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Papules below eyes
The FP looked at the small papules closely and recognized them as white milia cysts and flesh-colored syringomas. He explained to the patient that both conditions were benign and discussed treatment options.
Milia cysts, which appear as shiny white papules, can be extracted. This procedure is performed without local anesthesia, and the most uncomfortable part is when pressure is applied with the comedone extractor against the infraorbital bone. (The billing code for this procedure is the same as the one used for acne surgery.)
Syringomas, however, are not easily treated. New lesions can form even if some resolve. Treatment options for syringomas include topical trichloroacetic acid, cryosurgery, and electrosurgery. Because this patient’s lesions were on the eyelids, as they often are, there are risks involved.
The patient agreed to extraction of the milia cysts, so the FP removed a number of them using the tip of a Number 11 scalpel blade and a comedone extractor. The patient was happy to have them removed and said that he would think about the options for syringoma treatment at a future date.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Sebaceous hyperplasia. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 931-934.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
The FP looked at the small papules closely and recognized them as white milia cysts and flesh-colored syringomas. He explained to the patient that both conditions were benign and discussed treatment options.
Milia cysts, which appear as shiny white papules, can be extracted. This procedure is performed without local anesthesia, and the most uncomfortable part is when pressure is applied with the comedone extractor against the infraorbital bone. (The billing code for this procedure is the same as the one used for acne surgery.)
Syringomas, however, are not easily treated. New lesions can form even if some resolve. Treatment options for syringomas include topical trichloroacetic acid, cryosurgery, and electrosurgery. Because this patient’s lesions were on the eyelids, as they often are, there are risks involved.
The patient agreed to extraction of the milia cysts, so the FP removed a number of them using the tip of a Number 11 scalpel blade and a comedone extractor. The patient was happy to have them removed and said that he would think about the options for syringoma treatment at a future date.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Sebaceous hyperplasia. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 931-934.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
The FP looked at the small papules closely and recognized them as white milia cysts and flesh-colored syringomas. He explained to the patient that both conditions were benign and discussed treatment options.
Milia cysts, which appear as shiny white papules, can be extracted. This procedure is performed without local anesthesia, and the most uncomfortable part is when pressure is applied with the comedone extractor against the infraorbital bone. (The billing code for this procedure is the same as the one used for acne surgery.)
Syringomas, however, are not easily treated. New lesions can form even if some resolve. Treatment options for syringomas include topical trichloroacetic acid, cryosurgery, and electrosurgery. Because this patient’s lesions were on the eyelids, as they often are, there are risks involved.
The patient agreed to extraction of the milia cysts, so the FP removed a number of them using the tip of a Number 11 scalpel blade and a comedone extractor. The patient was happy to have them removed and said that he would think about the options for syringoma treatment at a future date.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Sebaceous hyperplasia. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 931-934.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
Ixekizumab beats ustekinumab for fingernail psoriasis, hands down
GENEVA – Ixekizumab improved fingernail psoriasis significantly faster and with a higher complete nail clearance rate by week 24 compared with ustekinumab in a head-to-head phase 3b randomized trial, Yves Dutronc, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.
This is a clinically important finding because – as dermatologists and psoriasis patients well know – nail and skin psoriasis are two different animals.
He presented a prespecified secondary analysis of the randomized, phase 3b, multicenter IXORA-S trial. The study pit the interleukin-17A inhibitor ixekizumab (Taltz) head-to-head against the interleukin 12/23 inhibitor ustekinumab (Stelara). The primary endpoint, which was the PASI 90 improvement rate, has previously been reported: 73% in the ixekizumab group versus 42% in the ustekinumab group at week 12, and 83% versus 59% at week 24. And ixekizumab’s superior efficacy was achieved with a safety profile similar to that of ustekinumab (Br J Dermatol. 2017 Oct;177[4]:1014-23).
However, change in PASI score or Investigator’s Global Assessment isn’t informative regarding a patient’s change in nail psoriasis status. This was the impetus for the secondary analysis focused on the IXORA-S subgroup with baseline fingernail psoriasis. For this purpose, Dr. Dutronc and his coinvestigators used as their metric the change over time in the Nail Psoriasis Severity Index (NAPSI) total score, which entails a quadrant-by-quadrant assessment of every fingernail.
By play of chance, the 84 patients randomized to ixekizumab had slightly more severe nail psoriasis at baseline than that of the 105 ustekinumab patients. Their mean baseline NAPSI total score was 28.3, compared with 24.8 for the ustekinumab group. More than one-quarter of patients in the ixekizumab arm had a baseline NAPSI score greater than 43, whereas the top quartile of nail psoriasis severity in the ustekinumab group began with a NAPSI score above 34.
