A lot has changed in acute myocardial infarction management in the 36 years since investigators for the Beta-Blocker Heart Attack Trial (BHAT) reported that the treatment of AMI in patients with propranolol, the beta-blocker of the day, reduced mortality by over 25% over 3 years (JAMA. 1981 Nov 6;246[18]:2073-4), and a European trial of timolol confirmed those findings.

New medications have been developed, including ACE inhibitors, statins, and a variety of drugs that modify the thrombotic process that occurs with the event. In addition, endovascular procedures have modified the obstructive coronary vascular anatomy that precipitated the event. At the same time, the definition of an AMI has changed dramatically, now depending in many instances on transitory elevation of the highly sensitive troponins. The BHAT definition depended largely on electrocardiographic changes associated with the event, which were ST-segment elevations in 79% of the occurrences, or significant ST-segment changes associated often with elevation of the insensitive enzyme, serum glutamic transaminase, and significant symptoms. The characteristics of the BHAT patient only faintly resemble the patients who we now classify with AMIs, and its definition expanded well beyond the BHAT patients. And yet beta-blocker therapy is still part of the class I or II recommendations for the treatment of an AMI.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

A lot has changed in acute myocardial infarction management in the 36 years since investigators for the Beta-Blocker Heart Attack Trial (BHAT) reported that the treatment of AMI in patients with propranolol, the beta-blocker of the day, reduced mortality by over 25% over 3 years (JAMA. 1981 Nov 6;246[18]:2073-4), and a European trial of timolol confirmed those findings.

New medications have been developed, including ACE inhibitors, statins, and a variety of drugs that modify the thrombotic process that occurs with the event. In addition, endovascular procedures have modified the obstructive coronary vascular anatomy that precipitated the event. At the same time, the definition of an AMI has changed dramatically, now depending in many instances on transitory elevation of the highly sensitive troponins. The BHAT definition depended largely on electrocardiographic changes associated with the event, which were ST-segment elevations in 79% of the occurrences, or significant ST-segment changes associated often with elevation of the insensitive enzyme, serum glutamic transaminase, and significant symptoms. The characteristics of the BHAT patient only faintly resemble the patients who we now classify with AMIs, and its definition expanded well beyond the BHAT patients. And yet beta-blocker therapy is still part of the class I or II recommendations for the treatment of an AMI.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

A lot has changed in acute myocardial infarction management in the 36 years since investigators for the Beta-Blocker Heart Attack Trial (BHAT) reported that the treatment of AMI in patients with propranolol, the beta-blocker of the day, reduced mortality by over 25% over 3 years (JAMA. 1981 Nov 6;246[18]:2073-4), and a European trial of timolol confirmed those findings.

New medications have been developed, including ACE inhibitors, statins, and a variety of drugs that modify the thrombotic process that occurs with the event. In addition, endovascular procedures have modified the obstructive coronary vascular anatomy that precipitated the event. At the same time, the definition of an AMI has changed dramatically, now depending in many instances on transitory elevation of the highly sensitive troponins. The BHAT definition depended largely on electrocardiographic changes associated with the event, which were ST-segment elevations in 79% of the occurrences, or significant ST-segment changes associated often with elevation of the insensitive enzyme, serum glutamic transaminase, and significant symptoms. The characteristics of the BHAT patient only faintly resemble the patients who we now classify with AMIs, and its definition expanded well beyond the BHAT patients. And yet beta-blocker therapy is still part of the class I or II recommendations for the treatment of an AMI.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

SAN FRANCISCO – Adding ramucirumab to first-line chemotherapy for gastric and gastroesophageal junction cancer prolongs progression-free survival, but not by much, according to results of the phase 3 international RAINFALL trial.

A total of 645 patients were randomized to receive chemotherapy (cisplatin with capecitabine or 5FU) plus either placebo or ramucirumab (Cyramza), an antibody that targets human vascular endothelial growth factor receptor 2. The antiangiogenic antibody has been found to prolong overall survival in the second-line setting, as shown in the REGARD monotherapy and RAINBOW combination therapy trials.

Clinical implications

“RAINFALL did meet its primary endpoint of progression-free survival. However, it was disappointing not to see some survival benefit,” commented invited discussant Stephen Leong, MD, of the University of Colorado Comprehensive Cancer Center, Denver. “Ramucirumab’s role in the first-line setting is debatable.”

The gain in median progression-free survival of 0.3 months, or 9 days, comes at an approximate drug cost of $67,112, he noted. And that does not include port or infusion costs.

Study details

In RAINFALL, median investigator-assessed progression-free survival in the final intention-to-treat analysis was 5.85 months with ramucirumab and 5.55 months with placebo (hazard ratio, 0.75; P = .0024), Dr. Fuchs reported at the symposium, which is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Median overall survival was 11.17 months with ramucirumab and 10.74 months with placebo, a nonsignificant difference. Findings for both endpoints were consistent across subgroups stratified by patient, disease, and treatment characteristics.

The overall response rate was 41% and 36%, respectively (P = .17), and the disease control rate was 82% and 77%, respectively (P = .10).

Treatment-emergent adverse events of grade 3 or worse were generally similar for the two groups, Dr. Fuchs reported. Patients in the ramucirumab group had higher rates of certain grade 3 or worse adverse events known to be related to the antibody’s mechanism of action (26% vs. 15%), such as hypertension (9.9% vs 1.5%) and gastrointestinal perforation (4.0% vs. 0.3%).

After the study, about half of patients in each group went on to receive additional (second-line) systemic therapy, mainly paclitaxel and (more) ramucirumab.

In an exploratory analysis, patients who received poststudy ramucirumab versus some other systemic therapy tended to have better overall survival, whether originally in the ramucirumab group (16.2 vs. 13.2 months) or the placebo group (14.9 vs. 13.0 months). Findings were similar when overall survival was assessed from initiation of the poststudy therapy.

Dr. Fuchs disclosed that he is a consultant to Agios, Bayer, Eli Lilly, Entrinsic Health, Five Prime Therapeutics, Genentech, Merck, Sanofi, and Taiho Pharmaceutical, and that he is on the board of directors of CytomX. The trial was sponsored by Eli Lilly.

[email protected]

SOURCE: Fuchs CS et al. GI CANCERS SYMPOSIUM Abstract 5

SAN FRANCISCO – Adding ramucirumab to first-line chemotherapy for gastric and gastroesophageal junction cancer prolongs progression-free survival, but not by much, according to results of the phase 3 international RAINFALL trial.

A total of 645 patients were randomized to receive chemotherapy (cisplatin with capecitabine or 5FU) plus either placebo or ramucirumab (Cyramza), an antibody that targets human vascular endothelial growth factor receptor 2. The antiangiogenic antibody has been found to prolong overall survival in the second-line setting, as shown in the REGARD monotherapy and RAINBOW combination therapy trials.

Clinical implications

“RAINFALL did meet its primary endpoint of progression-free survival. However, it was disappointing not to see some survival benefit,” commented invited discussant Stephen Leong, MD, of the University of Colorado Comprehensive Cancer Center, Denver. “Ramucirumab’s role in the first-line setting is debatable.”

The gain in median progression-free survival of 0.3 months, or 9 days, comes at an approximate drug cost of $67,112, he noted. And that does not include port or infusion costs.

Study details

In RAINFALL, median investigator-assessed progression-free survival in the final intention-to-treat analysis was 5.85 months with ramucirumab and 5.55 months with placebo (hazard ratio, 0.75; P = .0024), Dr. Fuchs reported at the symposium, which is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Median overall survival was 11.17 months with ramucirumab and 10.74 months with placebo, a nonsignificant difference. Findings for both endpoints were consistent across subgroups stratified by patient, disease, and treatment characteristics.

The overall response rate was 41% and 36%, respectively (P = .17), and the disease control rate was 82% and 77%, respectively (P = .10).

Treatment-emergent adverse events of grade 3 or worse were generally similar for the two groups, Dr. Fuchs reported. Patients in the ramucirumab group had higher rates of certain grade 3 or worse adverse events known to be related to the antibody’s mechanism of action (26% vs. 15%), such as hypertension (9.9% vs 1.5%) and gastrointestinal perforation (4.0% vs. 0.3%).

After the study, about half of patients in each group went on to receive additional (second-line) systemic therapy, mainly paclitaxel and (more) ramucirumab.

In an exploratory analysis, patients who received poststudy ramucirumab versus some other systemic therapy tended to have better overall survival, whether originally in the ramucirumab group (16.2 vs. 13.2 months) or the placebo group (14.9 vs. 13.0 months). Findings were similar when overall survival was assessed from initiation of the poststudy therapy.

Dr. Fuchs disclosed that he is a consultant to Agios, Bayer, Eli Lilly, Entrinsic Health, Five Prime Therapeutics, Genentech, Merck, Sanofi, and Taiho Pharmaceutical, and that he is on the board of directors of CytomX. The trial was sponsored by Eli Lilly.

[email protected]

SOURCE: Fuchs CS et al. GI CANCERS SYMPOSIUM Abstract 5

SAN FRANCISCO – Adding ramucirumab to first-line chemotherapy for gastric and gastroesophageal junction cancer prolongs progression-free survival, but not by much, according to results of the phase 3 international RAINFALL trial.

A total of 645 patients were randomized to receive chemotherapy (cisplatin with capecitabine or 5FU) plus either placebo or ramucirumab (Cyramza), an antibody that targets human vascular endothelial growth factor receptor 2. The antiangiogenic antibody has been found to prolong overall survival in the second-line setting, as shown in the REGARD monotherapy and RAINBOW combination therapy trials.

Clinical implications

“RAINFALL did meet its primary endpoint of progression-free survival. However, it was disappointing not to see some survival benefit,” commented invited discussant Stephen Leong, MD, of the University of Colorado Comprehensive Cancer Center, Denver. “Ramucirumab’s role in the first-line setting is debatable.”

The gain in median progression-free survival of 0.3 months, or 9 days, comes at an approximate drug cost of $67,112, he noted. And that does not include port or infusion costs.

Study details

In RAINFALL, median investigator-assessed progression-free survival in the final intention-to-treat analysis was 5.85 months with ramucirumab and 5.55 months with placebo (hazard ratio, 0.75; P = .0024), Dr. Fuchs reported at the symposium, which is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Median overall survival was 11.17 months with ramucirumab and 10.74 months with placebo, a nonsignificant difference. Findings for both endpoints were consistent across subgroups stratified by patient, disease, and treatment characteristics.

The overall response rate was 41% and 36%, respectively (P = .17), and the disease control rate was 82% and 77%, respectively (P = .10).

Treatment-emergent adverse events of grade 3 or worse were generally similar for the two groups, Dr. Fuchs reported. Patients in the ramucirumab group had higher rates of certain grade 3 or worse adverse events known to be related to the antibody’s mechanism of action (26% vs. 15%), such as hypertension (9.9% vs 1.5%) and gastrointestinal perforation (4.0% vs. 0.3%).

After the study, about half of patients in each group went on to receive additional (second-line) systemic therapy, mainly paclitaxel and (more) ramucirumab.

In an exploratory analysis, patients who received poststudy ramucirumab versus some other systemic therapy tended to have better overall survival, whether originally in the ramucirumab group (16.2 vs. 13.2 months) or the placebo group (14.9 vs. 13.0 months). Findings were similar when overall survival was assessed from initiation of the poststudy therapy.

Dr. Fuchs disclosed that he is a consultant to Agios, Bayer, Eli Lilly, Entrinsic Health, Five Prime Therapeutics, Genentech, Merck, Sanofi, and Taiho Pharmaceutical, and that he is on the board of directors of CytomX. The trial was sponsored by Eli Lilly.

