The Society of Hospital Medicine (SHM) has historically focused on meeting the needs of individual members of the hospital medicine team. Further investigation, however, revealed that the Society had members who were program directors, C-suite executives, multisite group leaders, and practice administrators who had more strategic needs, and SHM wanted to offer solutions that would also positively impact their staff.

One year ago, SHM launched a “listening tour” to gain an understanding of what some of these strategic objectives were and how the society might be able to assist. Representatives from SHM staff met with full teams from hospital systems as well as management companies and identified some common themes, including:

• Integrating nurse practitioners/physician assistants into their practices.
• Planning for growth and succession and incorporating SHM meetings, CME, and training into those plans.
• Proving the value of the hospital medicine program to the C-suite.

Why is Adfinitas Health choosing to become an institutional partner with SHM?

Adfinitas Health is a trusted partner to more than 50 diverse hospitals and post-acute facilities across Maryland, Virginia, Michigan, and Pennsylvania. We are mission focused and led by our core values, which means we always lead with a patient-centered approach to care that produces higher patient satisfaction, better clinical outcomes, and greater value for our partners. We focus on bringing leading-edge practices and protocols to our partner facilities to drive quality and elevate care.

Our decision to become an institutional partner with SHM was simple. Besides being the voice of our industry, SHM plays a critical role in advancing the field of hospital medicine. We know that our providers look to SHM as a resource for clinical and professional development; by becoming an institutional partner, we hope to support that growth objective.

We are looking forward to the opportunity to advance the field of hospital medicine and drive practices and innovations that better support patient-centered care.
 

Which SHM resources and opportunities do you find most valuable for your providers?

The most valuable resources for our providers are the opportunities for learning and professional development. The education offerings are comprehensive and evidence based, which is critical. Whether a provider is looking to fulfill a continuing medical education requirement or needs information to help enhance their performance, we know that they will get what they need from SHM.

The annual conferences, chapter events, and training academies also are valuable to our company and providers. We provide core hospitalist programs that can be customized with integrated complementary services – such as palliative care, pain management, pediatrics, and critical care – based on the needs of the client. We also heavily integrate advance practice providers into our programs. Therefore, we rely on the diverse set of training and learning opportunities that SHM holds throughout the year.

What does it mean to your organization to be the first partner in this program?

Adfinitas cofounders Doug Mitchell, MD, and Hung Davis, MD, have been committed to advancing the field of hospital medicine for nearly 2 decades. They were early members of SHM, along with our other company partners and many of our providers. So, it is an honor to be the first institutional partner – certainly an important milestone in our corporate history. The company has grown from 1 hospital in 2007 to more than 50 hospital and post-acute partners across four states over the past 11 years.

What long-term benefits do you see this partnership offering to your hospitalists?

At our size and scale, the need for a more formal institutional partnership with SHM made perfect sense. We strive to be an employer of choice for hospitalists, including physicians, nurse practitioners, and physician assistants. Our focus on core values builds a culture of engaged, talented employees who feel supported as they progress in their careers. We strive to do all we can to support that growth, and this partnership will help us meet and exceed that goal.

What message are you sending Adfinitas Health hospitalists by partnering with SHM?

We are encouraging our hospitalists to take full advantage of the many learning opportunities and resources that this partnership will bring to bear. We will be actively promoting the customized training that we’ll be offering, as well as the ease of accessing content through the online SHM Learning Portal.

In addition, we want our hospitalists to be connected to the field and remain on the cutting edge of what is important and how best to care for patients. We’ll be encouraging them to be active and involved members at the state and national levels and leverage SHM to grow their professional network.

For more information on SHM’s institutional partnerships, please contact Debra Beach, SHM customer experience manager, at 267-702-2644 or [email protected].
 

The Society of Hospital Medicine (SHM) has historically focused on meeting the needs of individual members of the hospital medicine team. Further investigation, however, revealed that the Society had members who were program directors, C-suite executives, multisite group leaders, and practice administrators who had more strategic needs, and SHM wanted to offer solutions that would also positively impact their staff.

One year ago, SHM launched a “listening tour” to gain an understanding of what some of these strategic objectives were and how the society might be able to assist. Representatives from SHM staff met with full teams from hospital systems as well as management companies and identified some common themes, including:

• Integrating nurse practitioners/physician assistants into their practices.
• Planning for growth and succession and incorporating SHM meetings, CME, and training into those plans.
• Proving the value of the hospital medicine program to the C-suite.

Why is Adfinitas Health choosing to become an institutional partner with SHM?

Adfinitas Health is a trusted partner to more than 50 diverse hospitals and post-acute facilities across Maryland, Virginia, Michigan, and Pennsylvania. We are mission focused and led by our core values, which means we always lead with a patient-centered approach to care that produces higher patient satisfaction, better clinical outcomes, and greater value for our partners. We focus on bringing leading-edge practices and protocols to our partner facilities to drive quality and elevate care.

Our decision to become an institutional partner with SHM was simple. Besides being the voice of our industry, SHM plays a critical role in advancing the field of hospital medicine. We know that our providers look to SHM as a resource for clinical and professional development; by becoming an institutional partner, we hope to support that growth objective.

We are looking forward to the opportunity to advance the field of hospital medicine and drive practices and innovations that better support patient-centered care.
 

Which SHM resources and opportunities do you find most valuable for your providers?

The most valuable resources for our providers are the opportunities for learning and professional development. The education offerings are comprehensive and evidence based, which is critical. Whether a provider is looking to fulfill a continuing medical education requirement or needs information to help enhance their performance, we know that they will get what they need from SHM.

The annual conferences, chapter events, and training academies also are valuable to our company and providers. We provide core hospitalist programs that can be customized with integrated complementary services – such as palliative care, pain management, pediatrics, and critical care – based on the needs of the client. We also heavily integrate advance practice providers into our programs. Therefore, we rely on the diverse set of training and learning opportunities that SHM holds throughout the year.

What does it mean to your organization to be the first partner in this program?

Adfinitas cofounders Doug Mitchell, MD, and Hung Davis, MD, have been committed to advancing the field of hospital medicine for nearly 2 decades. They were early members of SHM, along with our other company partners and many of our providers. So, it is an honor to be the first institutional partner – certainly an important milestone in our corporate history. The company has grown from 1 hospital in 2007 to more than 50 hospital and post-acute partners across four states over the past 11 years.

What long-term benefits do you see this partnership offering to your hospitalists?

At our size and scale, the need for a more formal institutional partnership with SHM made perfect sense. We strive to be an employer of choice for hospitalists, including physicians, nurse practitioners, and physician assistants. Our focus on core values builds a culture of engaged, talented employees who feel supported as they progress in their careers. We strive to do all we can to support that growth, and this partnership will help us meet and exceed that goal.

What message are you sending Adfinitas Health hospitalists by partnering with SHM?

We are encouraging our hospitalists to take full advantage of the many learning opportunities and resources that this partnership will bring to bear. We will be actively promoting the customized training that we’ll be offering, as well as the ease of accessing content through the online SHM Learning Portal.

In addition, we want our hospitalists to be connected to the field and remain on the cutting edge of what is important and how best to care for patients. We’ll be encouraging them to be active and involved members at the state and national levels and leverage SHM to grow their professional network.

For more information on SHM’s institutional partnerships, please contact Debra Beach, SHM customer experience manager, at 267-702-2644 or [email protected].
 

The Society of Hospital Medicine (SHM) has historically focused on meeting the needs of individual members of the hospital medicine team. Further investigation, however, revealed that the Society had members who were program directors, C-suite executives, multisite group leaders, and practice administrators who had more strategic needs, and SHM wanted to offer solutions that would also positively impact their staff.