Not surprisingly, not much happened in terms of improvement in nail appearance in the first 12 weeks, since new nail grows slowly. But by week 8 the between-group difference in improvement in NAPSI score had become significant in favor of ixekizumab, with a mean 12.9-point reduction from baseline versus a 5.6-point drop in the ustekinumab group. This difference continued to grow over time, such that at week 24 the ixekizumab had a mean 19.9-point reduction, compared with a 13.2-point decrease for the ustekinumab group.
At week 12, 15.5% of the ixekizumab group and 11.3% of the ustekinumab group had reached complete clearance of their fingernail psoriasis. At week 24, complete clearance had been achieved in 48.8% of the ixekizumab group and 22.9% of patients on ustekinumab.
This is an interim analysis. Final results of the IXORA-S nail psoriasis substudy will be reported at 52 weeks of follow-up.
SOURCE: Dutronc Y. https://eadvgeneva2017.org/
GENEVA – Ixekizumab improved fingernail psoriasis significantly faster and with a higher complete nail clearance rate by week 24 compared with ustekinumab in a head-to-head phase 3b randomized trial, Yves Dutronc, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.
This is a clinically important finding because – as dermatologists and psoriasis patients well know – nail and skin psoriasis are two different animals.
He presented a prespecified secondary analysis of the randomized, phase 3b, multicenter IXORA-S trial. The study pit the interleukin-17A inhibitor ixekizumab (Taltz) head-to-head against the interleukin 12/23 inhibitor ustekinumab (Stelara). The primary endpoint, which was the PASI 90 improvement rate, has previously been reported: 73% in the ixekizumab group versus 42% in the ustekinumab group at week 12, and 83% versus 59% at week 24. And ixekizumab’s superior efficacy was achieved with a safety profile similar to that of ustekinumab (Br J Dermatol. 2017 Oct;177[4]:1014-23).
However, change in PASI score or Investigator’s Global Assessment isn’t informative regarding a patient’s change in nail psoriasis status. This was the impetus for the secondary analysis focused on the IXORA-S subgroup with baseline fingernail psoriasis. For this purpose, Dr. Dutronc and his coinvestigators used as their metric the change over time in the Nail Psoriasis Severity Index (NAPSI) total score, which entails a quadrant-by-quadrant assessment of every fingernail.
By play of chance, the 84 patients randomized to ixekizumab had slightly more severe nail psoriasis at baseline than that of the 105 ustekinumab patients. Their mean baseline NAPSI total score was 28.3, compared with 24.8 for the ustekinumab group. More than one-quarter of patients in the ixekizumab arm had a baseline NAPSI score greater than 43, whereas the top quartile of nail psoriasis severity in the ustekinumab group began with a NAPSI score above 34.
Not surprisingly, not much happened in terms of improvement in nail appearance in the first 12 weeks, since new nail grows slowly. But by week 8 the between-group difference in improvement in NAPSI score had become significant in favor of ixekizumab, with a mean 12.9-point reduction from baseline versus a 5.6-point drop in the ustekinumab group. This difference continued to grow over time, such that at week 24 the ixekizumab had a mean 19.9-point reduction, compared with a 13.2-point decrease for the ustekinumab group.
At week 12, 15.5% of the ixekizumab group and 11.3% of the ustekinumab group had reached complete clearance of their fingernail psoriasis. At week 24, complete clearance had been achieved in 48.8% of the ixekizumab group and 22.9% of patients on ustekinumab.
This is an interim analysis. Final results of the IXORA-S nail psoriasis substudy will be reported at 52 weeks of follow-up.
SOURCE: Dutronc Y. https://eadvgeneva2017.org/
GENEVA – Ixekizumab improved fingernail psoriasis significantly faster and with a higher complete nail clearance rate by week 24 compared with ustekinumab in a head-to-head phase 3b randomized trial, Yves Dutronc, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.
This is a clinically important finding because – as dermatologists and psoriasis patients well know – nail and skin psoriasis are two different animals.
He presented a prespecified secondary analysis of the randomized, phase 3b, multicenter IXORA-S trial. The study pit the interleukin-17A inhibitor ixekizumab (Taltz) head-to-head against the interleukin 12/23 inhibitor ustekinumab (Stelara). The primary endpoint, which was the PASI 90 improvement rate, has previously been reported: 73% in the ixekizumab group versus 42% in the ustekinumab group at week 12, and 83% versus 59% at week 24. And ixekizumab’s superior efficacy was achieved with a safety profile similar to that of ustekinumab (Br J Dermatol. 2017 Oct;177[4]:1014-23).
