, FACP, FACEP, TeamHealth’s new regional medical director for acute care services, said he brought extensive positive experience with scribes to his new job and is quite excited about their potential for hospital medicine. “When I came to TeamHealth in July, I began to suggest that there was unrealized potential for scribes,” he said.

Dr. Corvini noted that a potential benefit of scribes for patients is that their presence may allow for more face time with the doctor. Providers, relieved of worrying about completing the chart in its entirety would be more able to focus on the patient and critical thinking. There are even benefits for scribes themselves. Often scribes are medical students, and those who are interested in pursuing a future in the health professions gain invaluable experience in the workings of medicine. “They are making a real contribution to patient care. They are a member of the health care team,” he said.

Dr. Corvini sees two primary areas in which scribes can contribute to hospital medicine. The first is shadowing the physician who is admitting patients during a high-volume admissions shift. Regular tasks like capturing the patient’s medication list and populating the History and Physical document lend themselves well to data entry by scribes, in contrast to completing more routine daily progress notes, which does not.

“They can also be helpful when there is a major transition from paper charting to the EHR or from one EHR system to another, when there is a lot of stress on the physician and risk for lost billing revenue,” Dr. Corvini said. “If scribes are trained in a particular EHR, they could help teach the physician how to use it.” TeamHealth is now in the process of running a trial of scribes at one of its sites, and the organization plans to measure productivity, provider satisfaction, and HCAHPS patient satisfaction scores.


 

A workaround – or a problem solver?

In a 2015 Viewpoint article in JAMA,³ George Gellert, MD, MPH, MPA, former chief medical information officer for the CHRISTUS Santa Rosa health system in San Antonio, Texas, and his coauthors labeled the use of scribes as a “workaround” that could curtail efforts to make EHRs more functionally operational because their use allows physicians to be satisfied with inferior EHR products.

In an interview, Dr. Gellert stated that he hasn’t changed his views about the negative consequences of scribes on EHR improvement. “The work of clinicians in using and advancing EHR technology is presently the only method we have for massively distributing and ensuring the use of evidence-based medicine,” he said. “That in turn is a critical strategy for reducing high rates of medical errors through a variety of decision-support applications.”

For better or worse, EHRs are an essential part of the solution to the epidemic of preventable, medical error–caused patient deaths, Dr. Gellert said. He also believes that substantial progress has already been made in advancing EHR usability, as reflected in the most recent product releases by leading EHR companies. However, considerable evolution is still needed in both usability and optimization of clinical decision support.

“With respect to your readers, my recommendation is to not use medical scribes, or else delimit their use to only where absolutely required. Instead, develop systematic processes to regularly capture specific physician concerns with the EHR being used, and transmit that critical information to their EHR vendor with a clear expectation that the manufacturer will address the issue in the near term, or at least in their next major product iteration or generation,” Dr. Gellert said.

By contrast, at the Management of the Hospitalized Patient conference in San Francisco in October 2015, Christine Sinsky, MD, FACP, vice president for professional satisfaction at the American Medical Association, identified documentation assistance as a helpful intervention for physician stress and burnout.⁴ In a recent email, Dr. Sinsky called documentation assistance “the most powerful intervention to give patients the time, attention, and care they need from their physicians. The data entry and data retrieval work of health care has grown over the last decade. Sharing this work with nonphysicians allows society to get the most value for its investment in physicians’ training.”

Dr. Sinsky calls documentation assistance – such as that provided by medical scribes – “a logical and strategic delegation of work according to ability for greater value,” not a workaround. She said it makes patient care safer by allowing physicians to focus on medical decision making and relationship building – rather than record keeping.
 

Experience from the front lines

Eric Edwards, MD, FAAP, FHM, of the division of hospital medicine at the University of North Carolina’s Hillsborough Hospital campus, recently presented a poster on his group’s experience with medical scribes at a meeting of the North Carolina Triangle Chapter of SHM. Their research concluded that scribes can be successfully incorporated into an inpatient hospital medicine practice and thus increase provider satisfaction and decrease the time clinicians spend charting.

“We were able to get the support of the hospital administration to pilot the use of scribes 3 days per week, which we’ve now done for almost a year,” Dr. Edwards said. Scribes are employed through a local company, MedScribes, and they work alongside admitting hospitalists during their 10-hour shifts. The hospitalists have been overwhelmingly positive about their experience, he said. “We established that it saves the physician 15 minutes per patient encounter by helping with documentation.”

It’s important that the scribe gets to know an individual provider’s personal preferences, Dr. Edwards said. Some hospitalists create their own charting templates. There’s also a need to train the clinician in how to use the medical scribe. For example, physicians are instructed to call out physical findings during their exam, which simultaneously informs the patient while allowing the scribe to document the exam.