[email protected]

SOURCE: Fuchs CS et al. GI CANCERS SYMPOSIUM Abstract 5

ANAHEIM, CALIF. – Eating an ounce and a half of walnuts daily led to favorable changes in gut microbiome composition and diversity in a prospective randomized controlled trial, Klaus G. Parhofer, MD, reported at the American Heart Association scientific session.

These changes in intestinal flora may account for the reductions in LDL cholesterol, triglycerides, apolipoprotein B, and non-HDL cholesterol previously documented with walnut consumption in the same trial, according to Dr. Parhofer, professor of endocrinology and metabolism at the University of Munich.

Bruce Jancin/Frontline Medical News

[email protected]

ANAHEIM, CALIF. – Eating an ounce and a half of walnuts daily led to favorable changes in gut microbiome composition and diversity in a prospective randomized controlled trial, Klaus G. Parhofer, MD, reported at the American Heart Association scientific session.

These changes in intestinal flora may account for the reductions in LDL cholesterol, triglycerides, apolipoprotein B, and non-HDL cholesterol previously documented with walnut consumption in the same trial, according to Dr. Parhofer, professor of endocrinology and metabolism at the University of Munich.

Bruce Jancin/Frontline Medical News

[email protected]

ANAHEIM, CALIF. – Eating an ounce and a half of walnuts daily led to favorable changes in gut microbiome composition and diversity in a prospective randomized controlled trial, Klaus G. Parhofer, MD, reported at the American Heart Association scientific session.

These changes in intestinal flora may account for the reductions in LDL cholesterol, triglycerides, apolipoprotein B, and non-HDL cholesterol previously documented with walnut consumption in the same trial, according to Dr. Parhofer, professor of endocrinology and metabolism at the University of Munich.

Bruce Jancin/Frontline Medical News

[email protected]

For patients with surgically resectable, BRAF-mutated melanoma, neoadjuvant and adjuvant treatment with the combination of dabrafenib and trametinib resulted in significantly longer event-free survival compared with standard care, according to results of a randomized study.

The trial was closed early because of the “large difference” in event-free survival favoring the neoadjuvant approach, the authors wrote (Lancet Oncol. 2018 Jan 17. doi: 10.1016/S1470-2045(18)30015-9.

While early closure limits interpretation of results, they do provide important proof-of-concept and data for future studies, wrote the authors, led by Rodabe N Amaria, MD, of the department of medical oncology, University of Texas MD Anderson Cancer Center, Houston.

“The clinical and translational results strongly support the rationale for further assessment of neoadjuvant therapy in patients with high-risk, surgically resectable melanoma,” Dr. Amaria and colleagues said in the report on the randomized trial, believed to be the first to evaluate the role of neoadjuvant therapy versus standard care in BRAF-mutated melanoma.

Dabrafenib and trametinib combination therapy is approved as a treatment for patients with unresectable or metastatic stage IV melanoma and a BRAF^V600 mutation, which is found in about half of cutaneous melanomas, authors said.

To evaluate the combination in earlier stage disease, Dr. Amaria and coinvestigators conducted a single-center, open-label, randomized, phase 2 trial of 21 patients with surgically resectable clinical stage III or oligometastatic stage IV melanoma with BRAF^V600E or BRAF^V600K mutations.

Patients were randomized 2:1 to receive the neoadjuvant/adjuvant treatment or to standard of care, which consisted of standard surgery plus consideration for adjuvant therapy, the authors said. Those patients assigned to the targeted therapy arm received 8 weeks of neoadjuvant dabrafenib and trametinib followed by surgery, then adjuvant dabrafenib and trametinib for up to 44 weeks.

Event-free survival, the primary endpoint of the trial, was a median of 19.7 months for neoadjuvant plus adjuvant dabrafenib and trametinib, versus 2.9 months for standard care (P less than .0001), the investigators reported.

Dabrafenib and trametinib combination therapy was well tolerated as neoadjuvant and adjuvant therapy, with no grade 4 adverse events or treatment related deaths, according to the investigators. The most common grade 3 adverse event seen with the combination was diarrhea, occurring in 2 patients (15%).

The trial is continuing as a single-arm study of neoadjuvant plus adjuvant dabrafenib and trametinib.

Dr. Amaria and colleagues reported individual disclosures related to Merck, Bristol-Myers Squibb, Array Biopharma, and others, including Novartis Pharmaceuticals Corp., which supplied drugs and funded clinical aspects of the study.

[email protected]

SOURCE: Amaria et al. 2018 Jan 17. doi: 10.1016/S1470-2045(18)30015-9

For patients with surgically resectable, BRAF-mutated melanoma, neoadjuvant and adjuvant treatment with the combination of dabrafenib and trametinib resulted in significantly longer event-free survival compared with standard care, according to results of a randomized study.

The trial was closed early because of the “large difference” in event-free survival favoring the neoadjuvant approach, the authors wrote (Lancet Oncol. 2018 Jan 17. doi: 10.1016/S1470-2045(18)30015-9.

While early closure limits interpretation of results, they do provide important proof-of-concept and data for future studies, wrote the authors, led by Rodabe N Amaria, MD, of the department of medical oncology, University of Texas MD Anderson Cancer Center, Houston.

“The clinical and translational results strongly support the rationale for further assessment of neoadjuvant therapy in patients with high-risk, surgically resectable melanoma,” Dr. Amaria and colleagues said in the report on the randomized trial, believed to be the first to evaluate the role of neoadjuvant therapy versus standard care in BRAF-mutated melanoma.

Dabrafenib and trametinib combination therapy is approved as a treatment for patients with unresectable or metastatic stage IV melanoma and a BRAF^V600 mutation, which is found in about half of cutaneous melanomas, authors said.

To evaluate the combination in earlier stage disease, Dr. Amaria and coinvestigators conducted a single-center, open-label, randomized, phase 2 trial of 21 patients with surgically resectable clinical stage III or oligometastatic stage IV melanoma with BRAF^V600E or BRAF^V600K mutations.

Patients were randomized 2:1 to receive the neoadjuvant/adjuvant treatment or to standard of care, which consisted of standard surgery plus consideration for adjuvant therapy, the authors said. Those patients assigned to the targeted therapy arm received 8 weeks of neoadjuvant dabrafenib and trametinib followed by surgery, then adjuvant dabrafenib and trametinib for up to 44 weeks.

Event-free survival, the primary endpoint of the trial, was a median of 19.7 months for neoadjuvant plus adjuvant dabrafenib and trametinib, versus 2.9 months for standard care (P less than .0001), the investigators reported.

Dabrafenib and trametinib combination therapy was well tolerated as neoadjuvant and adjuvant therapy, with no grade 4 adverse events or treatment related deaths, according to the investigators. The most common grade 3 adverse event seen with the combination was diarrhea, occurring in 2 patients (15%).

The trial is continuing as a single-arm study of neoadjuvant plus adjuvant dabrafenib and trametinib.

Dr. Amaria and colleagues reported individual disclosures related to Merck, Bristol-Myers Squibb, Array Biopharma, and others, including Novartis Pharmaceuticals Corp., which supplied drugs and funded clinical aspects of the study.

[email protected]

SOURCE: Amaria et al. 2018 Jan 17. doi: 10.1016/S1470-2045(18)30015-9

For patients with surgically resectable, BRAF-mutated melanoma, neoadjuvant and adjuvant treatment with the combination of dabrafenib and trametinib resulted in significantly longer event-free survival compared with standard care, according to results of a randomized study.

The trial was closed early because of the “large difference” in event-free survival favoring the neoadjuvant approach, the authors wrote (Lancet Oncol. 2018 Jan 17. doi: 10.1016/S1470-2045(18)30015-9.

While early closure limits interpretation of results, they do provide important proof-of-concept and data for future studies, wrote the authors, led by Rodabe N Amaria, MD, of the department of medical oncology, University of Texas MD Anderson Cancer Center, Houston.

“The clinical and translational results strongly support the rationale for further assessment of neoadjuvant therapy in patients with high-risk, surgically resectable melanoma,” Dr. Amaria and colleagues said in the report on the randomized trial, believed to be the first to evaluate the role of neoadjuvant therapy versus standard care in BRAF-mutated melanoma.

Dabrafenib and trametinib combination therapy is approved as a treatment for patients with unresectable or metastatic stage IV melanoma and a BRAF^V600 mutation, which is found in about half of cutaneous melanomas, authors said.

To evaluate the combination in earlier stage disease, Dr. Amaria and coinvestigators conducted a single-center, open-label, randomized, phase 2 trial of 21 patients with surgically resectable clinical stage III or oligometastatic stage IV melanoma with BRAF^V600E or BRAF^V600K mutations.

Patients were randomized 2:1 to receive the neoadjuvant/adjuvant treatment or to standard of care, which consisted of standard surgery plus consideration for adjuvant therapy, the authors said. Those patients assigned to the targeted therapy arm received 8 weeks of neoadjuvant dabrafenib and trametinib followed by surgery, then adjuvant dabrafenib and trametinib for up to 44 weeks.

Event-free survival, the primary endpoint of the trial, was a median of 19.7 months for neoadjuvant plus adjuvant dabrafenib and trametinib, versus 2.9 months for standard care (P less than .0001), the investigators reported.

Dabrafenib and trametinib combination therapy was well tolerated as neoadjuvant and adjuvant therapy, with no grade 4 adverse events or treatment related deaths, according to the investigators. The most common grade 3 adverse event seen with the combination was diarrhea, occurring in 2 patients (15%).

The trial is continuing as a single-arm study of neoadjuvant plus adjuvant dabrafenib and trametinib.

Dr. Amaria and colleagues reported individual disclosures related to Merck, Bristol-Myers Squibb, Array Biopharma, and others, including Novartis Pharmaceuticals Corp., which supplied drugs and funded clinical aspects of the study.

[email protected]

SOURCE: Amaria et al. 2018 Jan 17. doi: 10.1016/S1470-2045(18)30015-9

LAS VEGAS – Higher body mass index among inflammatory bowel disease patients is independently associated with an increased risk of treatment failure and IBD-related surgery or hospitalization, a single-center, retrospective cohort study demonstrated.

“The problem of IBD and obesity is on the rise,” Soumya Kurnool said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Today, 15%-40% of IBD patients are obese. This is significant because there is a decreased prevalence of remission and an increased risk of relapse in obese IBD patients. These patients also have a higher annual burden of hospitalization.”

Doug Brunk/Frontline Medical News

Ms. Kurnool reported results from 160 patients with a median age of 36 years. Half were male, and the mean follow-up was 24 months. The median BMI of the cohort was 24.3 kg/m²; 26% were overweight and 18% were obese. More than half of patients (55%) were on infliximab with weight-based dosing and 45% were on other fixed-dosing regimens, including 19% on vedolizumab. In terms of outcomes, 68% of patients experienced treatment failure. All who failed treatment underwent treatment modifications; 15% had IBD-related surgery, and 19% had IBD-related hospitalization.

After adjusting for age, sex, disease duration, prior hospitalization, prior anti-TNF therapy, steroid use, and albumin level, Ms. Kurnool and her associates found that every 1-kg/m² increase in BMI was associated with a 4% higher risk of treatment failure (adjusted hazard ratio, 1.04), an 8% higher risk of surgery or hospitalization (adjusted HR, 1.08), and a 6% lower risk of achieving endoscopic remission (adjusted HR, 0.94).

“This increase in the risk of treatment failure and IBD-related surgery or hospitalization was consistent across strata of patients treated with infliximab and fixed-dosing regimens,” she said. “Based on these findings, physicians should consider proactive monitoring in obese patients treated with biologic agents.”