However, change in PASI score or Investigator’s Global Assessment isn’t informative regarding a patient’s change in nail psoriasis status. This was the impetus for the secondary analysis focused on the IXORA-S subgroup with baseline fingernail psoriasis. For this purpose, Dr. Dutronc and his coinvestigators used as their metric the change over time in the Nail Psoriasis Severity Index (NAPSI) total score, which entails a quadrant-by-quadrant assessment of every fingernail.
By play of chance, the 84 patients randomized to ixekizumab had slightly more severe nail psoriasis at baseline than that of the 105 ustekinumab patients. Their mean baseline NAPSI total score was 28.3, compared with 24.8 for the ustekinumab group. More than one-quarter of patients in the ixekizumab arm had a baseline NAPSI score greater than 43, whereas the top quartile of nail psoriasis severity in the ustekinumab group began with a NAPSI score above 34.
Not surprisingly, not much happened in terms of improvement in nail appearance in the first 12 weeks, since new nail grows slowly. But by week 8 the between-group difference in improvement in NAPSI score had become significant in favor of ixekizumab, with a mean 12.9-point reduction from baseline versus a 5.6-point drop in the ustekinumab group. This difference continued to grow over time, such that at week 24 the ixekizumab had a mean 19.9-point reduction, compared with a 13.2-point decrease for the ustekinumab group.
At week 12, 15.5% of the ixekizumab group and 11.3% of the ustekinumab group had reached complete clearance of their fingernail psoriasis. At week 24, complete clearance had been achieved in 48.8% of the ixekizumab group and 22.9% of patients on ustekinumab.
This is an interim analysis. Final results of the IXORA-S nail psoriasis substudy will be reported at 52 weeks of follow-up.
SOURCE: Dutronc Y. https://eadvgeneva2017.org/
REPORTING FROM THE EADV CONGRESS
Key clinical point:
Major finding: At week 24, complete clearance of fingernail psoriasis was documented in 49% of patients on ixekizumab and 23% on ustekinumab.
Study details: This secondary analysis of the randomized, multicenter, prospective, phase 3b IXORA-S trial included 189 patients with moderate to severe plaque psoriasis with fingernail involvement.
Disclosures: The study was sponsored by Eli Lilly and presented by a company employee.
Source: Dutronc Y. https://eadvgeneva2017.org
Hospitalist leader: Are you burned out? Are you resilient?
I had the privilege of teaching two seminars at the recent Society of Hospital Medicine Leadership Academy in Scottsdale, Ariz. The theme of my second seminar was “Swarm Leadership,” the topic of my September column. There seemed to be enthusiasm and interest in the topic. Participants were intrigued at the notion of leveraging instinctual responses to encourage team spirit and collective outcomes.
The key principles of these swarm-like behaviors are: 1) unity of mission, 2) generosity of spirit, 3) staying in lanes and helping others succeed in theirs, 4) no ego/no blame, and 5) a foundation of trust among those working together. Leaders create the conditions in which these behaviors are more likely to emerge. The resulting team spirit and productivity raise morale and increase the sense of work-related purpose and mission.
People expressed their sense of being burned out and overworked, even to the extent of being exploited. I was stunned at the prevalence of this sensation in the room. Not everyone spoke though many people identified with the theme.
What I heard was enough to raise the question here: For hospitalist leaders, to what extent is burnout significant enough to give it serious attention? (I want to be abundantly clear: I report observations as anecdotal and impressionistic. There is no implied critique of hospitalists on the whole nor any individual or groups.)
Burnout includes sensations of being exhausted, overburdened, underappreciated, undercompensated, cynical, and depressed. These phenomena together can affect your productivity, the quality of your work, and your endurance when the workload gets tough.
By contrast, the opposite of burnout is balance, including sensations of being engaged, enthusiastic, energetic, absorbed, challenged, and dedicated. Work is part of the equilibrium you establish in your life, which includes a variety of fulfilling and motivating experiences and accomplishments.
Ideal balance would have all the different parts of your life – from family to hobbies to work – in perfect synergy with one another. Complete burnout would have all parts of your life imploding on one another, with little room for joy, personal contentment, and professional satisfaction.