“We are working on getting more formal data about the scribe experience,” he added. “But we have found that our providers love it, and it improves their efficiency and productivity. The danger is if the physician becomes too reliant on the scribe and fails to exercise due diligence in reviewing the scribe’s notes to ensure that all relevant information is in the chart and irrelevant information is not. We need to make sure we are carefully reviewing and signing off on the scribe’s notes,” he explained.

“I think we’re years away from improving the EHR to the point that would allow us to call it doctor friendly,” Dr. Edwards said. “For now, the scribe is a great way to alleviate some of the physician’s burden. But for hospitalist groups to use scribes successfully, it can’t be done haphazardly. We are lucky to have an experienced local scribe company to partner with. They provide systematic training and orientation. It’s also important that scribes are trained in the specific EHR that they will be using.”

Christine Lum Lung, MD, SFHM, CEO and medical director of Northern Colorado Hospitalists, a hospital medicine group at the University of Colorado’s North Campus hospitals in Fort Collins, has been studying the use of scribes since 2014. “We had a gap in bringing on new doctors fast enough for our group’s needs, so I looked into the return on investment from scribes and pitched it to our group,” she said. “It’s difficult to say what has been the actual impact on caseload, but we all think it has reduced physician workdays by an hour or greater.”

The 32-member hospitalist group, which covers two facilities, has a designated director of scribes who periodically surveys the hospitalists’ satisfaction with the scribes. “Now we all embrace the use of scribes. Satisfaction is high, and quality of life has improved,” Dr. Lum Lung said. “It’s hard to quantify, but we feel like it helps with burnout for us to be able to leave work earlier, and it alleviates some of the other stresses in our workday.”

She said scribes are important to the medical team not just with managing the EHR but also with other burdens such as documenting compliance with code status, VTEs, and other quality requirements, and to help with other regulatory issues. Scribes can look up lab values and radiology reports. When there are downtimes, they can prepare discharge plans.

Typically, there are five scribes on duty for 18 hours a day at each hospital, Dr. Lum Lung said. But only those doctors primarily doing admissions are assured of having a scribe to round with them. “Most doctors in the group would say the greatest efficiency of scribes is with admitting,” she said. The company that provides scribes to the UC hospitals, ScribeAmerica, handles administration, training, and human resource issues, and the scribe team has a designated Lead Scribe and Quality Scribe at their facility.


 

Studying the benefits

Andrew Friedson, PhD, a health care economist at the University of Colorado in Denver, recently conducted a 9-month randomized experiment in three hospital emergency rooms in the Denver area to determine the effects of scribes on measures of emergency physician productivity.⁵ He found that scribes reduced patient wait times in the emergency department by about 13 minutes per patient, while greatly decreasing the amount of time physicians spent after a shift completing their charting, which thus lowered overtime costs for ED physicians.

“This is one of the first times medical scribes have been studied with a randomized, controlled trial,” Dr. Friedson said. “I tracked the amount of overtime, patient waiting, and charge capture for each encounter. These were hospitals where the emergency doctors weren’t allowed to go home until their charting was done.” He discovered that there was a large drop in the time between when patients arrived at the ED and when a decision was made regarding whether to admit them. Additionally, charge capture increased significantly, and physicians had more time to perform medical procedures. Dr. Friedson believes that his findings hold implications for other settings and medical groups, including hospital medicine. To the extent that scribes free up hospitalists to perform tasks other than charting, they should provide an efficiency benefit.

So why hasn’t the medical scribe caught on in a bigger way for hospitalists, compared with ED physicians? For Dr. Corvini, the ED is an obvious, high-pressure, high-volume setting where the cost of the scribe can be easily recouped. “That doesn’t exist in such an obvious fashion in hospital medicine, except where high-volume admissions are concentrated in a single physician’s caseload,” he said. Not all hospitalist groups will fit that model. Some may divide admissions between hospitalists on a shift, and others may not be large enough to experience significant caseload pressures.

“EDs are obviously time pressured, and once scribes demonstrate the ability to produce documentation in a high-quality fashion, they are quickly accepted. In hospital medicine, the time pressures are different – not necessarily less, but different,” Dr. Corvini said. There are also differences in physician responsibilities between the ED and hospital medicine, as well as in physicians’ willingness to let go of documentation responsibilities. “My prediction, if the scribe test is rolled out successfully in TeamHealth, with measurable benefits, it will be adopted in other settings where it fits.”
 

References

1. Shanafelt TD et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48.

2. Collins TR. Use of medical scribes spurs debate about costs, difficulties of electronic health records. The Hospitalist; 2015 Oct.

3. Gellert GA et al. The rise of the medical scribe industry: Implications for the advancement of electronic health records. JAMA; 2015;313(13):1315-6.

4. Beresford L. Electronic Health Records Key Driver of Physician Burnout. The Hospitalist; 2015 Dec.

5. Friedson AI. Medical scribes as an input in healthcare production: Evidence from a randomized experiment. Am J Health Econ. 2017 Oct 2. doi: /10.1162/ajhe_a_00103.