Ms. Kurnool reported having received a National Institutes of Health Short Term Training Grant from the University of California, San Diego.

*This story was updated on 3/26.

[email protected]

SOURCE: Kurnool S et al. Crohn’s & Colitis Congress, Clinical Abstract 24.

LAS VEGAS – Higher body mass index among inflammatory bowel disease patients is independently associated with an increased risk of treatment failure and IBD-related surgery or hospitalization, a single-center, retrospective cohort study demonstrated.

“The problem of IBD and obesity is on the rise,” Soumya Kurnool said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Today, 15%-40% of IBD patients are obese. This is significant because there is a decreased prevalence of remission and an increased risk of relapse in obese IBD patients. These patients also have a higher annual burden of hospitalization.”

Doug Brunk/Frontline Medical News

Ms. Kurnool reported results from 160 patients with a median age of 36 years. Half were male, and the mean follow-up was 24 months. The median BMI of the cohort was 24.3 kg/m²; 26% were overweight and 18% were obese. More than half of patients (55%) were on infliximab with weight-based dosing and 45% were on other fixed-dosing regimens, including 19% on vedolizumab. In terms of outcomes, 68% of patients experienced treatment failure. All who failed treatment underwent treatment modifications; 15% had IBD-related surgery, and 19% had IBD-related hospitalization.

After adjusting for age, sex, disease duration, prior hospitalization, prior anti-TNF therapy, steroid use, and albumin level, Ms. Kurnool and her associates found that every 1-kg/m² increase in BMI was associated with a 4% higher risk of treatment failure (adjusted hazard ratio, 1.04), an 8% higher risk of surgery or hospitalization (adjusted HR, 1.08), and a 6% lower risk of achieving endoscopic remission (adjusted HR, 0.94).

“This increase in the risk of treatment failure and IBD-related surgery or hospitalization was consistent across strata of patients treated with infliximab and fixed-dosing regimens,” she said. “Based on these findings, physicians should consider proactive monitoring in obese patients treated with biologic agents.”

Ms. Kurnool reported having received a National Institutes of Health Short Term Training Grant from the University of California, San Diego.

*This story was updated on 3/26.

[email protected]

SOURCE: Kurnool S et al. Crohn’s & Colitis Congress, Clinical Abstract 24.

LAS VEGAS – Higher body mass index among inflammatory bowel disease patients is independently associated with an increased risk of treatment failure and IBD-related surgery or hospitalization, a single-center, retrospective cohort study demonstrated.

“The problem of IBD and obesity is on the rise,” Soumya Kurnool said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Today, 15%-40% of IBD patients are obese. This is significant because there is a decreased prevalence of remission and an increased risk of relapse in obese IBD patients. These patients also have a higher annual burden of hospitalization.”

Doug Brunk/Frontline Medical News

Ms. Kurnool reported results from 160 patients with a median age of 36 years. Half were male, and the mean follow-up was 24 months. The median BMI of the cohort was 24.3 kg/m²; 26% were overweight and 18% were obese. More than half of patients (55%) were on infliximab with weight-based dosing and 45% were on other fixed-dosing regimens, including 19% on vedolizumab. In terms of outcomes, 68% of patients experienced treatment failure. All who failed treatment underwent treatment modifications; 15% had IBD-related surgery, and 19% had IBD-related hospitalization.

After adjusting for age, sex, disease duration, prior hospitalization, prior anti-TNF therapy, steroid use, and albumin level, Ms. Kurnool and her associates found that every 1-kg/m² increase in BMI was associated with a 4% higher risk of treatment failure (adjusted hazard ratio, 1.04), an 8% higher risk of surgery or hospitalization (adjusted HR, 1.08), and a 6% lower risk of achieving endoscopic remission (adjusted HR, 0.94).

“This increase in the risk of treatment failure and IBD-related surgery or hospitalization was consistent across strata of patients treated with infliximab and fixed-dosing regimens,” she said. “Based on these findings, physicians should consider proactive monitoring in obese patients treated with biologic agents.”

Ms. Kurnool reported having received a National Institutes of Health Short Term Training Grant from the University of California, San Diego.

*This story was updated on 3/26.

[email protected]

SOURCE: Kurnool S et al. Crohn’s & Colitis Congress, Clinical Abstract 24.

Let face it, it’s hard enough to get a teen girl to look up long enough to answer basic questions during an exam, let alone start a completely uncomfortable conversation about vaginal hygiene. Realistically, though, if we don’t have the conversation, who will? Sure, moms give some instructions on how to wipe properly and remind teens to change their pads frequently, but are they giving the correct advice? Are many women just suffering in silence, assuming it’s just something women deal with? Or are they continuing harmful practices that have been passed down through the generations?

Rawpixel/Thinkstock

Bacterial vaginosis

Bacterial vaginosis (BV) is a polymicrobial syndrome characterized by an imbalance of resident bacteria flora in the vagina.¹ The normal flora is predominantly lactobacilli and produces hydrogen peroxide, which keeps the vaginal pH around 4.5. When normal flora is disrupted, other bacteria such as Gardnerella vaginalis, Mycoplasma hominis, and Prevotella bacteroides, to name just a few, can take over, resulting in an unpleasant odor, a watery discharge, and a lower pH. Although originally thought to be sexually transmitted, BV can occur at any age and without having intercourse.²

The incidence of BV varies among races, among socioeconomic classes, and with age. Cultural practices and resources play more of a role than physiologic differences.² For example, African American women, particularly Caribbean blacks, have higher rates than white women, but douching also is more common among African American and Caribbean blacks than whites. Washing with harsh antiseptics or perfumed soaps also can increase risk, and BV can be sexually transmitted, so the number of partners a woman has can increase that risk.

The presence of BV also has significant social, interpersonal, and work effects and, for some women, is the source of extreme anxiety and distress, which is why many women turn to extreme measures such as douching to control it.<sup>3,5

Furthermore,</sup> BV is associated with preterm labor and low birth weight infants. Studies have shown that women who are culture positive in their second trimester are at greater risk for adverse outcomes.⁶

Douching

Douching began in the mid-1800s with the advent of the Eguisier irrigator, which was sold in French pharmacies and consisted of a plunger and a nozzle and was used to prevent pregnancy. Then, in the 1920’s, Lysol was used as the antiseptic, with claims that it acted as a spermicide. Rinsing out the vagina after coitus was believed to kill any sperm in the body and prevent pregnancy. It wasn’t until the 1980’s that the ill effects of Lysol on the vagina were acknowledged and the practice was discontinued.⁴

Although, generally, douching has fallen out of favor and most authorities advise against it,studies have shown that there can be a benefit when used for vaginosis or vaginitis in relieving symptoms.^5,2 Those benefits do not outweigh the possible adverse effects. The process of douching allows for a pressurized solution to be injected into the vagina, thereby flushing bacteria throughout the vagina and into the uterus. In adolescence, the endothelial lining is more prone to adherence of the bacteria, so contracting a sexually transmitted infection is more likely and can increase the risk for ectopic pregnancy.² The mucus lining of the vagina also tends to be thick; using harsh soaps thins the mucosa, again increasing the likelihood of infections. Furthermore, studies have confirmed that there also is a higher transmission rate of HIV and chlamydia when BV is present.²
 

Treating and preventing BV

The treatment of choice for BV is metronidazole taken orally or introduced vaginally. Studies have shown that recolonization of the lactobacilli can be slow, so the addition of lactic acid can be helpful. Clindamycin orally or vaginally also is a reasonable choice. Given that most of the bacteria causing BV have beta-lactamase, penicillin is not effective.⁷

Probiotics taken orally have a natural migration to the vaginal area and promote recolonization.⁷ Taking 250 mg of vitamin C 6 days/month for 6 months also has been shown to be helpful in recolonization and prevention of recurrence.⁸

A discussion of proper vaginal hygiene is important for adolescents and teens. Poor hygiene can significantly affect their social and interpersonal relationships, as well as their self-esteem. It puts them at greater risk for contracting sexually transmitted infections, and if they become pregnant, of having an adverse outcome.

Make teens aware that any vaginal odor is abnormal, and explain the different types of discharge and which require a doctor visit. In addition, inform them that douching with harsh or perfumed soaps changes the pH of the vagina, which can lead to bacterial overgrowth, so douching should be avoided. Advise them to change pads used during the menstrual cycle every 4-6 hours, and that cotton underwear and loose-fitting clothes also can reduce vaginal irritation. Lastly, advise teens to drink lots of fluids, eat yogurt, and take vitamin C and probiotics to reduce the risk of recurrence.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

References

1. Das P et al. PLoS One. 2015 Jun 30;10(6):e0130777.

2. Martino JL et al. Epidemiologic reviews. 2002;24(2):109-24.

3. Bilardi JE et al. PLoS ONE 2013;8(9):e74378.

4. www.Timeline.com/sexist-history-douching-bcc39f3d216c. 2016 Aug 14.

5. Fashemi B et al. Microb Ecol Health Dis. 2013 Feb 25. doi: 10.3402/mehd.v24i0.19703.

6. Hillier SL et al. N Engl J Med. 1995 Dec 28;333(26):1737-42.

7. Kumar N et al. J Pharm Bioallied Sci. 2011 Oct;3(4):496-503.

8. Krasnopolsky VN et al. J Clin Med Res. 2013 Aug;5(4):309-15..


 

Let face it, it’s hard enough to get a teen girl to look up long enough to answer basic questions during an exam, let alone start a completely uncomfortable conversation about vaginal hygiene. Realistically, though, if we don’t have the conversation, who will? Sure, moms give some instructions on how to wipe properly and remind teens to change their pads frequently, but are they giving the correct advice? Are many women just suffering in silence, assuming it’s just something women deal with? Or are they continuing harmful practices that have been passed down through the generations?

Rawpixel/Thinkstock

Bacterial vaginosis

Bacterial vaginosis (BV) is a polymicrobial syndrome characterized by an imbalance of resident bacteria flora in the vagina.¹ The normal flora is predominantly lactobacilli and produces hydrogen peroxide, which keeps the vaginal pH around 4.5. When normal flora is disrupted, other bacteria such as Gardnerella vaginalis, Mycoplasma hominis, and Prevotella bacteroides, to name just a few, can take over, resulting in an unpleasant odor, a watery discharge, and a lower pH. Although originally thought to be sexually transmitted, BV can occur at any age and without having intercourse.²

The incidence of BV varies among races, among socioeconomic classes, and with age. Cultural practices and resources play more of a role than physiologic differences.² For example, African American women, particularly Caribbean blacks, have higher rates than white women, but douching also is more common among African American and Caribbean blacks than whites. Washing with harsh antiseptics or perfumed soaps also can increase risk, and BV can be sexually transmitted, so the number of partners a woman has can increase that risk.