One year ago, SHM launched a “listening tour” to gain an understanding of what some of these strategic objectives were and how the society might be able to assist. Representatives from SHM staff met with full teams from hospital systems as well as management companies and identified some common themes, including:

• Integrating nurse practitioners/physician assistants into their practices.
• Planning for growth and succession and incorporating SHM meetings, CME, and training into those plans.
• Proving the value of the hospital medicine program to the C-suite.

Why is Adfinitas Health choosing to become an institutional partner with SHM?

Adfinitas Health is a trusted partner to more than 50 diverse hospitals and post-acute facilities across Maryland, Virginia, Michigan, and Pennsylvania. We are mission focused and led by our core values, which means we always lead with a patient-centered approach to care that produces higher patient satisfaction, better clinical outcomes, and greater value for our partners. We focus on bringing leading-edge practices and protocols to our partner facilities to drive quality and elevate care.

Our decision to become an institutional partner with SHM was simple. Besides being the voice of our industry, SHM plays a critical role in advancing the field of hospital medicine. We know that our providers look to SHM as a resource for clinical and professional development; by becoming an institutional partner, we hope to support that growth objective.

We are looking forward to the opportunity to advance the field of hospital medicine and drive practices and innovations that better support patient-centered care.
 

Which SHM resources and opportunities do you find most valuable for your providers?

The most valuable resources for our providers are the opportunities for learning and professional development. The education offerings are comprehensive and evidence based, which is critical. Whether a provider is looking to fulfill a continuing medical education requirement or needs information to help enhance their performance, we know that they will get what they need from SHM.

The annual conferences, chapter events, and training academies also are valuable to our company and providers. We provide core hospitalist programs that can be customized with integrated complementary services – such as palliative care, pain management, pediatrics, and critical care – based on the needs of the client. We also heavily integrate advance practice providers into our programs. Therefore, we rely on the diverse set of training and learning opportunities that SHM holds throughout the year.

What does it mean to your organization to be the first partner in this program?

Adfinitas cofounders Doug Mitchell, MD, and Hung Davis, MD, have been committed to advancing the field of hospital medicine for nearly 2 decades. They were early members of SHM, along with our other company partners and many of our providers. So, it is an honor to be the first institutional partner – certainly an important milestone in our corporate history. The company has grown from 1 hospital in 2007 to more than 50 hospital and post-acute partners across four states over the past 11 years.

What long-term benefits do you see this partnership offering to your hospitalists?

At our size and scale, the need for a more formal institutional partnership with SHM made perfect sense. We strive to be an employer of choice for hospitalists, including physicians, nurse practitioners, and physician assistants. Our focus on core values builds a culture of engaged, talented employees who feel supported as they progress in their careers. We strive to do all we can to support that growth, and this partnership will help us meet and exceed that goal.

What message are you sending Adfinitas Health hospitalists by partnering with SHM?

We are encouraging our hospitalists to take full advantage of the many learning opportunities and resources that this partnership will bring to bear. We will be actively promoting the customized training that we’ll be offering, as well as the ease of accessing content through the online SHM Learning Portal.

In addition, we want our hospitalists to be connected to the field and remain on the cutting edge of what is important and how best to care for patients. We’ll be encouraging them to be active and involved members at the state and national levels and leverage SHM to grow their professional network.

For more information on SHM’s institutional partnerships, please contact Debra Beach, SHM customer experience manager, at 267-702-2644 or [email protected].
 

SILVER SPRING, MD. – In an effort to better match the vaccine to the virus, federal advisors have recommended two new strains be swapped into the 2018-2019 quadrivalent influenza vaccine.

The updates should be the influenza A(H3N2) component and the influenza B components.

Singapore A(H3N2) and the B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) are recommended be added to A/Michigan/45/2015 (H1N1)pdm09-like virus and B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage) for the upcoming season, according to a near-unanimous vote at a meeting of the Food and Drug Administration Vaccines and Related Biological Products Advisory Committee.

Trivalent vaccines should include the same strains, with the exception of B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage), the committee recommended.

The panel voted separately on the strains, and all votes were unanimous, except for the vote on the B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) in the trivalent vaccine, which was supported with 11 positive votes with 1 abstention.

[email protected]

SILVER SPRING, MD. – In an effort to better match the vaccine to the virus, federal advisors have recommended two new strains be swapped into the 2018-2019 quadrivalent influenza vaccine.

The updates should be the influenza A(H3N2) component and the influenza B components.

Singapore A(H3N2) and the B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) are recommended be added to A/Michigan/45/2015 (H1N1)pdm09-like virus and B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage) for the upcoming season, according to a near-unanimous vote at a meeting of the Food and Drug Administration Vaccines and Related Biological Products Advisory Committee.

Trivalent vaccines should include the same strains, with the exception of B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage), the committee recommended.

The panel voted separately on the strains, and all votes were unanimous, except for the vote on the B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) in the trivalent vaccine, which was supported with 11 positive votes with 1 abstention.

[email protected]

SILVER SPRING, MD. – In an effort to better match the vaccine to the virus, federal advisors have recommended two new strains be swapped into the 2018-2019 quadrivalent influenza vaccine.

The updates should be the influenza A(H3N2) component and the influenza B components.

Singapore A(H3N2) and the B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) are recommended be added to A/Michigan/45/2015 (H1N1)pdm09-like virus and B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage) for the upcoming season, according to a near-unanimous vote at a meeting of the Food and Drug Administration Vaccines and Related Biological Products Advisory Committee.

Trivalent vaccines should include the same strains, with the exception of B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage), the committee recommended.

The panel voted separately on the strains, and all votes were unanimous, except for the vote on the B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) in the trivalent vaccine, which was supported with 11 positive votes with 1 abstention.

[email protected]

ANAHEIM, CALIF. – Patients with heart disease can safely be reassured that sexual intercourse as a trigger for sudden cardiac death is extremely rare, Aapo Aro, MD, said at the American Heart Association scientific sessions.

He presented an analysis from the ongoing Oregon Sudden Unexpected Death Study, a population-based case-control study that captures all cases of sudden cardiac arrest (SCA) in the Portland, Ore., area.

This was the first-ever study to examine the burden of SCA triggered by sexual activity. Of 4,557 adjudicated cases of SCA in adults during 2002-2015, a mere 34, or 0.7%, happened during or within 1 hour of sexual intercourse.

Thirty-two of the 34 cases occurred in men. That works out to 1% of SCAs in men being related to sexual activity. In women, the rate was 10-fold lower, at 0.1%, noted Dr. Aro, a cardiologist at Helsinki University Hospital who was at Cedars-Sinai Medical Center in Los Angeles at the time he conducted this research.

Many of the Oregonians who experienced SCA had known heart disease at the time, regardless of whether the event occurred during sexual activity or at another time. Of note, however, SCA during sexual activity presented with ventricular fibrillation/ventricular tachycardia in 76% of cases, versus a 45% rate in individuals whose SCA was not associated with sexual intercourse.

“The data are very reassuring,” Dr. Aro said in an interview. “Many of these patients had known cardiac disease, but still the absolute numbers of events are very small. Our take home message from this study is that sexual activity can be regarded as safe even in cardiac patients.”

The Oregon Sudden Unexpected Death Study is funded by the National Heart, Lung, and Blood Institute and the American Heart Association. Dr. Aro reported having no financial conflicts of interest.

[email protected]

ANAHEIM, CALIF. – Patients with heart disease can safely be reassured that sexual intercourse as a trigger for sudden cardiac death is extremely rare, Aapo Aro, MD, said at the American Heart Association scientific sessions.

He presented an analysis from the ongoing Oregon Sudden Unexpected Death Study, a population-based case-control study that captures all cases of sudden cardiac arrest (SCA) in the Portland, Ore., area.

This was the first-ever study to examine the burden of SCA triggered by sexual activity. Of 4,557 adjudicated cases of SCA in adults during 2002-2015, a mere 34, or 0.7%, happened during or within 1 hour of sexual intercourse.