How do you assess the differences between burnout and balance? First, this is a very individual metric. What one person might consider challenging and engaging another would experience as overwhelming and alienating. When you assess a group of people, these differences are important and could inform how work assignments and heavy lifting are assigned.
During the SHM session and in private comments, people described this rise in burnout not as a personal phenomena. Rather, it results from the health system expecting more of hospitalists than they can reasonably and reliably produce. People described hospitalists getting to the breaking point with no relief in sight. What can be done about this phenomenon?
First, hold a mirror up to yourself. You cannot help others as a leader if you are not clear with your own state of burnout and balance. The questions for you – a leader of other hospitalists – include: To what extent are you burned out? If so, why? If not, why not? If you were to draw a continuum between burned out and balanced, where on that range would you place yourself? Where would others in your group or department pinpoint themselves, relative to one another, on this continuum?
How might burnout develop for hospitalist leaders? Like a car, even a high performance vehicle, you can only go so fast and so far. Push too hard on the accelerator and the vehicle begins to shake as performance declines. If your system is expecting the pace and productivity to outstrip what you consider reasonable, your performance, job satisfaction and morale drops. Impose those demands upon a group of people and the unhappiness can become infectious.
With a decline in performance comes a decline in confidence. You and your colleagues strive for top-rate outcomes. Fatigue, pressure, and unreasonable expectations challenge your ability to feel good about what you are doing. That satisfaction is part of why you chose hospital medicine and without it, you wonder about what you are doing and why you are doing it.
When you and your colleagues sense that you are unappreciated, it can spark a profound sense of disappointment. That realization could express itself in many forms, including unhappiness about pay and workload to dissatisfaction with professional support or acknowledgment. When the system on the whole is driving so fast that it cannot stop to ensure and reward good work, the rattling can have a stunting effect on performance.
When I first began teaching at SHM conferences and had hospitalists in my classes at the Harvard School of Public Health – way back when – the field was novel, revolutionary, and striving to establish a newly effective and efficient way to provide patient services. It is useful to keep these roots in perspective – hospital medicine over the arc of time – from what WAS, to what IS and eventually what WILL BE. The cleverness of hospitalist leaders has been their capacity to understand this evolution and work with it. Hospitalist medicine built opportunities in response to high costs, the lack of continuity of care, and problems of communication. It was a solution.
How might you diagnose your burnout – and that of others with whom you work – in order to build solutions? Is it a phenomenon that involves just several individuals or is it characteristic of your group as a whole? What are the causes? What are the symptoms and what are the core issues? Some are system problems in which expectations for performance – and the resources to meet those objectives – are not reasonably aligned. There is a cost for trying to reduce costs on the backs of overworked clinicians.
If this is more than an individual problem, systematically ask the question and seek systematic answers. The better you document root causes and implications, the better are you able to make a data-driven case for change. Interview, survey, and with all this, you demonstrate your concern for staff, their work, and their work experience.
Showing that you care about the professional and personal well-being and balance of your workforce, in and of itself, is the beginning of an intervention. Be honest with yourself about your own experience. And then be open to the experiences of others. As a leader, your colleagues may suggest changes you make in your own leadership that could ameliorate some of that burnout. Better communication? Improved organization? Enhanced flexibility as appropriate? These are problems you can fix.
Other solutions must be negotiated with others on the systems level. With documentation in hand, build your case for the necessary changes, whatever that might entail. Hospitalist leaders negotiated their way into respected and productive positions in the health care system. Similarly, they must negotiate the right balance now to ensure the quality, morale, and reasonable productivity of their departments and workforce.
As a hospitalist leader, you know that each day will bring its complexities, challenges, and at times, its burdens. Your objective is to encourage – for yourself, for your colleagues, and for your system – resilience that is both personal and organizational. That resilience – the ability to take a hit and bounce back – is an encouraging signal of hope and recovery, for your workforce as well as the people for whom you care. The principles of swarm leadership – reinvigorated for your group – could very well provide signposts on that everyday quest for personal and group resilience.
Leonard J. Marcus, PhD, is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].
I had the privilege of teaching two seminars at the recent Society of Hospital Medicine Leadership Academy in Scottsdale, Ariz. The theme of my second seminar was “Swarm Leadership,” the topic of my September column. There seemed to be enthusiasm and interest in the topic. Participants were intrigued at the notion of leveraging instinctual responses to encourage team spirit and collective outcomes.
The key principles of these swarm-like behaviors are: 1) unity of mission, 2) generosity of spirit, 3) staying in lanes and helping others succeed in theirs, 4) no ego/no blame, and 5) a foundation of trust among those working together. Leaders create the conditions in which these behaviors are more likely to emerge. The resulting team spirit and productivity raise morale and increase the sense of work-related purpose and mission.