The presence of BV also has significant social, interpersonal, and work effects and, for some women, is the source of extreme anxiety and distress, which is why many women turn to extreme measures such as douching to control it.<sup>3,5

Furthermore,</sup> BV is associated with preterm labor and low birth weight infants. Studies have shown that women who are culture positive in their second trimester are at greater risk for adverse outcomes.⁶

Douching

Douching began in the mid-1800s with the advent of the Eguisier irrigator, which was sold in French pharmacies and consisted of a plunger and a nozzle and was used to prevent pregnancy. Then, in the 1920’s, Lysol was used as the antiseptic, with claims that it acted as a spermicide. Rinsing out the vagina after coitus was believed to kill any sperm in the body and prevent pregnancy. It wasn’t until the 1980’s that the ill effects of Lysol on the vagina were acknowledged and the practice was discontinued.⁴

Although, generally, douching has fallen out of favor and most authorities advise against it,studies have shown that there can be a benefit when used for vaginosis or vaginitis in relieving symptoms.^5,2 Those benefits do not outweigh the possible adverse effects. The process of douching allows for a pressurized solution to be injected into the vagina, thereby flushing bacteria throughout the vagina and into the uterus. In adolescence, the endothelial lining is more prone to adherence of the bacteria, so contracting a sexually transmitted infection is more likely and can increase the risk for ectopic pregnancy.² The mucus lining of the vagina also tends to be thick; using harsh soaps thins the mucosa, again increasing the likelihood of infections. Furthermore, studies have confirmed that there also is a higher transmission rate of HIV and chlamydia when BV is present.²
 

Treating and preventing BV

The treatment of choice for BV is metronidazole taken orally or introduced vaginally. Studies have shown that recolonization of the lactobacilli can be slow, so the addition of lactic acid can be helpful. Clindamycin orally or vaginally also is a reasonable choice. Given that most of the bacteria causing BV have beta-lactamase, penicillin is not effective.⁷

Probiotics taken orally have a natural migration to the vaginal area and promote recolonization.⁷ Taking 250 mg of vitamin C 6 days/month for 6 months also has been shown to be helpful in recolonization and prevention of recurrence.⁸

A discussion of proper vaginal hygiene is important for adolescents and teens. Poor hygiene can significantly affect their social and interpersonal relationships, as well as their self-esteem. It puts them at greater risk for contracting sexually transmitted infections, and if they become pregnant, of having an adverse outcome.

Make teens aware that any vaginal odor is abnormal, and explain the different types of discharge and which require a doctor visit. In addition, inform them that douching with harsh or perfumed soaps changes the pH of the vagina, which can lead to bacterial overgrowth, so douching should be avoided. Advise them to change pads used during the menstrual cycle every 4-6 hours, and that cotton underwear and loose-fitting clothes also can reduce vaginal irritation. Lastly, advise teens to drink lots of fluids, eat yogurt, and take vitamin C and probiotics to reduce the risk of recurrence.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

References

1. Das P et al. PLoS One. 2015 Jun 30;10(6):e0130777.

2. Martino JL et al. Epidemiologic reviews. 2002;24(2):109-24.

3. Bilardi JE et al. PLoS ONE 2013;8(9):e74378.

4. www.Timeline.com/sexist-history-douching-bcc39f3d216c. 2016 Aug 14.

5. Fashemi B et al. Microb Ecol Health Dis. 2013 Feb 25. doi: 10.3402/mehd.v24i0.19703.

6. Hillier SL et al. N Engl J Med. 1995 Dec 28;333(26):1737-42.

7. Kumar N et al. J Pharm Bioallied Sci. 2011 Oct;3(4):496-503.

8. Krasnopolsky VN et al. J Clin Med Res. 2013 Aug;5(4):309-15..


 

Let face it, it’s hard enough to get a teen girl to look up long enough to answer basic questions during an exam, let alone start a completely uncomfortable conversation about vaginal hygiene. Realistically, though, if we don’t have the conversation, who will? Sure, moms give some instructions on how to wipe properly and remind teens to change their pads frequently, but are they giving the correct advice? Are many women just suffering in silence, assuming it’s just something women deal with? Or are they continuing harmful practices that have been passed down through the generations?

Rawpixel/Thinkstock

Bacterial vaginosis

Bacterial vaginosis (BV) is a polymicrobial syndrome characterized by an imbalance of resident bacteria flora in the vagina.¹ The normal flora is predominantly lactobacilli and produces hydrogen peroxide, which keeps the vaginal pH around 4.5. When normal flora is disrupted, other bacteria such as Gardnerella vaginalis, Mycoplasma hominis, and Prevotella bacteroides, to name just a few, can take over, resulting in an unpleasant odor, a watery discharge, and a lower pH. Although originally thought to be sexually transmitted, BV can occur at any age and without having intercourse.²

The incidence of BV varies among races, among socioeconomic classes, and with age. Cultural practices and resources play more of a role than physiologic differences.² For example, African American women, particularly Caribbean blacks, have higher rates than white women, but douching also is more common among African American and Caribbean blacks than whites. Washing with harsh antiseptics or perfumed soaps also can increase risk, and BV can be sexually transmitted, so the number of partners a woman has can increase that risk.

The presence of BV also has significant social, interpersonal, and work effects and, for some women, is the source of extreme anxiety and distress, which is why many women turn to extreme measures such as douching to control it.<sup>3,5

Furthermore,</sup> BV is associated with preterm labor and low birth weight infants. Studies have shown that women who are culture positive in their second trimester are at greater risk for adverse outcomes.⁶

Douching

Douching began in the mid-1800s with the advent of the Eguisier irrigator, which was sold in French pharmacies and consisted of a plunger and a nozzle and was used to prevent pregnancy. Then, in the 1920’s, Lysol was used as the antiseptic, with claims that it acted as a spermicide. Rinsing out the vagina after coitus was believed to kill any sperm in the body and prevent pregnancy. It wasn’t until the 1980’s that the ill effects of Lysol on the vagina were acknowledged and the practice was discontinued.⁴

Although, generally, douching has fallen out of favor and most authorities advise against it,studies have shown that there can be a benefit when used for vaginosis or vaginitis in relieving symptoms.^5,2 Those benefits do not outweigh the possible adverse effects. The process of douching allows for a pressurized solution to be injected into the vagina, thereby flushing bacteria throughout the vagina and into the uterus. In adolescence, the endothelial lining is more prone to adherence of the bacteria, so contracting a sexually transmitted infection is more likely and can increase the risk for ectopic pregnancy.² The mucus lining of the vagina also tends to be thick; using harsh soaps thins the mucosa, again increasing the likelihood of infections. Furthermore, studies have confirmed that there also is a higher transmission rate of HIV and chlamydia when BV is present.²
 

Treating and preventing BV

The treatment of choice for BV is metronidazole taken orally or introduced vaginally. Studies have shown that recolonization of the lactobacilli can be slow, so the addition of lactic acid can be helpful. Clindamycin orally or vaginally also is a reasonable choice. Given that most of the bacteria causing BV have beta-lactamase, penicillin is not effective.⁷

Probiotics taken orally have a natural migration to the vaginal area and promote recolonization.⁷ Taking 250 mg of vitamin C 6 days/month for 6 months also has been shown to be helpful in recolonization and prevention of recurrence.⁸

A discussion of proper vaginal hygiene is important for adolescents and teens. Poor hygiene can significantly affect their social and interpersonal relationships, as well as their self-esteem. It puts them at greater risk for contracting sexually transmitted infections, and if they become pregnant, of having an adverse outcome.

Make teens aware that any vaginal odor is abnormal, and explain the different types of discharge and which require a doctor visit. In addition, inform them that douching with harsh or perfumed soaps changes the pH of the vagina, which can lead to bacterial overgrowth, so douching should be avoided. Advise them to change pads used during the menstrual cycle every 4-6 hours, and that cotton underwear and loose-fitting clothes also can reduce vaginal irritation. Lastly, advise teens to drink lots of fluids, eat yogurt, and take vitamin C and probiotics to reduce the risk of recurrence.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

References

1. Das P et al. PLoS One. 2015 Jun 30;10(6):e0130777.

2. Martino JL et al. Epidemiologic reviews. 2002;24(2):109-24.

3. Bilardi JE et al. PLoS ONE 2013;8(9):e74378.

4. www.Timeline.com/sexist-history-douching-bcc39f3d216c. 2016 Aug 14.

5. Fashemi B et al. Microb Ecol Health Dis. 2013 Feb 25. doi: 10.3402/mehd.v24i0.19703.

6. Hillier SL et al. N Engl J Med. 1995 Dec 28;333(26):1737-42.

7. Kumar N et al. J Pharm Bioallied Sci. 2011 Oct;3(4):496-503.

8. Krasnopolsky VN et al. J Clin Med Res. 2013 Aug;5(4):309-15..


 

Medicine is an evolving field, and in this era of ever-changing medicine, physicians-in-training often lag behind in understanding the nuances of “real-world” medicine. From negotiating job contracts to understanding medical billing, coding systems, and performance metrics, physicians who are fresh out of training often feel ill prepared to deal with these issues that are rarely discussed during fellowship.

The American Gastroenterological Association’s Regional Practice Skills Workshops are designed to fill this void and provide the tools necessary to navigate the challenging transition from training into practice. Since the first pilot workshops were held in 2014, AGA’s Trainee and Early Career Committee has been diligently working to expand the number of workshop sites so that more trainees can benefit from them. This year, workshops will be held in Columbus, Ohio (Feb. 24), and in Philadelphia (April 11). An exciting development in 2017 was the opportunity to live stream the event held at the University of California, Los Angeles, to Stanford (Calif.) University and the University of Iowa, Iowa City.

This aforementioned workshop at UCLA was divided into two sessions. The first was focused on “Practice Options,” with talks geared toward highlighting the different practice models available in the GI market, including positions in academia, private practice, and mixed environments.

William Chey, MD, a professor of medicine at the University of Michigan, Ann Arbor, shared his experience as an academic gastroenterologist as well as his experience in managing a GI consulting firm. His advice to young gastroenterologists was to diversify. He suggested options such as working for pharmaceutical companies, being involved in drug trials, working in the innovation industry, and proactively seeking leadership positions in different organizations. V. Raman Muthusamy MD, AGAF, a clinical professor of medicine at UCLA, led the discussion with the million-dollar question: What is my net worth? He suggested doing some homework before negotiating one’s salary by visiting the Medical Group Management Association’s website. Having this information can provide a trainee with a head start in the negotiation process. Dr. Muthusamy recommended recalculating one’s net worth every 5 years and renegotiating your contract based on this information. In addition to possibly leading to a salary boost, such knowledge will render internal validation and boost self-confidence about one’s skill set. Keep in mind however, that checking this too often can be adversely distracting. Lynn S. Connolly, MD, also of UCLA brought to light the important fact that female gastroenterologists are often paid lower salaries than their male counterparts, even after adjusting for vacation time, practice type, and work hours. She urged female gastroenterologists not to undervalue themselves and avoid falling into this pitfall. Lin Chang, MD, a professor of medicine at UCLA, reinforced the need for young GI fellows to be passionate about the path they choose and to not make random choices or decisions based on convenience alone.

Gareth Dulai, MD, a gastroenterologist with Kaiser Permanente in Downey, CA, discussed the advantages of working in a big company, including salaries that are transparent and match the national average. One also does not have to worry about hiring staff and managing overhead costs. Martha Hierro, MD, who has been in private practice since fellowship, felt that a private group practice enables a higher salary potential and better flexibility with one’s schedule. Her group also has a pathology lab, research lab, and imaging center, which further augments the group’s earnings. The downsides to private practice, compared with bigger academic settings, include cumbersome negotiations with insurance companies and financial constraints when purchasing new technology. She advised young GI physicians to go through the partnership clause very carefully before joining any private practice. She recommended being prepared and fully informed before negotiating a contract, including speaking to other practicing gastroenterologists in the area about the earning potential in the practice. In the end, both speakers agreed that all types of practices have pros and cons and one can always move from one setting to another.

For young GI fellows who want to work as administrators, the common consensus among the panel members was that fellows should attend leadership courses at national meetings early in training and participate in the committees of national organizations like the AGA. Reaching out to educators and mentors is of key importance. Dr. Chey recommended that, when fellows are provided with an opportunity to work with a potential mentor, they should think it through before accepting the opportunity and, if they do accept it, make sure they finish the task in a timely manner.