Thirty-two of the 34 cases occurred in men. That works out to 1% of SCAs in men being related to sexual activity. In women, the rate was 10-fold lower, at 0.1%, noted Dr. Aro, a cardiologist at Helsinki University Hospital who was at Cedars-Sinai Medical Center in Los Angeles at the time he conducted this research.

Many of the Oregonians who experienced SCA had known heart disease at the time, regardless of whether the event occurred during sexual activity or at another time. Of note, however, SCA during sexual activity presented with ventricular fibrillation/ventricular tachycardia in 76% of cases, versus a 45% rate in individuals whose SCA was not associated with sexual intercourse.

“The data are very reassuring,” Dr. Aro said in an interview. “Many of these patients had known cardiac disease, but still the absolute numbers of events are very small. Our take home message from this study is that sexual activity can be regarded as safe even in cardiac patients.”

The Oregon Sudden Unexpected Death Study is funded by the National Heart, Lung, and Blood Institute and the American Heart Association. Dr. Aro reported having no financial conflicts of interest.

[email protected]

ANAHEIM, CALIF. – Patients with heart disease can safely be reassured that sexual intercourse as a trigger for sudden cardiac death is extremely rare, Aapo Aro, MD, said at the American Heart Association scientific sessions.

He presented an analysis from the ongoing Oregon Sudden Unexpected Death Study, a population-based case-control study that captures all cases of sudden cardiac arrest (SCA) in the Portland, Ore., area.

This was the first-ever study to examine the burden of SCA triggered by sexual activity. Of 4,557 adjudicated cases of SCA in adults during 2002-2015, a mere 34, or 0.7%, happened during or within 1 hour of sexual intercourse.

Thirty-two of the 34 cases occurred in men. That works out to 1% of SCAs in men being related to sexual activity. In women, the rate was 10-fold lower, at 0.1%, noted Dr. Aro, a cardiologist at Helsinki University Hospital who was at Cedars-Sinai Medical Center in Los Angeles at the time he conducted this research.

Many of the Oregonians who experienced SCA had known heart disease at the time, regardless of whether the event occurred during sexual activity or at another time. Of note, however, SCA during sexual activity presented with ventricular fibrillation/ventricular tachycardia in 76% of cases, versus a 45% rate in individuals whose SCA was not associated with sexual intercourse.

“The data are very reassuring,” Dr. Aro said in an interview. “Many of these patients had known cardiac disease, but still the absolute numbers of events are very small. Our take home message from this study is that sexual activity can be regarded as safe even in cardiac patients.”

The Oregon Sudden Unexpected Death Study is funded by the National Heart, Lung, and Blood Institute and the American Heart Association. Dr. Aro reported having no financial conflicts of interest.

[email protected]

KAUAI, HAWAII – A topical halobetasol/tazarotene fixed-combination lotion for moderate to severe psoriasis hit all of its efficacy and safety endpoints in two phase 3 randomized, double-blind, multicenter clinical trials, Linda Stein Gold, MD, reported at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

The fixed combination of halobetasol 0.01%/tazarotene 0.045% lotion takes advantage of an observation made 20 years ago: When tazarotene is combined with a potent topical corticosteroid, therapeutic efficacy is amplified synergistically while the problematic local side effects of each agent are diminished, explained Dr. Stein Gold, director of dermatology research at the Henry Ford Health System, Detroit.

Bruce Jancin/Frontline Medical News

[email protected]

KAUAI, HAWAII – A topical halobetasol/tazarotene fixed-combination lotion for moderate to severe psoriasis hit all of its efficacy and safety endpoints in two phase 3 randomized, double-blind, multicenter clinical trials, Linda Stein Gold, MD, reported at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

The fixed combination of halobetasol 0.01%/tazarotene 0.045% lotion takes advantage of an observation made 20 years ago: When tazarotene is combined with a potent topical corticosteroid, therapeutic efficacy is amplified synergistically while the problematic local side effects of each agent are diminished, explained Dr. Stein Gold, director of dermatology research at the Henry Ford Health System, Detroit.

Bruce Jancin/Frontline Medical News

[email protected]

KAUAI, HAWAII – A topical halobetasol/tazarotene fixed-combination lotion for moderate to severe psoriasis hit all of its efficacy and safety endpoints in two phase 3 randomized, double-blind, multicenter clinical trials, Linda Stein Gold, MD, reported at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

The fixed combination of halobetasol 0.01%/tazarotene 0.045% lotion takes advantage of an observation made 20 years ago: When tazarotene is combined with a potent topical corticosteroid, therapeutic efficacy is amplified synergistically while the problematic local side effects of each agent are diminished, explained Dr. Stein Gold, director of dermatology research at the Henry Ford Health System, Detroit.

Bruce Jancin/Frontline Medical News

[email protected]

Henry Ng, MD, MPH, an internal medicine physician and pediatrician in Cleveland who specializes in the treatment of lesbian, gay, bisexual, and transgender (LGBT) patients, walked into an exam room to meet a patient several years ago. The patient was 65 years old and presented as a man.

“I made an assumption about this person based on the cues that I saw and I misperceived this person’s identity,” he said. “A patient less comfortable in their skin may have left. And a younger patient would likely have been offended if I had met and misgendered them.”

If Dr. Ng could make this kind of error, it’s clear how easy it is for clinicians with less training and experience to make clumsy assumptions about gender identity.

Even with wider societal awareness of gender identity issues, the cultural sensibilities and training among hospitalists and other clinicians required for quality care of transgender patients is still lacking, Dr. Ng said. Unfortunately, many physicians may have little interest in providing this care, or lack the skills for it, he said.

In the hospital, patients already feel vulnerable because of their medical conditions, and treating transgender inpatients may require additional layers of complexity, experts say. For instance, how should a physician address a patient? The initial encounter can have a huge impact on the clinician’s ability to earn the patient’s trust, and sets the tone for the entire hospital stay. Which bathroom should a transgender patient use? What unique family issues must clinicians be aware of? Transgender patients may be more likely to have simmering tensions with immediate and extended family, and may not want certain family members involved in medical decisions.

Physicians and nurses must be aware of these issues to create a welcoming and logistically sound environment, said Nicole Rosendale, MD, a neurohospitalist at the University of California San Francisco who has a special interest in LGBT care.

Need for more training

Hospitalists will increasingly find themselves caring for transgender patients, as more people openly claim a gender identity outside the traditional gender categories. A recent study in the United Kingdom found that 20%-25% of people under 25 did not identify as heterosexual, or considered themselves as having a personal gender identity that did not correspond with the sex assigned at birth, Dr. Ng said.

“I don’t think this is something that is a trend, I don’t think it’s a fad,” Dr. Ng said. “I don’t think it’s going to go away.”

The amount of resources available for training clinicians in caring for transgender patients is expanding, he said, and both trainees and veteran clinicians can find educational programs tailored to their needs, although they might have to seek them out. Nonetheless, Dr. Ng thinks hospitalists would be wise to pursue such training.

Unfortunately, most medical schools do not as yet offer targeted training in transgender care, or even LGBT care more broadly, said Vin Tangpricha, MD, PhD, president elect of the World Professional Association for Transgender Health (WPATH).

“The biggest gap is training in medical school and residency,” Dr. Tangpricha said. “Only one out of three medical schools have any transgender curriculum taught to students. Physicians lack knowledge on the diagnosis of gender dysphoria and the hormone regimens that are commonly used. Also, physicians don’t feel comfortable speaking to transgender patients because they lack experience working with this population.”

Training in caring for transgender patients and other segments of the LGBT patient population is available through WPATH, the Fenway Institute in Boston, and GLMA, formerly known as the Gay & Lesbian Medical Association, as well some other organizations, Dr. Tangpricha said.

Dr. Rosendale took training into her own hands. She saw gaps in the curriculum, and started LGBT training programs at New York University, where she went to medical school, and at UCSF, where she completed her neurology residency and neurohospitalist fellowship.