People expressed their sense of being burned out and overworked, even to the extent of being exploited. I was stunned at the prevalence of this sensation in the room. Not everyone spoke though many people identified with the theme.
What I heard was enough to raise the question here: For hospitalist leaders, to what extent is burnout significant enough to give it serious attention? (I want to be abundantly clear: I report observations as anecdotal and impressionistic. There is no implied critique of hospitalists on the whole nor any individual or groups.)
Burnout includes sensations of being exhausted, overburdened, underappreciated, undercompensated, cynical, and depressed. These phenomena together can affect your productivity, the quality of your work, and your endurance when the workload gets tough.
By contrast, the opposite of burnout is balance, including sensations of being engaged, enthusiastic, energetic, absorbed, challenged, and dedicated. Work is part of the equilibrium you establish in your life, which includes a variety of fulfilling and motivating experiences and accomplishments.
Ideal balance would have all the different parts of your life – from family to hobbies to work – in perfect synergy with one another. Complete burnout would have all parts of your life imploding on one another, with little room for joy, personal contentment, and professional satisfaction.
How do you assess the differences between burnout and balance? First, this is a very individual metric. What one person might consider challenging and engaging another would experience as overwhelming and alienating. When you assess a group of people, these differences are important and could inform how work assignments and heavy lifting are assigned.
During the SHM session and in private comments, people described this rise in burnout not as a personal phenomena. Rather, it results from the health system expecting more of hospitalists than they can reasonably and reliably produce. People described hospitalists getting to the breaking point with no relief in sight. What can be done about this phenomenon?
First, hold a mirror up to yourself. You cannot help others as a leader if you are not clear with your own state of burnout and balance. The questions for you – a leader of other hospitalists – include: To what extent are you burned out? If so, why? If not, why not? If you were to draw a continuum between burned out and balanced, where on that range would you place yourself? Where would others in your group or department pinpoint themselves, relative to one another, on this continuum?
How might burnout develop for hospitalist leaders? Like a car, even a high performance vehicle, you can only go so fast and so far. Push too hard on the accelerator and the vehicle begins to shake as performance declines. If your system is expecting the pace and productivity to outstrip what you consider reasonable, your performance, job satisfaction and morale drops. Impose those demands upon a group of people and the unhappiness can become infectious.
With a decline in performance comes a decline in confidence. You and your colleagues strive for top-rate outcomes. Fatigue, pressure, and unreasonable expectations challenge your ability to feel good about what you are doing. That satisfaction is part of why you chose hospital medicine and without it, you wonder about what you are doing and why you are doing it.
When you and your colleagues sense that you are unappreciated, it can spark a profound sense of disappointment. That realization could express itself in many forms, including unhappiness about pay and workload to dissatisfaction with professional support or acknowledgment. When the system on the whole is driving so fast that it cannot stop to ensure and reward good work, the rattling can have a stunting effect on performance.
When I first began teaching at SHM conferences and had hospitalists in my classes at the Harvard School of Public Health – way back when – the field was novel, revolutionary, and striving to establish a newly effective and efficient way to provide patient services. It is useful to keep these roots in perspective – hospital medicine over the arc of time – from what WAS, to what IS and eventually what WILL BE. The cleverness of hospitalist leaders has been their capacity to understand this evolution and work with it. Hospitalist medicine built opportunities in response to high costs, the lack of continuity of care, and problems of communication. It was a solution.
How might you diagnose your burnout – and that of others with whom you work – in order to build solutions? Is it a phenomenon that involves just several individuals or is it characteristic of your group as a whole? What are the causes? What are the symptoms and what are the core issues? Some are system problems in which expectations for performance – and the resources to meet those objectives – are not reasonably aligned. There is a cost for trying to reduce costs on the backs of overworked clinicians.
If this is more than an individual problem, systematically ask the question and seek systematic answers. The better you document root causes and implications, the better are you able to make a data-driven case for change. Interview, survey, and with all this, you demonstrate your concern for staff, their work, and their work experience.
Showing that you care about the professional and personal well-being and balance of your workforce, in and of itself, is the beginning of an intervention. Be honest with yourself about your own experience. And then be open to the experiences of others. As a leader, your colleagues may suggest changes you make in your own leadership that could ameliorate some of that burnout. Better communication? Improved organization? Enhanced flexibility as appropriate? These are problems you can fix.