The second session of the workshop was geared toward the interview process. James H. Tabibian, MD, PhD, of the University of California, Davis, shared some useful tips for job hunting. It is never too early to start the process of job hunting, and timing depends on the type of position one is seeking. For a competitive position, it may be best to start the process early. When looking for jobs, contact methods could include in-person encounters at national meetings, such as Digestive Disease Week, or through a mutual colleague or mentor. Emails to potential future employers should be succinct with an updated resume attached. Most importantly, make sure to follow up in a professional manner.

Dr. Connolly, who also spoke about interviewing, pointed out that one should always ask questions about the program and never offer any negative information about oneself. Discussing salary potential during an interview may not be perceived as a positive sign. One might ask the interviewer about what things the interviewer enjoys the most at work, what defines success in this position at the institution, what constitutes an ideal candidate for the program, and what is the growth plan for the program over the next 5-10 years. For subspecialty interviews, some questions that are good to ask include the volume of procedures done at the institute, what might a typical day for a fellow look like, where do fellows typically work after finishing, and how is the call schedule set up. In the end, look confident, be humble, and believe in yourself. You control how you are perceived.
 

Once you are offered a job, the next big task is contract negotiation. Negotiating a contract can be very time consuming and stressful. Some key concepts to keep in mind are: a) prepare ahead of time and know the institution well; b) the more offers you have, the more leverage you can get; c) take adequate time to evaluate the contract before signing; d) establish which clauses are nonnegotiable for you; e) try to get something back for everything you give up during negotiations; f) do not negotiate with yourself; g) keep calm and be flexible; and h) know what you want out of your job. Always keep in mind base salary and bonuses, student loan repayment, relocation expenses, medical and disability insurance, and malpractice insurance coverage. Always consider the possibility of buying into the practice. Be wary of indemnification and unreasonable noncompete clauses.

Overall, my colleagues and I found the workshop to be extremely informative. The live stream format was very well received, and as an audience, we felt engaged and encouraged to participate. We certainly appreciated the opportunity to ask questions in real time. This format allowed all our fellows to participate without needing to travel and to gain access to invaluable content that will surely help us in making important career decisions.
 

Dr. Ashat is a first-year gastroenterology fellow at The University of Iowa, Iowa City.

Medicine is an evolving field, and in this era of ever-changing medicine, physicians-in-training often lag behind in understanding the nuances of “real-world” medicine. From negotiating job contracts to understanding medical billing, coding systems, and performance metrics, physicians who are fresh out of training often feel ill prepared to deal with these issues that are rarely discussed during fellowship.

The American Gastroenterological Association’s Regional Practice Skills Workshops are designed to fill this void and provide the tools necessary to navigate the challenging transition from training into practice. Since the first pilot workshops were held in 2014, AGA’s Trainee and Early Career Committee has been diligently working to expand the number of workshop sites so that more trainees can benefit from them. This year, workshops will be held in Columbus, Ohio (Feb. 24), and in Philadelphia (April 11). An exciting development in 2017 was the opportunity to live stream the event held at the University of California, Los Angeles, to Stanford (Calif.) University and the University of Iowa, Iowa City.

This aforementioned workshop at UCLA was divided into two sessions. The first was focused on “Practice Options,” with talks geared toward highlighting the different practice models available in the GI market, including positions in academia, private practice, and mixed environments.

William Chey, MD, a professor of medicine at the University of Michigan, Ann Arbor, shared his experience as an academic gastroenterologist as well as his experience in managing a GI consulting firm. His advice to young gastroenterologists was to diversify. He suggested options such as working for pharmaceutical companies, being involved in drug trials, working in the innovation industry, and proactively seeking leadership positions in different organizations. V. Raman Muthusamy MD, AGAF, a clinical professor of medicine at UCLA, led the discussion with the million-dollar question: What is my net worth? He suggested doing some homework before negotiating one’s salary by visiting the Medical Group Management Association’s website. Having this information can provide a trainee with a head start in the negotiation process. Dr. Muthusamy recommended recalculating one’s net worth every 5 years and renegotiating your contract based on this information. In addition to possibly leading to a salary boost, such knowledge will render internal validation and boost self-confidence about one’s skill set. Keep in mind however, that checking this too often can be adversely distracting. Lynn S. Connolly, MD, also of UCLA brought to light the important fact that female gastroenterologists are often paid lower salaries than their male counterparts, even after adjusting for vacation time, practice type, and work hours. She urged female gastroenterologists not to undervalue themselves and avoid falling into this pitfall. Lin Chang, MD, a professor of medicine at UCLA, reinforced the need for young GI fellows to be passionate about the path they choose and to not make random choices or decisions based on convenience alone.

Gareth Dulai, MD, a gastroenterologist with Kaiser Permanente in Downey, CA, discussed the advantages of working in a big company, including salaries that are transparent and match the national average. One also does not have to worry about hiring staff and managing overhead costs. Martha Hierro, MD, who has been in private practice since fellowship, felt that a private group practice enables a higher salary potential and better flexibility with one’s schedule. Her group also has a pathology lab, research lab, and imaging center, which further augments the group’s earnings. The downsides to private practice, compared with bigger academic settings, include cumbersome negotiations with insurance companies and financial constraints when purchasing new technology. She advised young GI physicians to go through the partnership clause very carefully before joining any private practice. She recommended being prepared and fully informed before negotiating a contract, including speaking to other practicing gastroenterologists in the area about the earning potential in the practice. In the end, both speakers agreed that all types of practices have pros and cons and one can always move from one setting to another.

For young GI fellows who want to work as administrators, the common consensus among the panel members was that fellows should attend leadership courses at national meetings early in training and participate in the committees of national organizations like the AGA. Reaching out to educators and mentors is of key importance. Dr. Chey recommended that, when fellows are provided with an opportunity to work with a potential mentor, they should think it through before accepting the opportunity and, if they do accept it, make sure they finish the task in a timely manner.

The second session of the workshop was geared toward the interview process. James H. Tabibian, MD, PhD, of the University of California, Davis, shared some useful tips for job hunting. It is never too early to start the process of job hunting, and timing depends on the type of position one is seeking. For a competitive position, it may be best to start the process early. When looking for jobs, contact methods could include in-person encounters at national meetings, such as Digestive Disease Week, or through a mutual colleague or mentor. Emails to potential future employers should be succinct with an updated resume attached. Most importantly, make sure to follow up in a professional manner.

Dr. Connolly, who also spoke about interviewing, pointed out that one should always ask questions about the program and never offer any negative information about oneself. Discussing salary potential during an interview may not be perceived as a positive sign. One might ask the interviewer about what things the interviewer enjoys the most at work, what defines success in this position at the institution, what constitutes an ideal candidate for the program, and what is the growth plan for the program over the next 5-10 years. For subspecialty interviews, some questions that are good to ask include the volume of procedures done at the institute, what might a typical day for a fellow look like, where do fellows typically work after finishing, and how is the call schedule set up. In the end, look confident, be humble, and believe in yourself. You control how you are perceived.
 

Once you are offered a job, the next big task is contract negotiation. Negotiating a contract can be very time consuming and stressful. Some key concepts to keep in mind are: a) prepare ahead of time and know the institution well; b) the more offers you have, the more leverage you can get; c) take adequate time to evaluate the contract before signing; d) establish which clauses are nonnegotiable for you; e) try to get something back for everything you give up during negotiations; f) do not negotiate with yourself; g) keep calm and be flexible; and h) know what you want out of your job. Always keep in mind base salary and bonuses, student loan repayment, relocation expenses, medical and disability insurance, and malpractice insurance coverage. Always consider the possibility of buying into the practice. Be wary of indemnification and unreasonable noncompete clauses.

Overall, my colleagues and I found the workshop to be extremely informative. The live stream format was very well received, and as an audience, we felt engaged and encouraged to participate. We certainly appreciated the opportunity to ask questions in real time. This format allowed all our fellows to participate without needing to travel and to gain access to invaluable content that will surely help us in making important career decisions.
 

Dr. Ashat is a first-year gastroenterology fellow at The University of Iowa, Iowa City.

Medicine is an evolving field, and in this era of ever-changing medicine, physicians-in-training often lag behind in understanding the nuances of “real-world” medicine. From negotiating job contracts to understanding medical billing, coding systems, and performance metrics, physicians who are fresh out of training often feel ill prepared to deal with these issues that are rarely discussed during fellowship.

The American Gastroenterological Association’s Regional Practice Skills Workshops are designed to fill this void and provide the tools necessary to navigate the challenging transition from training into practice. Since the first pilot workshops were held in 2014, AGA’s Trainee and Early Career Committee has been diligently working to expand the number of workshop sites so that more trainees can benefit from them. This year, workshops will be held in Columbus, Ohio (Feb. 24), and in Philadelphia (April 11). An exciting development in 2017 was the opportunity to live stream the event held at the University of California, Los Angeles, to Stanford (Calif.) University and the University of Iowa, Iowa City.

This aforementioned workshop at UCLA was divided into two sessions. The first was focused on “Practice Options,” with talks geared toward highlighting the different practice models available in the GI market, including positions in academia, private practice, and mixed environments.

William Chey, MD, a professor of medicine at the University of Michigan, Ann Arbor, shared his experience as an academic gastroenterologist as well as his experience in managing a GI consulting firm. His advice to young gastroenterologists was to diversify. He suggested options such as working for pharmaceutical companies, being involved in drug trials, working in the innovation industry, and proactively seeking leadership positions in different organizations. V. Raman Muthusamy MD, AGAF, a clinical professor of medicine at UCLA, led the discussion with the million-dollar question: What is my net worth? He suggested doing some homework before negotiating one’s salary by visiting the Medical Group Management Association’s website. Having this information can provide a trainee with a head start in the negotiation process. Dr. Muthusamy recommended recalculating one’s net worth every 5 years and renegotiating your contract based on this information. In addition to possibly leading to a salary boost, such knowledge will render internal validation and boost self-confidence about one’s skill set. Keep in mind however, that checking this too often can be adversely distracting. Lynn S. Connolly, MD, also of UCLA brought to light the important fact that female gastroenterologists are often paid lower salaries than their male counterparts, even after adjusting for vacation time, practice type, and work hours. She urged female gastroenterologists not to undervalue themselves and avoid falling into this pitfall. Lin Chang, MD, a professor of medicine at UCLA, reinforced the need for young GI fellows to be passionate about the path they choose and to not make random choices or decisions based on convenience alone.

Gareth Dulai, MD, a gastroenterologist with Kaiser Permanente in Downey, CA, discussed the advantages of working in a big company, including salaries that are transparent and match the national average. One also does not have to worry about hiring staff and managing overhead costs. Martha Hierro, MD, who has been in private practice since fellowship, felt that a private group practice enables a higher salary potential and better flexibility with one’s schedule. Her group also has a pathology lab, research lab, and imaging center, which further augments the group’s earnings. The downsides to private practice, compared with bigger academic settings, include cumbersome negotiations with insurance companies and financial constraints when purchasing new technology. She advised young GI physicians to go through the partnership clause very carefully before joining any private practice. She recommended being prepared and fully informed before negotiating a contract, including speaking to other practicing gastroenterologists in the area about the earning potential in the practice. In the end, both speakers agreed that all types of practices have pros and cons and one can always move from one setting to another.

For young GI fellows who want to work as administrators, the common consensus among the panel members was that fellows should attend leadership courses at national meetings early in training and participate in the committees of national organizations like the AGA. Reaching out to educators and mentors is of key importance. Dr. Chey recommended that, when fellows are provided with an opportunity to work with a potential mentor, they should think it through before accepting the opportunity and, if they do accept it, make sure they finish the task in a timely manner.