The curriculum, which was blended with diversity training at UCSF, involved basic concepts such as terminology, the difference between gender identity and sexual orientation, communication tips, and discussions of the health care experience from the LGBT patient perspective. Even a relatively small amount of training can go a long way, she said.

“When I work with trainees now who have heard some of the lectures and have gone through some of the training, their fluency and their comfort with the terminology, with the concepts that are used within the LGBT community, is much better than it was before,” Dr. Rosendale said.

Demonstrating the importance of training to those in charge of curriculum decisions is the most important step for anyone interested in adding instruction for transgender care at their centers, she said.

Katie Imborek, MD, cofounder of the University of Iowa LGBTQ Clinic, has worked with hospitalists on improving their care for transgender patients. She and internal medicine physician Nicole Nisly, MD, opened the clinic when a need became apparent.

Before the University of Iowa clinic opened, a transgender advocacy group hosted a forum on LGBT health care, at which patients shared stories of frustration. One patient related a story about calling a department at the university, only to be told, “We don’t take care of people like you.” In another frustrating case, a transgender man had been having vaginal bleeding and called the obstetrics department seeking help. He was repeatedly told he was calling the wrong place. During a white board exercise at the forum, one patient drew buildings representing the university health care system surrounded by barbed wire, symbolizing an off-putting atmosphere in the emergency department that was rife with misgendering of patients.

Henry Ng, MD, MPH, an internal medicine physician and pediatrician in Cleveland who specializes in the treatment of lesbian, gay, bisexual, and transgender (LGBT) patients, walked into an exam room to meet a patient several years ago. The patient was 65 years old and presented as a man.

“I made an assumption about this person based on the cues that I saw and I misperceived this person’s identity,” he said. “A patient less comfortable in their skin may have left. And a younger patient would likely have been offended if I had met and misgendered them.”

If Dr. Ng could make this kind of error, it’s clear how easy it is for clinicians with less training and experience to make clumsy assumptions about gender identity.

Even with wider societal awareness of gender identity issues, the cultural sensibilities and training among hospitalists and other clinicians required for quality care of transgender patients is still lacking, Dr. Ng said. Unfortunately, many physicians may have little interest in providing this care, or lack the skills for it, he said.

In the hospital, patients already feel vulnerable because of their medical conditions, and treating transgender inpatients may require additional layers of complexity, experts say. For instance, how should a physician address a patient? The initial encounter can have a huge impact on the clinician’s ability to earn the patient’s trust, and sets the tone for the entire hospital stay. Which bathroom should a transgender patient use? What unique family issues must clinicians be aware of? Transgender patients may be more likely to have simmering tensions with immediate and extended family, and may not want certain family members involved in medical decisions.

Physicians and nurses must be aware of these issues to create a welcoming and logistically sound environment, said Nicole Rosendale, MD, a neurohospitalist at the University of California San Francisco who has a special interest in LGBT care.

Need for more training

Hospitalists will increasingly find themselves caring for transgender patients, as more people openly claim a gender identity outside the traditional gender categories. A recent study in the United Kingdom found that 20%-25% of people under 25 did not identify as heterosexual, or considered themselves as having a personal gender identity that did not correspond with the sex assigned at birth, Dr. Ng said.

“I don’t think this is something that is a trend, I don’t think it’s a fad,” Dr. Ng said. “I don’t think it’s going to go away.”

The amount of resources available for training clinicians in caring for transgender patients is expanding, he said, and both trainees and veteran clinicians can find educational programs tailored to their needs, although they might have to seek them out. Nonetheless, Dr. Ng thinks hospitalists would be wise to pursue such training.

Unfortunately, most medical schools do not as yet offer targeted training in transgender care, or even LGBT care more broadly, said Vin Tangpricha, MD, PhD, president elect of the World Professional Association for Transgender Health (WPATH).

“The biggest gap is training in medical school and residency,” Dr. Tangpricha said. “Only one out of three medical schools have any transgender curriculum taught to students. Physicians lack knowledge on the diagnosis of gender dysphoria and the hormone regimens that are commonly used. Also, physicians don’t feel comfortable speaking to transgender patients because they lack experience working with this population.”

Training in caring for transgender patients and other segments of the LGBT patient population is available through WPATH, the Fenway Institute in Boston, and GLMA, formerly known as the Gay & Lesbian Medical Association, as well some other organizations, Dr. Tangpricha said.

Dr. Rosendale took training into her own hands. She saw gaps in the curriculum, and started LGBT training programs at New York University, where she went to medical school, and at UCSF, where she completed her neurology residency and neurohospitalist fellowship.

The curriculum, which was blended with diversity training at UCSF, involved basic concepts such as terminology, the difference between gender identity and sexual orientation, communication tips, and discussions of the health care experience from the LGBT patient perspective. Even a relatively small amount of training can go a long way, she said.

“When I work with trainees now who have heard some of the lectures and have gone through some of the training, their fluency and their comfort with the terminology, with the concepts that are used within the LGBT community, is much better than it was before,” Dr. Rosendale said.

Demonstrating the importance of training to those in charge of curriculum decisions is the most important step for anyone interested in adding instruction for transgender care at their centers, she said.

Katie Imborek, MD, cofounder of the University of Iowa LGBTQ Clinic, has worked with hospitalists on improving their care for transgender patients. She and internal medicine physician Nicole Nisly, MD, opened the clinic when a need became apparent.

Before the University of Iowa clinic opened, a transgender advocacy group hosted a forum on LGBT health care, at which patients shared stories of frustration. One patient related a story about calling a department at the university, only to be told, “We don’t take care of people like you.” In another frustrating case, a transgender man had been having vaginal bleeding and called the obstetrics department seeking help. He was repeatedly told he was calling the wrong place. During a white board exercise at the forum, one patient drew buildings representing the university health care system surrounded by barbed wire, symbolizing an off-putting atmosphere in the emergency department that was rife with misgendering of patients.

Henry Ng, MD, MPH, an internal medicine physician and pediatrician in Cleveland who specializes in the treatment of lesbian, gay, bisexual, and transgender (LGBT) patients, walked into an exam room to meet a patient several years ago. The patient was 65 years old and presented as a man.

“I made an assumption about this person based on the cues that I saw and I misperceived this person’s identity,” he said. “A patient less comfortable in their skin may have left. And a younger patient would likely have been offended if I had met and misgendered them.”

If Dr. Ng could make this kind of error, it’s clear how easy it is for clinicians with less training and experience to make clumsy assumptions about gender identity.

Even with wider societal awareness of gender identity issues, the cultural sensibilities and training among hospitalists and other clinicians required for quality care of transgender patients is still lacking, Dr. Ng said. Unfortunately, many physicians may have little interest in providing this care, or lack the skills for it, he said.

In the hospital, patients already feel vulnerable because of their medical conditions, and treating transgender inpatients may require additional layers of complexity, experts say. For instance, how should a physician address a patient? The initial encounter can have a huge impact on the clinician’s ability to earn the patient’s trust, and sets the tone for the entire hospital stay. Which bathroom should a transgender patient use? What unique family issues must clinicians be aware of? Transgender patients may be more likely to have simmering tensions with immediate and extended family, and may not want certain family members involved in medical decisions.

Physicians and nurses must be aware of these issues to create a welcoming and logistically sound environment, said Nicole Rosendale, MD, a neurohospitalist at the University of California San Francisco who has a special interest in LGBT care.

Need for more training

Hospitalists will increasingly find themselves caring for transgender patients, as more people openly claim a gender identity outside the traditional gender categories. A recent study in the United Kingdom found that 20%-25% of people under 25 did not identify as heterosexual, or considered themselves as having a personal gender identity that did not correspond with the sex assigned at birth, Dr. Ng said.

“I don’t think this is something that is a trend, I don’t think it’s a fad,” Dr. Ng said. “I don’t think it’s going to go away.”