The second session of the workshop was geared toward the interview process. James H. Tabibian, MD, PhD, of the University of California, Davis, shared some useful tips for job hunting. It is never too early to start the process of job hunting, and timing depends on the type of position one is seeking. For a competitive position, it may be best to start the process early. When looking for jobs, contact methods could include in-person encounters at national meetings, such as Digestive Disease Week, or through a mutual colleague or mentor. Emails to potential future employers should be succinct with an updated resume attached. Most importantly, make sure to follow up in a professional manner.

Dr. Connolly, who also spoke about interviewing, pointed out that one should always ask questions about the program and never offer any negative information about oneself. Discussing salary potential during an interview may not be perceived as a positive sign. One might ask the interviewer about what things the interviewer enjoys the most at work, what defines success in this position at the institution, what constitutes an ideal candidate for the program, and what is the growth plan for the program over the next 5-10 years. For subspecialty interviews, some questions that are good to ask include the volume of procedures done at the institute, what might a typical day for a fellow look like, where do fellows typically work after finishing, and how is the call schedule set up. In the end, look confident, be humble, and believe in yourself. You control how you are perceived.
 

Once you are offered a job, the next big task is contract negotiation. Negotiating a contract can be very time consuming and stressful. Some key concepts to keep in mind are: a) prepare ahead of time and know the institution well; b) the more offers you have, the more leverage you can get; c) take adequate time to evaluate the contract before signing; d) establish which clauses are nonnegotiable for you; e) try to get something back for everything you give up during negotiations; f) do not negotiate with yourself; g) keep calm and be flexible; and h) know what you want out of your job. Always keep in mind base salary and bonuses, student loan repayment, relocation expenses, medical and disability insurance, and malpractice insurance coverage. Always consider the possibility of buying into the practice. Be wary of indemnification and unreasonable noncompete clauses.

Overall, my colleagues and I found the workshop to be extremely informative. The live stream format was very well received, and as an audience, we felt engaged and encouraged to participate. We certainly appreciated the opportunity to ask questions in real time. This format allowed all our fellows to participate without needing to travel and to gain access to invaluable content that will surely help us in making important career decisions.
 

Dr. Ashat is a first-year gastroenterology fellow at The University of Iowa, Iowa City.

Dermatology residency training can feel endless at the outset; an arduous intern year followed by 3 years of specialized training. However, I have realized that, within residency, time moves quickly. As I look ahead to postresidency life, I realize that residents are all facing the same question: What do you want to be when you grow up?

You may think you have answered that question already; however, there are many different careers within the field of dermatology and no amount of studying or reading will help you choose the right one. In an attempt to make sense of these choices, I have spoken to many recent dermatology graduates over the last several months to get a sense of how they made their postresidency decisions, and I want to share their pearls.

Pearl: Explore Fellowship Opportunities Early

The first decision is whether or not to pursue a fellowship after residency. There currently are 2 Accreditation Council for Graduate Medical Education–approved fellowships after dermatology residency: dermatopathology and micrographic surgery. Pediatric dermatology is another board-certified fellowship. A list of these training programs and the requirements can be found on the American Board of Dermatology website (www.abderm.org). There also are several nonaccredited fellowships including pediatrics, cosmetics, complex medical dermatology, cutaneous oncology, and rheumatology.

Even if you are not completely committed to pursuing a fellowship, it is beneficial to explore any fellowship options early in residency. Spend extra time in any field you are considering for fellowship and consider research in the field. If there is a fellowship position at your institution, try to rotate there early in residency. Rotations at other institutions can demonstrate your interest and enthusiasm while also helping you to network within your chosen subspecialty. Several of the dermatology interest groups even sponsor rotations at outside institutions, if extra funding is needed. If recent graduates from your program have matched in fellowship, it is always a good idea to reach out to them to get program-specific advice. It takes a lot of time, confidence, and persistence to organize the opportunities that will help you maximize your fellowship potential, but it is well worth the effort.

Fellowships can occur through an official “match,” similar to residency, or can be accepted on a rolling basis. For example, many dermatopathology fellowships can begin accepting applications as early as the summer between the first and second year of residency (www.abderm.org). It is important to get this information early so that you do not miss any application deadlines.

Pearl: Prioritize Where You Want to Practice

If you have decided that fellowship is not for you, then it is time to apply for your first job as a physician. There are several big factors that help narrow the search. It is best to start the search early to allow yourself time and different options. According to the 2016 American Academy of Dermatology database, there currently are approximately 3.4 dermatologists per 100,000 Americans; however, they are unevenly distributed throughout the country. In this study, the researchers found the highest density of dermatologists on the Upper East Side of Manhattan (41.8 per 100,000 dermatologists) compared to Swainsboro, Georgia (0.45 per 100,000 dermatologists).¹

With more competition for jobs in areas with a higher concentration of dermatologists, compensation often is lower. There also are many personal factors that contribute to where you want to live and work, and if you prioritize them, it will lead to greater overall satisfaction in postresidency life.

Another large factor to consider is private practice versus academic dermatology. Academic dermatology can provide opportunities for research as well as the opportunity to work with students and residents. As part of a larger hospital system, there often is the opportunity for benefits, such as 401(k) matching, that might be less accessible in small practices.

Pearl: Get Recruiter Recommendations From Your Peers

There are many recruiting services that can help put you in touch with practices that are hiring. These services can be helpful but also can be overwhelming at times, with many emails and telephone calls. In my experience, recent graduates had mixed feelings about recruiting services. Those who had been the happiest with their recruiting experience had often gotten the name of a specific recruiter from someone else in their program who had a positive experience. Mentors at your training institution or beyond also can be a good source of information for job opportunities. It can be helpful to get involved early in the various dermatologic societies and network at academic conferences throughout your training.

Pearl: Talk to Partners and Nonpartners About the Practice’s Philosophy

When picking a private practice for your first job, make sure you get a sense of the philosophy of the practice, including the partners’ goals for the office, the patient population, and the dynamic of the office staff. If there is a cosmetic component, it is important to know what devices are available and which products are sold. It is important to talk to nonpartners at a practice and get a sense of their satisfaction. If you sign the employment contract, you will be in their shoes soon!

Pearl: Have an Attorney Review Your Contract

There are many important topics in your employment contract. After years of medical school loans and resident salary, it is easy to focus only on compensation. However, pay attention to the other aspects of reimbursement including bonuses, benefits, noncompete clauses, and call schedules. Also consider the termination policies. The general advice I have received is to have a lawyer look at your contract. Although it may be tempting to skip the lawyer’s fee and review it yourself, you may actually end up negotiating a contract that benefits you more in the long-run or avoid signing a contract that will limit you.

Dermatology residency training can feel endless at the outset; an arduous intern year followed by 3 years of specialized training. However, I have realized that, within residency, time moves quickly. As I look ahead to postresidency life, I realize that residents are all facing the same question: What do you want to be when you grow up?

You may think you have answered that question already; however, there are many different careers within the field of dermatology and no amount of studying or reading will help you choose the right one. In an attempt to make sense of these choices, I have spoken to many recent dermatology graduates over the last several months to get a sense of how they made their postresidency decisions, and I want to share their pearls.

Pearl: Explore Fellowship Opportunities Early

The first decision is whether or not to pursue a fellowship after residency. There currently are 2 Accreditation Council for Graduate Medical Education–approved fellowships after dermatology residency: dermatopathology and micrographic surgery. Pediatric dermatology is another board-certified fellowship. A list of these training programs and the requirements can be found on the American Board of Dermatology website (www.abderm.org). There also are several nonaccredited fellowships including pediatrics, cosmetics, complex medical dermatology, cutaneous oncology, and rheumatology.

Even if you are not completely committed to pursuing a fellowship, it is beneficial to explore any fellowship options early in residency. Spend extra time in any field you are considering for fellowship and consider research in the field. If there is a fellowship position at your institution, try to rotate there early in residency. Rotations at other institutions can demonstrate your interest and enthusiasm while also helping you to network within your chosen subspecialty. Several of the dermatology interest groups even sponsor rotations at outside institutions, if extra funding is needed. If recent graduates from your program have matched in fellowship, it is always a good idea to reach out to them to get program-specific advice. It takes a lot of time, confidence, and persistence to organize the opportunities that will help you maximize your fellowship potential, but it is well worth the effort.

Fellowships can occur through an official “match,” similar to residency, or can be accepted on a rolling basis. For example, many dermatopathology fellowships can begin accepting applications as early as the summer between the first and second year of residency (www.abderm.org). It is important to get this information early so that you do not miss any application deadlines.

Pearl: Prioritize Where You Want to Practice

If you have decided that fellowship is not for you, then it is time to apply for your first job as a physician. There are several big factors that help narrow the search. It is best to start the search early to allow yourself time and different options. According to the 2016 American Academy of Dermatology database, there currently are approximately 3.4 dermatologists per 100,000 Americans; however, they are unevenly distributed throughout the country. In this study, the researchers found the highest density of dermatologists on the Upper East Side of Manhattan (41.8 per 100,000 dermatologists) compared to Swainsboro, Georgia (0.45 per 100,000 dermatologists).¹

With more competition for jobs in areas with a higher concentration of dermatologists, compensation often is lower. There also are many personal factors that contribute to where you want to live and work, and if you prioritize them, it will lead to greater overall satisfaction in postresidency life.

Another large factor to consider is private practice versus academic dermatology. Academic dermatology can provide opportunities for research as well as the opportunity to work with students and residents. As part of a larger hospital system, there often is the opportunity for benefits, such as 401(k) matching, that might be less accessible in small practices.

Pearl: Get Recruiter Recommendations From Your Peers

There are many recruiting services that can help put you in touch with practices that are hiring. These services can be helpful but also can be overwhelming at times, with many emails and telephone calls. In my experience, recent graduates had mixed feelings about recruiting services. Those who had been the happiest with their recruiting experience had often gotten the name of a specific recruiter from someone else in their program who had a positive experience. Mentors at your training institution or beyond also can be a good source of information for job opportunities. It can be helpful to get involved early in the various dermatologic societies and network at academic conferences throughout your training.

Pearl: Talk to Partners and Nonpartners About the Practice’s Philosophy

When picking a private practice for your first job, make sure you get a sense of the philosophy of the practice, including the partners’ goals for the office, the patient population, and the dynamic of the office staff. If there is a cosmetic component, it is important to know what devices are available and which products are sold. It is important to talk to nonpartners at a practice and get a sense of their satisfaction. If you sign the employment contract, you will be in their shoes soon!

Pearl: Have an Attorney Review Your Contract

There are many important topics in your employment contract. After years of medical school loans and resident salary, it is easy to focus only on compensation. However, pay attention to the other aspects of reimbursement including bonuses, benefits, noncompete clauses, and call schedules. Also consider the termination policies. The general advice I have received is to have a lawyer look at your contract. Although it may be tempting to skip the lawyer’s fee and review it yourself, you may actually end up negotiating a contract that benefits you more in the long-run or avoid signing a contract that will limit you.

Dermatology residency training can feel endless at the outset; an arduous intern year followed by 3 years of specialized training. However, I have realized that, within residency, time moves quickly. As I look ahead to postresidency life, I realize that residents are all facing the same question: What do you want to be when you grow up?

You may think you have answered that question already; however, there are many different careers within the field of dermatology and no amount of studying or reading will help you choose the right one. In an attempt to make sense of these choices, I have spoken to many recent dermatology graduates over the last several months to get a sense of how they made their postresidency decisions, and I want to share their pearls.