The amount of resources available for training clinicians in caring for transgender patients is expanding, he said, and both trainees and veteran clinicians can find educational programs tailored to their needs, although they might have to seek them out. Nonetheless, Dr. Ng thinks hospitalists would be wise to pursue such training.

Unfortunately, most medical schools do not as yet offer targeted training in transgender care, or even LGBT care more broadly, said Vin Tangpricha, MD, PhD, president elect of the World Professional Association for Transgender Health (WPATH).

“The biggest gap is training in medical school and residency,” Dr. Tangpricha said. “Only one out of three medical schools have any transgender curriculum taught to students. Physicians lack knowledge on the diagnosis of gender dysphoria and the hormone regimens that are commonly used. Also, physicians don’t feel comfortable speaking to transgender patients because they lack experience working with this population.”

Training in caring for transgender patients and other segments of the LGBT patient population is available through WPATH, the Fenway Institute in Boston, and GLMA, formerly known as the Gay & Lesbian Medical Association, as well some other organizations, Dr. Tangpricha said.

Dr. Rosendale took training into her own hands. She saw gaps in the curriculum, and started LGBT training programs at New York University, where she went to medical school, and at UCSF, where she completed her neurology residency and neurohospitalist fellowship.

The curriculum, which was blended with diversity training at UCSF, involved basic concepts such as terminology, the difference between gender identity and sexual orientation, communication tips, and discussions of the health care experience from the LGBT patient perspective. Even a relatively small amount of training can go a long way, she said.

“When I work with trainees now who have heard some of the lectures and have gone through some of the training, their fluency and their comfort with the terminology, with the concepts that are used within the LGBT community, is much better than it was before,” Dr. Rosendale said.

Demonstrating the importance of training to those in charge of curriculum decisions is the most important step for anyone interested in adding instruction for transgender care at their centers, she said.

Katie Imborek, MD, cofounder of the University of Iowa LGBTQ Clinic, has worked with hospitalists on improving their care for transgender patients. She and internal medicine physician Nicole Nisly, MD, opened the clinic when a need became apparent.

Before the University of Iowa clinic opened, a transgender advocacy group hosted a forum on LGBT health care, at which patients shared stories of frustration. One patient related a story about calling a department at the university, only to be told, “We don’t take care of people like you.” In another frustrating case, a transgender man had been having vaginal bleeding and called the obstetrics department seeking help. He was repeatedly told he was calling the wrong place. During a white board exercise at the forum, one patient drew buildings representing the university health care system surrounded by barbed wire, symbolizing an off-putting atmosphere in the emergency department that was rife with misgendering of patients.

LAS VEGAS – On April 16, 2007, a 23-year-old man shot 32 people to death and injured 23 others during a massacre on the campus of Virginia Tech University in Blacksburg, before taking his own life. On the same day, 231 other gun casualties occurred in other areas of the United States, 83 of them fatal and 148 nonfatal, according to Jeffrey W. Swanson, PhD.

“These were domestic violence incidents, suicides, some unintentional injuries, and a few law enforcement actions,” he said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This is the daily drip, drip, drip of gun violence in our country.”

According to data from the Substance Abuse and Mental Health Services Administration, 9.8 million adults in the United States have a serious mental illness, 2.5 million have a co-occurring substance use disorder, 1.9 million have no insurance, 3.1 million go without treatment for their mental illness, 100,000 are homeless, and about 1 million find themselves in jail or in prison. “We probably have more people with a serious mental illness in one of our big-city jails every day than we ever had in the largest asylum in the middle of the 20th century,” said Dr. Swanson, professor of psychiatry and behavioral sciences at Duke University, Durham, N.C. “I think that’s scandalous. It probably costs our society $318 billion per year. On the other hand, we have gun-related violence that claims 36,000 lives each year. One economist estimates that costs our society $174 billion per year. Those are two different public health problems that come together on their edges.”

Doug Brunk/Frontline Medical News

• Prioritize contemporaneous risk assessment based on evidence of behaviors that correlate with violence and self-harm at specific times, not mental illness or treatment history per se as a category of exclusion.
• Preempt existing gun access, rather than simply thwarting a new gun purchase by a dangerous person.
• Provide legal due process for deprivation of gun rights.
• Preserve confidential therapeutic relationships. “You don’t want a crisis-driven law that requires doctors to report any patient who talks with them about suicide, because that can have a chilling effect and keep people away from seeking treatment, and also inhibit their disclosures in therapy,” he said.

Prevent the unpredictable through comprehensive background checks, but also by reducing the social determinant of violence and investing in improved access to mental health and substance abuse services.

“This is a complex puzzle, with maybe a couple of pieces hidden under the rug,” Dr. Swanson said.

He reported having no financial disclosures.

[email protected]

LAS VEGAS – On April 16, 2007, a 23-year-old man shot 32 people to death and injured 23 others during a massacre on the campus of Virginia Tech University in Blacksburg, before taking his own life. On the same day, 231 other gun casualties occurred in other areas of the United States, 83 of them fatal and 148 nonfatal, according to Jeffrey W. Swanson, PhD.

“These were domestic violence incidents, suicides, some unintentional injuries, and a few law enforcement actions,” he said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This is the daily drip, drip, drip of gun violence in our country.”

According to data from the Substance Abuse and Mental Health Services Administration, 9.8 million adults in the United States have a serious mental illness, 2.5 million have a co-occurring substance use disorder, 1.9 million have no insurance, 3.1 million go without treatment for their mental illness, 100,000 are homeless, and about 1 million find themselves in jail or in prison. “We probably have more people with a serious mental illness in one of our big-city jails every day than we ever had in the largest asylum in the middle of the 20th century,” said Dr. Swanson, professor of psychiatry and behavioral sciences at Duke University, Durham, N.C. “I think that’s scandalous. It probably costs our society $318 billion per year. On the other hand, we have gun-related violence that claims 36,000 lives each year. One economist estimates that costs our society $174 billion per year. Those are two different public health problems that come together on their edges.”

Doug Brunk/Frontline Medical News

• Prioritize contemporaneous risk assessment based on evidence of behaviors that correlate with violence and self-harm at specific times, not mental illness or treatment history per se as a category of exclusion.
• Preempt existing gun access, rather than simply thwarting a new gun purchase by a dangerous person.
• Provide legal due process for deprivation of gun rights.
• Preserve confidential therapeutic relationships. “You don’t want a crisis-driven law that requires doctors to report any patient who talks with them about suicide, because that can have a chilling effect and keep people away from seeking treatment, and also inhibit their disclosures in therapy,” he said.

Prevent the unpredictable through comprehensive background checks, but also by reducing the social determinant of violence and investing in improved access to mental health and substance abuse services.

“This is a complex puzzle, with maybe a couple of pieces hidden under the rug,” Dr. Swanson said.

He reported having no financial disclosures.

[email protected]

LAS VEGAS – On April 16, 2007, a 23-year-old man shot 32 people to death and injured 23 others during a massacre on the campus of Virginia Tech University in Blacksburg, before taking his own life. On the same day, 231 other gun casualties occurred in other areas of the United States, 83 of them fatal and 148 nonfatal, according to Jeffrey W. Swanson, PhD.

“These were domestic violence incidents, suicides, some unintentional injuries, and a few law enforcement actions,” he said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This is the daily drip, drip, drip of gun violence in our country.”

According to data from the Substance Abuse and Mental Health Services Administration, 9.8 million adults in the United States have a serious mental illness, 2.5 million have a co-occurring substance use disorder, 1.9 million have no insurance, 3.1 million go without treatment for their mental illness, 100,000 are homeless, and about 1 million find themselves in jail or in prison. “We probably have more people with a serious mental illness in one of our big-city jails every day than we ever had in the largest asylum in the middle of the 20th century,” said Dr. Swanson, professor of psychiatry and behavioral sciences at Duke University, Durham, N.C. “I think that’s scandalous. It probably costs our society $318 billion per year. On the other hand, we have gun-related violence that claims 36,000 lives each year. One economist estimates that costs our society $174 billion per year. Those are two different public health problems that come together on their edges.”

Doug Brunk/Frontline Medical News

• Prioritize contemporaneous risk assessment based on evidence of behaviors that correlate with violence and self-harm at specific times, not mental illness or treatment history per se as a category of exclusion.
• Preempt existing gun access, rather than simply thwarting a new gun purchase by a dangerous person.
• Provide legal due process for deprivation of gun rights.
• Preserve confidential therapeutic relationships. “You don’t want a crisis-driven law that requires doctors to report any patient who talks with them about suicide, because that can have a chilling effect and keep people away from seeking treatment, and also inhibit their disclosures in therapy,” he said.

Prevent the unpredictable through comprehensive background checks, but also by reducing the social determinant of violence and investing in improved access to mental health and substance abuse services.

“This is a complex puzzle, with maybe a couple of pieces hidden under the rug,” Dr. Swanson said.

He reported having no financial disclosures.

[email protected]

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest – a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly one in three Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Rita Redberg, M.D., a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Dr. Redberg, who at the University of California–San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries – typically paid for by Medicare, the government health insurance program for people over 65 – involve more than money, said Amber Barnato, MD, professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8% in their final week, according to a 2011 study in The Lancet.

More than 12% of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Eleni Linos, MD, has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When less is more

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20% die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors – ever.”

Margaret Schwarze, MD, a surgeon and associate professor at the University of Wisconsin, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Dr. Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Dr. Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Dr. Redberg said doctors recently treated her mother for melanoma – the most serious type of skin cancer. After the cancer was removed from her leg, Dr. Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Dr. Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken 3 months. When Dr. Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within 3-5 years.

Dr. Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in 3-5 years. I doubt I’ll be here.”

Finding solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Jacqueline Kruser, MD, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26%, while knee replacements declined 38%, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Dr. Schwarze, Dr. Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20% risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just 2-3 months after surgery.

Dr. Schwarze said, “If someone says they can’t tolerate the best-case scenario – which involves them being in a nursing home – then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test – not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Dr. Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another 2 years and 3 months, dying at home just after her 90th birthday in 2010.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest – a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly one in three Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Rita Redberg, M.D., a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Dr. Redberg, who at the University of California–San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries – typically paid for by Medicare, the government health insurance program for people over 65 – involve more than money, said Amber Barnato, MD, professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8% in their final week, according to a 2011 study in The Lancet.

More than 12% of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Eleni Linos, MD, has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When less is more

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20% die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors – ever.”

Margaret Schwarze, MD, a surgeon and associate professor at the University of Wisconsin, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Dr. Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Dr. Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Dr. Redberg said doctors recently treated her mother for melanoma – the most serious type of skin cancer. After the cancer was removed from her leg, Dr. Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Dr. Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken 3 months. When Dr. Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within 3-5 years.

Dr. Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in 3-5 years. I doubt I’ll be here.”

Finding solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Jacqueline Kruser, MD, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26%, while knee replacements declined 38%, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Dr. Schwarze, Dr. Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20% risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just 2-3 months after surgery.

Dr. Schwarze said, “If someone says they can’t tolerate the best-case scenario – which involves them being in a nursing home – then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test – not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Dr. Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another 2 years and 3 months, dying at home just after her 90th birthday in 2010.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest – a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly one in three Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Rita Redberg, M.D., a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Dr. Redberg, who at the University of California–San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries – typically paid for by Medicare, the government health insurance program for people over 65 – involve more than money, said Amber Barnato, MD, professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8% in their final week, according to a 2011 study in The Lancet.

More than 12% of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Eleni Linos, MD, has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When less is more

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20% die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors – ever.”

Margaret Schwarze, MD, a surgeon and associate professor at the University of Wisconsin, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Dr. Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Dr. Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Dr. Redberg said doctors recently treated her mother for melanoma – the most serious type of skin cancer. After the cancer was removed from her leg, Dr. Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Dr. Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken 3 months. When Dr. Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within 3-5 years.

Dr. Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in 3-5 years. I doubt I’ll be here.”

Finding solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Jacqueline Kruser, MD, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26%, while knee replacements declined 38%, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Dr. Schwarze, Dr. Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20% risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just 2-3 months after surgery.

Dr. Schwarze said, “If someone says they can’t tolerate the best-case scenario – which involves them being in a nursing home – then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test – not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Dr. Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another 2 years and 3 months, dying at home just after her 90th birthday in 2010.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

SAN DIEGO—Vitamin D levels may be associated with brain imaging measures in patients with progressive multiple sclerosis (MS), according to an analysis presented at the ACTRIMS 2018 Forum. The association appears to be similar in primary progressive MS and secondary progressive MS and may reflect vitamin D’s protective effect on myelin in gray matter.

Research has identified vitamin D deficiency as a risk factor for MS. Low levels of the vitamin are associated with increased risk of brain lesions, relapses, and early progression of disability. Much of the literature focuses on relapsing-remitting MS. Less is known about the part that vitamin D plays in progressive MS, particularly with respect to clinical and imaging findings.

An Analysis of Phase II Data

Justin Abbatemarco, MD, a neurologist at Cleveland Clinic, and colleagues studied results from the phase II clinical trial of ibudilast to examine the association between vitamin D levels and clinical and MRI features in progressive MS. In the trial, investigators measured participants’ serum 25 OH vitamin D levels. At baseline, they collected demographic information such as age, gender, race, disease duration, duration of progression, prior treatment history, Expanded Disability Status Scale score, MS Functional Composite, and neurocognitive testing. Baseline MRI information included brain parenchymal fraction, diffusion tensor imaging (DTI), and magnetization transfer ratio (MTR).

Dr. Abbatemarco and colleagues used Spearman correlation to evaluate the associations between total vitamin D and vitamin D3 levels and clinical or imaging characteristics. They created a linear regression model to predict clinical and imaging outcome variables.

Vitamin D Was Associated With Whole Brain MTR

The analysis included 267 patients (47.2% male) with a mean age of 55.6. In all, 137 participants had primary progressive MS, and 130 participants had secondary progressive MS. Mean disease duration was 16.4 years. The population’s mean vitamin D3 level was 40.7 ng/mL, and mean total vitamin D level was 43.8 ng/mL. Mean brain parenchymal fraction was 0.8, mean T2 lesion volume was 10.3 mL, and mean whole brain MTR was 0.1.

The investigators did not observe a significant difference in mean vitamin D levels between patients with secondary progressive MS (44.7 ng/mL) and those with primary progressive MS (42.9 ng/mL). They did find positive associations between vitamin D3 and whole brain MTR, normal appearing brain tissue MTR, and normal appearing gray matter MTR. Dr. Abbatemarco’s group found no significant associations between vitamin D levels and brain parenchymal fraction, T1 or T2 lesion volume, or DTI metrics. The associations between vitamin D3 and MRI features were similar in patients with primary progressive MS and those with secondary progressive MS.

In a multivariate analysis that controlled for age, gender, disease duration, the time that vitamin D level was obtained, and latitude of study site, associations between vitamin D3 level and whole brain MTR remained significant. Every 10-ng/mL increase in vitamin D3 was associated with a 2.1% unit increase in whole brain MTR. The investigators found no association between vitamin D3 and brain parenchymal fraction, T2 lesion volume, T1 lesion volume, and clinical scores.

Dr. Abbatemarco and colleagues plan to test the effect of longitudinal changes on clinical and MRI measures once data become available.

—Erik Greb

Suggested Reading

Smolders J, Menheere P, Kessels A, et al. Association of vitamin D metabolite levels with relapse rate and disability in multiple sclerosis. Mult Scler. 2008;14(9):1220-1224.