Pearl: Explore Fellowship Opportunities Early

The first decision is whether or not to pursue a fellowship after residency. There currently are 2 Accreditation Council for Graduate Medical Education–approved fellowships after dermatology residency: dermatopathology and micrographic surgery. Pediatric dermatology is another board-certified fellowship. A list of these training programs and the requirements can be found on the American Board of Dermatology website (www.abderm.org). There also are several nonaccredited fellowships including pediatrics, cosmetics, complex medical dermatology, cutaneous oncology, and rheumatology.

Even if you are not completely committed to pursuing a fellowship, it is beneficial to explore any fellowship options early in residency. Spend extra time in any field you are considering for fellowship and consider research in the field. If there is a fellowship position at your institution, try to rotate there early in residency. Rotations at other institutions can demonstrate your interest and enthusiasm while also helping you to network within your chosen subspecialty. Several of the dermatology interest groups even sponsor rotations at outside institutions, if extra funding is needed. If recent graduates from your program have matched in fellowship, it is always a good idea to reach out to them to get program-specific advice. It takes a lot of time, confidence, and persistence to organize the opportunities that will help you maximize your fellowship potential, but it is well worth the effort.

Fellowships can occur through an official “match,” similar to residency, or can be accepted on a rolling basis. For example, many dermatopathology fellowships can begin accepting applications as early as the summer between the first and second year of residency (www.abderm.org). It is important to get this information early so that you do not miss any application deadlines.

Pearl: Prioritize Where You Want to Practice

If you have decided that fellowship is not for you, then it is time to apply for your first job as a physician. There are several big factors that help narrow the search. It is best to start the search early to allow yourself time and different options. According to the 2016 American Academy of Dermatology database, there currently are approximately 3.4 dermatologists per 100,000 Americans; however, they are unevenly distributed throughout the country. In this study, the researchers found the highest density of dermatologists on the Upper East Side of Manhattan (41.8 per 100,000 dermatologists) compared to Swainsboro, Georgia (0.45 per 100,000 dermatologists).¹

With more competition for jobs in areas with a higher concentration of dermatologists, compensation often is lower. There also are many personal factors that contribute to where you want to live and work, and if you prioritize them, it will lead to greater overall satisfaction in postresidency life.

Another large factor to consider is private practice versus academic dermatology. Academic dermatology can provide opportunities for research as well as the opportunity to work with students and residents. As part of a larger hospital system, there often is the opportunity for benefits, such as 401(k) matching, that might be less accessible in small practices.

Pearl: Get Recruiter Recommendations From Your Peers

There are many recruiting services that can help put you in touch with practices that are hiring. These services can be helpful but also can be overwhelming at times, with many emails and telephone calls. In my experience, recent graduates had mixed feelings about recruiting services. Those who had been the happiest with their recruiting experience had often gotten the name of a specific recruiter from someone else in their program who had a positive experience. Mentors at your training institution or beyond also can be a good source of information for job opportunities. It can be helpful to get involved early in the various dermatologic societies and network at academic conferences throughout your training.

Pearl: Talk to Partners and Nonpartners About the Practice’s Philosophy

When picking a private practice for your first job, make sure you get a sense of the philosophy of the practice, including the partners’ goals for the office, the patient population, and the dynamic of the office staff. If there is a cosmetic component, it is important to know what devices are available and which products are sold. It is important to talk to nonpartners at a practice and get a sense of their satisfaction. If you sign the employment contract, you will be in their shoes soon!

Pearl: Have an Attorney Review Your Contract

There are many important topics in your employment contract. After years of medical school loans and resident salary, it is easy to focus only on compensation. However, pay attention to the other aspects of reimbursement including bonuses, benefits, noncompete clauses, and call schedules. Also consider the termination policies. The general advice I have received is to have a lawyer look at your contract. Although it may be tempting to skip the lawyer’s fee and review it yourself, you may actually end up negotiating a contract that benefits you more in the long-run or avoid signing a contract that will limit you.

Older adults who received an interdisciplinary intervention before surgery had fewer complications and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.

Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.

©Wavebreakmedia Ltd/thinkstockphotos.com

SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.

Older adults who received an interdisciplinary intervention before surgery had fewer complications and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.

Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.

©Wavebreakmedia Ltd/thinkstockphotos.com

SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.

Older adults who received an interdisciplinary intervention before surgery had fewer complications and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.

Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.

©Wavebreakmedia Ltd/thinkstockphotos.com

SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.

Over the past few decades, there has been a dramatic increase in the number of shoulder arthroplasties performed around the world. This increase is the result of an aging and increasingly more active population, better implant technology, and the advent of reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy. Additionally, as the indications for RSA have expanded to include pathologies such as rotator cuff insufficiency, chronic instabilities, trauma, and tumors, the number of arthroplasties will continue to increase. Although the results of most arthroplasties are good and predictable, any glenoid and/or humeral bone deficiencies can have detrimental effects on the clinical outcomes of these procedures. Bone loss becomes more of a problem in revision cases, and, as the number of primary arthroplasties increases, it follows that the number of revision procedures will also increase.

Many of the disease- or procedure-specific processes indicated for shoulder arthroplasty have predictable patterns of bone loss, especially on the glenoid side. Walch and colleagues¹ and Bercik and colleagues² made us aware that many patients with primary osteoarthritis have significant glenoid bone deformity. Similarly, there have been a number of first- and second-generation classification systems for delineating glenoid deformity in rotator cuff tear arthropathy and in revision settings. In revision settings, both glenoid and humeral bone deficiencies can occur as a result of implant removal, iatrogenic fracture, and even infection. Each of these bone loss patterns must be recognized and treated appropriately for the best surgical outcome.

The articles in this month of The American Journal of Orthopedics address the most up-to-date concepts and solutions regarding both humeral and glenoid bone loss in shoulder arthroplasty of all types.

HUMERAL BONE LOSS

Humeral bone loss is typically encountered in proximal humerus fractures, in revision surgery necessitating humeral component removal, and, less commonly, in tumors and infection.

In many displaced proximal humeral fractures indicated for shoulder arthroplasty, the bone is comminuted with displacement of the lesser and greater tuberosities. In these situations, failure of tuberosity healing may result in loss of rotator cuff function with loss of elevation, rotation, and even instability. Humeral shortening can also occur as a result of bone loss and can compromise deltoid function by loss of proper muscle tension, leading to instability, dysfunction, or both. In addition to possible instability, humeral shortening with metaphyseal bone loss can adversely affect long-term fixation of the humeral component, leading to stem loosening or failure. Cuff and colleagues³ showed significantly more rotational micromotion in cases lacking metaphyseal support, leading to aseptic loosening of the humeral stem.

Humeral bone loss can also result from humeral stem component removal in revision shoulder arthroplasty for infection, component failure or loosening, and even periprosthetic fracture resulting from surgery or trauma.

For the surgeon, humeral bone loss can create a complex set of circumstances related to rotator cuff attachment failure, soft-tissue balancing effects, and component fixation issues. Any such issue must be recognized and addressed for best outcomes. Best results can be obtained with preoperative imaging, planning, use of bone graft techniques, proximal humeral allografts, and, more recently, modular and patient-specific implants. All of these issues are discussed comprehensively in the articles this month.

Continue to: GLENOID BONE LOSS

Proper glenoid component placement with durable fixation is crucial for success in anatomical total shoulder arthroplasty and RSA. Glenoid bone deformity and loss can result from intrinsic deformity characteristics seen in primary osteoarthritis, cuff tear arthropathy, or glenoid component removal in revision situations and infection. These bone deformity complications can be extremely difficult to treat and in some cases lead to catastrophic failure of the index arthroplasty.

We are now aware that one key to success in the face of moderate to severe deformity is proper recognition. Newer imaging techniques, including 2-dimensional (2-D) computed tomography (CT) and 3-dimensional (3-D) modeling and surgical planning software tools, which are outlined in an upcoming article, have given surgeons important new instruments that can help in treating these difficult cases.

Glenoid bone deformity in primary osteoarthritis was well delineated in the 1999 seminal study of CT changes by Walch and colleagues.¹ The Walch classification system, which characterized glenoid morphology based on 2-D CT findings, was recently upgraded, based on 3-D imaging technology, to include Walch B3 and D patterns (Figure 1).² Recognition of certain primary deformities in osteoarthritis has led to increased use of RSA in some cases of Walch B2, B3, and C deformities with substantial glenoid retroversion and/or humeral head subluxation.⁴

In cases of rotator cuff tear arthropathy, glenoid bone deformities are well described with several classification systems based on degree and dimension of bone insufficiency. The Hamada classification system defines the degree of medial glenoid erosion and superior bone loss, as well as acetabularization of the acromion in 5 grades; ⁵ Rispoli and colleagues⁶ defined and graded the degree of medicalization of the glenohumeral joint based on degree of subchondral plate erosion; and Visotsky and colleagues⁷ based their classification system on wear patterns of bone loss, alignment, and concomitant soft-tissue insufficiencies leading to instability and rotation loss.

In severe glenoid bone deficiency after glenoid component removal, Antuna and colleagues⁸ described the classic findings related to medial bone loss, anterior and posterior wall failure, and combinations thereof.

Continue to: All these classification systems...

All these classification systems are based on the 2-D appearance of the glenoid and should be considered cautiously. The glenoid is a complex 3-D structure that can be affected by any number of disease processes, trauma, and surgical intervention. Using more modern CT techniques and 3-D imaging, we now know that many deformities previously classified as unidirectional are, instead, complex and multidirectional.

Frankle and colleagues⁹ developed a classification based more 3-D CT models which has further classified severe glenoid vault deformities in relation to direction and degree of bone loss (Figures 2A-2E). Using this system, they were better able to determine degree and direction of deformity than in previous 2-D evaluations, and they were able to determine the amount of glenoid vault bone available for baseplate fixation. Scalise and colleagues¹⁰ further defined the influence of such 3-D planning in total shoulder arthroplasty.

With knowledge of these classification systems and use of contemporary imaging systems, shoulder arthroplasty in cases of severe glenoid deficiency can be more successful. Potentially, we can improve outcomes even more in the more severe cases of bone loss with use of patient-specific planning tools, including the guides and patient-specific implants that are now readily available with many implant systems.¹¹

Preoperative planning tools, bone-grafting techniques, augmented and specialized glenoid and humeral implants, and patient-specific implants are discussed this month to give our readers a comprehensive review of the latest concepts in shoulder arthroplasty in cases of significant bone loss or deformity.

This month of The American Journal of Orthopedics presents the most current and cutting-edge solutions for humeral and glenoid bone deformities and deficiencies in contemporary shoulder arthroplasties.

Over the past few decades, there has been a dramatic increase in the number of shoulder arthroplasties performed around the world. This increase is the result of an aging and increasingly more active population, better implant technology, and the advent of reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy. Additionally, as the indications for RSA have expanded to include pathologies such as rotator cuff insufficiency, chronic instabilities, trauma, and tumors, the number of arthroplasties will continue to increase. Although the results of most arthroplasties are good and predictable, any glenoid and/or humeral bone deficiencies can have detrimental effects on the clinical outcomes of these procedures. Bone loss becomes more of a problem in revision cases, and, as the number of primary arthroplasties increases, it follows that the number of revision procedures will also increase.