SAN DIEGO—Vitamin D levels may be associated with brain imaging measures in patients with progressive multiple sclerosis (MS), according to an analysis presented at the ACTRIMS 2018 Forum. The association appears to be similar in primary progressive MS and secondary progressive MS and may reflect vitamin D’s protective effect on myelin in gray matter.

Research has identified vitamin D deficiency as a risk factor for MS. Low levels of the vitamin are associated with increased risk of brain lesions, relapses, and early progression of disability. Much of the literature focuses on relapsing-remitting MS. Less is known about the part that vitamin D plays in progressive MS, particularly with respect to clinical and imaging findings.

An Analysis of Phase II Data

Justin Abbatemarco, MD, a neurologist at Cleveland Clinic, and colleagues studied results from the phase II clinical trial of ibudilast to examine the association between vitamin D levels and clinical and MRI features in progressive MS. In the trial, investigators measured participants’ serum 25 OH vitamin D levels. At baseline, they collected demographic information such as age, gender, race, disease duration, duration of progression, prior treatment history, Expanded Disability Status Scale score, MS Functional Composite, and neurocognitive testing. Baseline MRI information included brain parenchymal fraction, diffusion tensor imaging (DTI), and magnetization transfer ratio (MTR).

Dr. Abbatemarco and colleagues used Spearman correlation to evaluate the associations between total vitamin D and vitamin D3 levels and clinical or imaging characteristics. They created a linear regression model to predict clinical and imaging outcome variables.

Vitamin D Was Associated With Whole Brain MTR

The analysis included 267 patients (47.2% male) with a mean age of 55.6. In all, 137 participants had primary progressive MS, and 130 participants had secondary progressive MS. Mean disease duration was 16.4 years. The population’s mean vitamin D3 level was 40.7 ng/mL, and mean total vitamin D level was 43.8 ng/mL. Mean brain parenchymal fraction was 0.8, mean T2 lesion volume was 10.3 mL, and mean whole brain MTR was 0.1.

The investigators did not observe a significant difference in mean vitamin D levels between patients with secondary progressive MS (44.7 ng/mL) and those with primary progressive MS (42.9 ng/mL). They did find positive associations between vitamin D3 and whole brain MTR, normal appearing brain tissue MTR, and normal appearing gray matter MTR. Dr. Abbatemarco’s group found no significant associations between vitamin D levels and brain parenchymal fraction, T1 or T2 lesion volume, or DTI metrics. The associations between vitamin D3 and MRI features were similar in patients with primary progressive MS and those with secondary progressive MS.

In a multivariate analysis that controlled for age, gender, disease duration, the time that vitamin D level was obtained, and latitude of study site, associations between vitamin D3 level and whole brain MTR remained significant. Every 10-ng/mL increase in vitamin D3 was associated with a 2.1% unit increase in whole brain MTR. The investigators found no association between vitamin D3 and brain parenchymal fraction, T2 lesion volume, T1 lesion volume, and clinical scores.

Dr. Abbatemarco and colleagues plan to test the effect of longitudinal changes on clinical and MRI measures once data become available.

—Erik Greb

Suggested Reading

Smolders J, Menheere P, Kessels A, et al. Association of vitamin D metabolite levels with relapse rate and disability in multiple sclerosis. Mult Scler. 2008;14(9):1220-1224.

SAN DIEGO—Vitamin D levels may be associated with brain imaging measures in patients with progressive multiple sclerosis (MS), according to an analysis presented at the ACTRIMS 2018 Forum. The association appears to be similar in primary progressive MS and secondary progressive MS and may reflect vitamin D’s protective effect on myelin in gray matter.

Research has identified vitamin D deficiency as a risk factor for MS. Low levels of the vitamin are associated with increased risk of brain lesions, relapses, and early progression of disability. Much of the literature focuses on relapsing-remitting MS. Less is known about the part that vitamin D plays in progressive MS, particularly with respect to clinical and imaging findings.

An Analysis of Phase II Data

Justin Abbatemarco, MD, a neurologist at Cleveland Clinic, and colleagues studied results from the phase II clinical trial of ibudilast to examine the association between vitamin D levels and clinical and MRI features in progressive MS. In the trial, investigators measured participants’ serum 25 OH vitamin D levels. At baseline, they collected demographic information such as age, gender, race, disease duration, duration of progression, prior treatment history, Expanded Disability Status Scale score, MS Functional Composite, and neurocognitive testing. Baseline MRI information included brain parenchymal fraction, diffusion tensor imaging (DTI), and magnetization transfer ratio (MTR).

Dr. Abbatemarco and colleagues used Spearman correlation to evaluate the associations between total vitamin D and vitamin D3 levels and clinical or imaging characteristics. They created a linear regression model to predict clinical and imaging outcome variables.

Vitamin D Was Associated With Whole Brain MTR

The analysis included 267 patients (47.2% male) with a mean age of 55.6. In all, 137 participants had primary progressive MS, and 130 participants had secondary progressive MS. Mean disease duration was 16.4 years. The population’s mean vitamin D3 level was 40.7 ng/mL, and mean total vitamin D level was 43.8 ng/mL. Mean brain parenchymal fraction was 0.8, mean T2 lesion volume was 10.3 mL, and mean whole brain MTR was 0.1.

The investigators did not observe a significant difference in mean vitamin D levels between patients with secondary progressive MS (44.7 ng/mL) and those with primary progressive MS (42.9 ng/mL). They did find positive associations between vitamin D3 and whole brain MTR, normal appearing brain tissue MTR, and normal appearing gray matter MTR. Dr. Abbatemarco’s group found no significant associations between vitamin D levels and brain parenchymal fraction, T1 or T2 lesion volume, or DTI metrics. The associations between vitamin D3 and MRI features were similar in patients with primary progressive MS and those with secondary progressive MS.

In a multivariate analysis that controlled for age, gender, disease duration, the time that vitamin D level was obtained, and latitude of study site, associations between vitamin D3 level and whole brain MTR remained significant. Every 10-ng/mL increase in vitamin D3 was associated with a 2.1% unit increase in whole brain MTR. The investigators found no association between vitamin D3 and brain parenchymal fraction, T2 lesion volume, T1 lesion volume, and clinical scores.

Dr. Abbatemarco and colleagues plan to test the effect of longitudinal changes on clinical and MRI measures once data become available.

—Erik Greb

Suggested Reading

Smolders J, Menheere P, Kessels A, et al. Association of vitamin D metabolite levels with relapse rate and disability in multiple sclerosis. Mult Scler. 2008;14(9):1220-1224.

Think of it as a biological nuclear export ban: A combination of the nuclear export protein inhibitor selinexor and dexamethasone was associated with relatively good objective response rates and clinical benefit rates among some patients with relapsed or refractory multiple myeloma (MM).

In the dose-expansion portion of a phase 1 dose-finding trial, the objective response rate (ORR) among 12 patients treated with selinexor 45 mg/m² and 20 mg dexamethasone twice weekly was 50%, and the clinical benefit rate – a composite of complete responses, very good partial responses, partial responses and minimal responses – was 58%, reported Christine Chen, MD, of Princess Margaret Cancer Centre in Toronto, and her colleagues.

“Selinexor is an oral agent with a completely novel mechanism of action and anti-MM activity in combination with dexamethasone that could provide a new option for patients suffering from this incurable disease,” wrote Dr. Chen and her colleagues. The report was published in Blood.

Selinexor is a selective oral inhibitor of the cellular nuclear export protein exportin 1 (XPO1). Inhibition of this protein causes tumor suppressor proteins to accumulate in the nuclei of malignant cells, leading to programmed cell death (apoptosis) of malignant cells, but with minimal effects on normal cells.

In the safety analysis, which included all patients who received at least one dose of selinexor, the most common grade 3 or 4 adverse events included thrombocytopenia in 45% of patients, hyponatremia in 26% of patients, and anemia and neutropenia in 23% each.