Many of the disease- or procedure-specific processes indicated for shoulder arthroplasty have predictable patterns of bone loss, especially on the glenoid side. Walch and colleagues¹ and Bercik and colleagues² made us aware that many patients with primary osteoarthritis have significant glenoid bone deformity. Similarly, there have been a number of first- and second-generation classification systems for delineating glenoid deformity in rotator cuff tear arthropathy and in revision settings. In revision settings, both glenoid and humeral bone deficiencies can occur as a result of implant removal, iatrogenic fracture, and even infection. Each of these bone loss patterns must be recognized and treated appropriately for the best surgical outcome.

The articles in this month of The American Journal of Orthopedics address the most up-to-date concepts and solutions regarding both humeral and glenoid bone loss in shoulder arthroplasty of all types.

HUMERAL BONE LOSS

Humeral bone loss is typically encountered in proximal humerus fractures, in revision surgery necessitating humeral component removal, and, less commonly, in tumors and infection.

In many displaced proximal humeral fractures indicated for shoulder arthroplasty, the bone is comminuted with displacement of the lesser and greater tuberosities. In these situations, failure of tuberosity healing may result in loss of rotator cuff function with loss of elevation, rotation, and even instability. Humeral shortening can also occur as a result of bone loss and can compromise deltoid function by loss of proper muscle tension, leading to instability, dysfunction, or both. In addition to possible instability, humeral shortening with metaphyseal bone loss can adversely affect long-term fixation of the humeral component, leading to stem loosening or failure. Cuff and colleagues³ showed significantly more rotational micromotion in cases lacking metaphyseal support, leading to aseptic loosening of the humeral stem.

Humeral bone loss can also result from humeral stem component removal in revision shoulder arthroplasty for infection, component failure or loosening, and even periprosthetic fracture resulting from surgery or trauma.

For the surgeon, humeral bone loss can create a complex set of circumstances related to rotator cuff attachment failure, soft-tissue balancing effects, and component fixation issues. Any such issue must be recognized and addressed for best outcomes. Best results can be obtained with preoperative imaging, planning, use of bone graft techniques, proximal humeral allografts, and, more recently, modular and patient-specific implants. All of these issues are discussed comprehensively in the articles this month.

Continue to: GLENOID BONE LOSS

Proper glenoid component placement with durable fixation is crucial for success in anatomical total shoulder arthroplasty and RSA. Glenoid bone deformity and loss can result from intrinsic deformity characteristics seen in primary osteoarthritis, cuff tear arthropathy, or glenoid component removal in revision situations and infection. These bone deformity complications can be extremely difficult to treat and in some cases lead to catastrophic failure of the index arthroplasty.

We are now aware that one key to success in the face of moderate to severe deformity is proper recognition. Newer imaging techniques, including 2-dimensional (2-D) computed tomography (CT) and 3-dimensional (3-D) modeling and surgical planning software tools, which are outlined in an upcoming article, have given surgeons important new instruments that can help in treating these difficult cases.

Glenoid bone deformity in primary osteoarthritis was well delineated in the 1999 seminal study of CT changes by Walch and colleagues.¹ The Walch classification system, which characterized glenoid morphology based on 2-D CT findings, was recently upgraded, based on 3-D imaging technology, to include Walch B3 and D patterns (Figure 1).² Recognition of certain primary deformities in osteoarthritis has led to increased use of RSA in some cases of Walch B2, B3, and C deformities with substantial glenoid retroversion and/or humeral head subluxation.⁴

In cases of rotator cuff tear arthropathy, glenoid bone deformities are well described with several classification systems based on degree and dimension of bone insufficiency. The Hamada classification system defines the degree of medial glenoid erosion and superior bone loss, as well as acetabularization of the acromion in 5 grades; ⁵ Rispoli and colleagues⁶ defined and graded the degree of medicalization of the glenohumeral joint based on degree of subchondral plate erosion; and Visotsky and colleagues⁷ based their classification system on wear patterns of bone loss, alignment, and concomitant soft-tissue insufficiencies leading to instability and rotation loss.

In severe glenoid bone deficiency after glenoid component removal, Antuna and colleagues⁸ described the classic findings related to medial bone loss, anterior and posterior wall failure, and combinations thereof.

Continue to: All these classification systems...

All these classification systems are based on the 2-D appearance of the glenoid and should be considered cautiously. The glenoid is a complex 3-D structure that can be affected by any number of disease processes, trauma, and surgical intervention. Using more modern CT techniques and 3-D imaging, we now know that many deformities previously classified as unidirectional are, instead, complex and multidirectional.

Frankle and colleagues⁹ developed a classification based more 3-D CT models which has further classified severe glenoid vault deformities in relation to direction and degree of bone loss (Figures 2A-2E). Using this system, they were better able to determine degree and direction of deformity than in previous 2-D evaluations, and they were able to determine the amount of glenoid vault bone available for baseplate fixation. Scalise and colleagues¹⁰ further defined the influence of such 3-D planning in total shoulder arthroplasty.

With knowledge of these classification systems and use of contemporary imaging systems, shoulder arthroplasty in cases of severe glenoid deficiency can be more successful. Potentially, we can improve outcomes even more in the more severe cases of bone loss with use of patient-specific planning tools, including the guides and patient-specific implants that are now readily available with many implant systems.¹¹

Preoperative planning tools, bone-grafting techniques, augmented and specialized glenoid and humeral implants, and patient-specific implants are discussed this month to give our readers a comprehensive review of the latest concepts in shoulder arthroplasty in cases of significant bone loss or deformity.

This month of The American Journal of Orthopedics presents the most current and cutting-edge solutions for humeral and glenoid bone deformities and deficiencies in contemporary shoulder arthroplasties.

Over the past few decades, there has been a dramatic increase in the number of shoulder arthroplasties performed around the world. This increase is the result of an aging and increasingly more active population, better implant technology, and the advent of reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy. Additionally, as the indications for RSA have expanded to include pathologies such as rotator cuff insufficiency, chronic instabilities, trauma, and tumors, the number of arthroplasties will continue to increase. Although the results of most arthroplasties are good and predictable, any glenoid and/or humeral bone deficiencies can have detrimental effects on the clinical outcomes of these procedures. Bone loss becomes more of a problem in revision cases, and, as the number of primary arthroplasties increases, it follows that the number of revision procedures will also increase.

Many of the disease- or procedure-specific processes indicated for shoulder arthroplasty have predictable patterns of bone loss, especially on the glenoid side. Walch and colleagues¹ and Bercik and colleagues² made us aware that many patients with primary osteoarthritis have significant glenoid bone deformity. Similarly, there have been a number of first- and second-generation classification systems for delineating glenoid deformity in rotator cuff tear arthropathy and in revision settings. In revision settings, both glenoid and humeral bone deficiencies can occur as a result of implant removal, iatrogenic fracture, and even infection. Each of these bone loss patterns must be recognized and treated appropriately for the best surgical outcome.

The articles in this month of The American Journal of Orthopedics address the most up-to-date concepts and solutions regarding both humeral and glenoid bone loss in shoulder arthroplasty of all types.

HUMERAL BONE LOSS

Humeral bone loss is typically encountered in proximal humerus fractures, in revision surgery necessitating humeral component removal, and, less commonly, in tumors and infection.

In many displaced proximal humeral fractures indicated for shoulder arthroplasty, the bone is comminuted with displacement of the lesser and greater tuberosities. In these situations, failure of tuberosity healing may result in loss of rotator cuff function with loss of elevation, rotation, and even instability. Humeral shortening can also occur as a result of bone loss and can compromise deltoid function by loss of proper muscle tension, leading to instability, dysfunction, or both. In addition to possible instability, humeral shortening with metaphyseal bone loss can adversely affect long-term fixation of the humeral component, leading to stem loosening or failure. Cuff and colleagues³ showed significantly more rotational micromotion in cases lacking metaphyseal support, leading to aseptic loosening of the humeral stem.

Humeral bone loss can also result from humeral stem component removal in revision shoulder arthroplasty for infection, component failure or loosening, and even periprosthetic fracture resulting from surgery or trauma.

For the surgeon, humeral bone loss can create a complex set of circumstances related to rotator cuff attachment failure, soft-tissue balancing effects, and component fixation issues. Any such issue must be recognized and addressed for best outcomes. Best results can be obtained with preoperative imaging, planning, use of bone graft techniques, proximal humeral allografts, and, more recently, modular and patient-specific implants. All of these issues are discussed comprehensively in the articles this month.

Continue to: GLENOID BONE LOSS

Proper glenoid component placement with durable fixation is crucial for success in anatomical total shoulder arthroplasty and RSA. Glenoid bone deformity and loss can result from intrinsic deformity characteristics seen in primary osteoarthritis, cuff tear arthropathy, or glenoid component removal in revision situations and infection. These bone deformity complications can be extremely difficult to treat and in some cases lead to catastrophic failure of the index arthroplasty.

We are now aware that one key to success in the face of moderate to severe deformity is proper recognition. Newer imaging techniques, including 2-dimensional (2-D) computed tomography (CT) and 3-dimensional (3-D) modeling and surgical planning software tools, which are outlined in an upcoming article, have given surgeons important new instruments that can help in treating these difficult cases.

Glenoid bone deformity in primary osteoarthritis was well delineated in the 1999 seminal study of CT changes by Walch and colleagues.¹ The Walch classification system, which characterized glenoid morphology based on 2-D CT findings, was recently upgraded, based on 3-D imaging technology, to include Walch B3 and D patterns (Figure 1).² Recognition of certain primary deformities in osteoarthritis has led to increased use of RSA in some cases of Walch B2, B3, and C deformities with substantial glenoid retroversion and/or humeral head subluxation.⁴

In cases of rotator cuff tear arthropathy, glenoid bone deformities are well described with several classification systems based on degree and dimension of bone insufficiency. The Hamada classification system defines the degree of medial glenoid erosion and superior bone loss, as well as acetabularization of the acromion in 5 grades; ⁵ Rispoli and colleagues⁶ defined and graded the degree of medicalization of the glenohumeral joint based on degree of subchondral plate erosion; and Visotsky and colleagues⁷ based their classification system on wear patterns of bone loss, alignment, and concomitant soft-tissue insufficiencies leading to instability and rotation loss.

In severe glenoid bone deficiency after glenoid component removal, Antuna and colleagues⁸ described the classic findings related to medial bone loss, anterior and posterior wall failure, and combinations thereof.

Continue to: All these classification systems...

All these classification systems are based on the 2-D appearance of the glenoid and should be considered cautiously. The glenoid is a complex 3-D structure that can be affected by any number of disease processes, trauma, and surgical intervention. Using more modern CT techniques and 3-D imaging, we now know that many deformities previously classified as unidirectional are, instead, complex and multidirectional.

Frankle and colleagues⁹ developed a classification based more 3-D CT models which has further classified severe glenoid vault deformities in relation to direction and degree of bone loss (Figures 2A-2E). Using this system, they were better able to determine degree and direction of deformity than in previous 2-D evaluations, and they were able to determine the amount of glenoid vault bone available for baseplate fixation. Scalise and colleagues¹⁰ further defined the influence of such 3-D planning in total shoulder arthroplasty.

With knowledge of these classification systems and use of contemporary imaging systems, shoulder arthroplasty in cases of severe glenoid deficiency can be more successful. Potentially, we can improve outcomes even more in the more severe cases of bone loss with use of patient-specific planning tools, including the guides and patient-specific implants that are now readily available with many implant systems.¹¹

Preoperative planning tools, bone-grafting techniques, augmented and specialized glenoid and humeral implants, and patient-specific implants are discussed this month to give our readers a comprehensive review of the latest concepts in shoulder arthroplasty in cases of significant bone loss or deformity.

This month of The American Journal of Orthopedics presents the most current and cutting-edge solutions for humeral and glenoid bone deformities and deficiencies in contemporary shoulder arthroplasties.