The most common nonhematologic adverse events – primarily grade 1 or 2 – included nausea, fatigue, anorexia, vomiting, and weight loss and diarrhea.

The combination of selinexor and dexamethasone is currently being investigated in the phase 2 Selinexor Treatment of Refractory Myeloma study, in combination with standard multiple myeloma therapies in the STOMP trial (Selinexor and Backbone Treatments of Multiple Myeloma Patients), and with bortezomib in the BOSTON trial (Bortezomib, Selinexor and Dexamethasone in Patients with Multiple Myeloma).

Dr. Chen reported no conflicts of interest. Her coauthors reported financial ties to Karyopharm Therapeutics, which funded the study.

[email protected]

SOURCE: Chen C et al. Blood. 2018;131(8):855-63.

Think of it as a biological nuclear export ban: A combination of the nuclear export protein inhibitor selinexor and dexamethasone was associated with relatively good objective response rates and clinical benefit rates among some patients with relapsed or refractory multiple myeloma (MM).

In the dose-expansion portion of a phase 1 dose-finding trial, the objective response rate (ORR) among 12 patients treated with selinexor 45 mg/m² and 20 mg dexamethasone twice weekly was 50%, and the clinical benefit rate – a composite of complete responses, very good partial responses, partial responses and minimal responses – was 58%, reported Christine Chen, MD, of Princess Margaret Cancer Centre in Toronto, and her colleagues.

“Selinexor is an oral agent with a completely novel mechanism of action and anti-MM activity in combination with dexamethasone that could provide a new option for patients suffering from this incurable disease,” wrote Dr. Chen and her colleagues. The report was published in Blood.

Selinexor is a selective oral inhibitor of the cellular nuclear export protein exportin 1 (XPO1). Inhibition of this protein causes tumor suppressor proteins to accumulate in the nuclei of malignant cells, leading to programmed cell death (apoptosis) of malignant cells, but with minimal effects on normal cells.

In the safety analysis, which included all patients who received at least one dose of selinexor, the most common grade 3 or 4 adverse events included thrombocytopenia in 45% of patients, hyponatremia in 26% of patients, and anemia and neutropenia in 23% each.

The most common nonhematologic adverse events – primarily grade 1 or 2 – included nausea, fatigue, anorexia, vomiting, and weight loss and diarrhea.

The combination of selinexor and dexamethasone is currently being investigated in the phase 2 Selinexor Treatment of Refractory Myeloma study, in combination with standard multiple myeloma therapies in the STOMP trial (Selinexor and Backbone Treatments of Multiple Myeloma Patients), and with bortezomib in the BOSTON trial (Bortezomib, Selinexor and Dexamethasone in Patients with Multiple Myeloma).

Dr. Chen reported no conflicts of interest. Her coauthors reported financial ties to Karyopharm Therapeutics, which funded the study.

[email protected]

SOURCE: Chen C et al. Blood. 2018;131(8):855-63.

Think of it as a biological nuclear export ban: A combination of the nuclear export protein inhibitor selinexor and dexamethasone was associated with relatively good objective response rates and clinical benefit rates among some patients with relapsed or refractory multiple myeloma (MM).

In the dose-expansion portion of a phase 1 dose-finding trial, the objective response rate (ORR) among 12 patients treated with selinexor 45 mg/m² and 20 mg dexamethasone twice weekly was 50%, and the clinical benefit rate – a composite of complete responses, very good partial responses, partial responses and minimal responses – was 58%, reported Christine Chen, MD, of Princess Margaret Cancer Centre in Toronto, and her colleagues.

“Selinexor is an oral agent with a completely novel mechanism of action and anti-MM activity in combination with dexamethasone that could provide a new option for patients suffering from this incurable disease,” wrote Dr. Chen and her colleagues. The report was published in Blood.

Selinexor is a selective oral inhibitor of the cellular nuclear export protein exportin 1 (XPO1). Inhibition of this protein causes tumor suppressor proteins to accumulate in the nuclei of malignant cells, leading to programmed cell death (apoptosis) of malignant cells, but with minimal effects on normal cells.

In the safety analysis, which included all patients who received at least one dose of selinexor, the most common grade 3 or 4 adverse events included thrombocytopenia in 45% of patients, hyponatremia in 26% of patients, and anemia and neutropenia in 23% each.

The most common nonhematologic adverse events – primarily grade 1 or 2 – included nausea, fatigue, anorexia, vomiting, and weight loss and diarrhea.

The combination of selinexor and dexamethasone is currently being investigated in the phase 2 Selinexor Treatment of Refractory Myeloma study, in combination with standard multiple myeloma therapies in the STOMP trial (Selinexor and Backbone Treatments of Multiple Myeloma Patients), and with bortezomib in the BOSTON trial (Bortezomib, Selinexor and Dexamethasone in Patients with Multiple Myeloma).

Dr. Chen reported no conflicts of interest. Her coauthors reported financial ties to Karyopharm Therapeutics, which funded the study.

[email protected]

SOURCE: Chen C et al. Blood. 2018;131(8):855-63.

The coming months will provide us a welcome relief from health care politics as we turn our attention to the science of medicine. Digestive Disease Week® (DDW) will occur from June 2 to 5 in Washington, DC. Major themes already are emerging and implications for our clinical practices are exciting. In this month’s issue of GI & Hepatology News, we summarize a presentation about the IBD medication pipeline given by Dr. Bill Sandborn (UCSD) at the Crohn’s & Colitis Congress^TM (a partnership between the Crohn’s & Colitis Foundation and AGA, in Las Vegas). The number of medications that will enter clinical practice is impressive and so is the variety of antigen targets. Over the last several decades, we have defined multiple inflammatory pathways that can lead to IBD and developed medications that modify abnormal immune responses. We are entering an era of precision medicine never before seen in our specialty. Most of these biological medications can be given orally or subcutaneously, precluding the need for infusion centers. I anticipate an enormous offering of IBD-related science at DDW^®.

John I. Allen, MD, MBA, AGAF

Editor in Chief

The coming months will provide us a welcome relief from health care politics as we turn our attention to the science of medicine. Digestive Disease Week® (DDW) will occur from June 2 to 5 in Washington, DC. Major themes already are emerging and implications for our clinical practices are exciting. In this month’s issue of GI & Hepatology News, we summarize a presentation about the IBD medication pipeline given by Dr. Bill Sandborn (UCSD) at the Crohn’s & Colitis Congress^TM (a partnership between the Crohn’s & Colitis Foundation and AGA, in Las Vegas). The number of medications that will enter clinical practice is impressive and so is the variety of antigen targets. Over the last several decades, we have defined multiple inflammatory pathways that can lead to IBD and developed medications that modify abnormal immune responses. We are entering an era of precision medicine never before seen in our specialty. Most of these biological medications can be given orally or subcutaneously, precluding the need for infusion centers. I anticipate an enormous offering of IBD-related science at DDW^®.

John I. Allen, MD, MBA, AGAF

Editor in Chief

The coming months will provide us a welcome relief from health care politics as we turn our attention to the science of medicine. Digestive Disease Week® (DDW) will occur from June 2 to 5 in Washington, DC. Major themes already are emerging and implications for our clinical practices are exciting. In this month’s issue of GI & Hepatology News, we summarize a presentation about the IBD medication pipeline given by Dr. Bill Sandborn (UCSD) at the Crohn’s & Colitis Congress^TM (a partnership between the Crohn’s & Colitis Foundation and AGA, in Las Vegas). The number of medications that will enter clinical practice is impressive and so is the variety of antigen targets. Over the last several decades, we have defined multiple inflammatory pathways that can lead to IBD and developed medications that modify abnormal immune responses. We are entering an era of precision medicine never before seen in our specialty. Most of these biological medications can be given orally or subcutaneously, precluding the need for infusion centers. I anticipate an enormous offering of IBD-related science at DDW^®.

John I. Allen, MD, MBA, AGAF

Editor in Chief