Other solutions must be negotiated with others on the systems level. With documentation in hand, build your case for the necessary changes, whatever that might entail. Hospitalist leaders negotiated their way into respected and productive positions in the health care system. Similarly, they must negotiate the right balance now to ensure the quality, morale, and reasonable productivity of their departments and workforce.
As a hospitalist leader, you know that each day will bring its complexities, challenges, and at times, its burdens. Your objective is to encourage – for yourself, for your colleagues, and for your system – resilience that is both personal and organizational. That resilience – the ability to take a hit and bounce back – is an encouraging signal of hope and recovery, for your workforce as well as the people for whom you care. The principles of swarm leadership – reinvigorated for your group – could very well provide signposts on that everyday quest for personal and group resilience.
Leonard J. Marcus, PhD, is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].
I had the privilege of teaching two seminars at the recent Society of Hospital Medicine Leadership Academy in Scottsdale, Ariz. The theme of my second seminar was “Swarm Leadership,” the topic of my September column. There seemed to be enthusiasm and interest in the topic. Participants were intrigued at the notion of leveraging instinctual responses to encourage team spirit and collective outcomes.
The key principles of these swarm-like behaviors are: 1) unity of mission, 2) generosity of spirit, 3) staying in lanes and helping others succeed in theirs, 4) no ego/no blame, and 5) a foundation of trust among those working together. Leaders create the conditions in which these behaviors are more likely to emerge. The resulting team spirit and productivity raise morale and increase the sense of work-related purpose and mission.
People expressed their sense of being burned out and overworked, even to the extent of being exploited. I was stunned at the prevalence of this sensation in the room. Not everyone spoke though many people identified with the theme.
What I heard was enough to raise the question here: For hospitalist leaders, to what extent is burnout significant enough to give it serious attention? (I want to be abundantly clear: I report observations as anecdotal and impressionistic. There is no implied critique of hospitalists on the whole nor any individual or groups.)
Burnout includes sensations of being exhausted, overburdened, underappreciated, undercompensated, cynical, and depressed. These phenomena together can affect your productivity, the quality of your work, and your endurance when the workload gets tough.
By contrast, the opposite of burnout is balance, including sensations of being engaged, enthusiastic, energetic, absorbed, challenged, and dedicated. Work is part of the equilibrium you establish in your life, which includes a variety of fulfilling and motivating experiences and accomplishments.
Ideal balance would have all the different parts of your life – from family to hobbies to work – in perfect synergy with one another. Complete burnout would have all parts of your life imploding on one another, with little room for joy, personal contentment, and professional satisfaction.
How do you assess the differences between burnout and balance? First, this is a very individual metric. What one person might consider challenging and engaging another would experience as overwhelming and alienating. When you assess a group of people, these differences are important and could inform how work assignments and heavy lifting are assigned.
During the SHM session and in private comments, people described this rise in burnout not as a personal phenomena. Rather, it results from the health system expecting more of hospitalists than they can reasonably and reliably produce. People described hospitalists getting to the breaking point with no relief in sight. What can be done about this phenomenon?
First, hold a mirror up to yourself. You cannot help others as a leader if you are not clear with your own state of burnout and balance. The questions for you – a leader of other hospitalists – include: To what extent are you burned out? If so, why? If not, why not? If you were to draw a continuum between burned out and balanced, where on that range would you place yourself? Where would others in your group or department pinpoint themselves, relative to one another, on this continuum?
How might burnout develop for hospitalist leaders? Like a car, even a high performance vehicle, you can only go so fast and so far. Push too hard on the accelerator and the vehicle begins to shake as performance declines. If your system is expecting the pace and productivity to outstrip what you consider reasonable, your performance, job satisfaction and morale drops. Impose those demands upon a group of people and the unhappiness can become infectious.
With a decline in performance comes a decline in confidence. You and your colleagues strive for top-rate outcomes. Fatigue, pressure, and unreasonable expectations challenge your ability to feel good about what you are doing. That satisfaction is part of why you chose hospital medicine and without it, you wonder about what you are doing and why you are doing it.
When you and your colleagues sense that you are unappreciated, it can spark a profound sense of disappointment. That realization could express itself in many forms, including unhappiness about pay and workload to dissatisfaction with professional support or acknowledgment. When the system on the whole is driving so fast that it cannot stop to ensure and reward good work, the rattling can have a stunting effect on performance.
When I first began teaching at SHM conferences and had hospitalists in my classes at the Harvard School of Public Health – way back when – the field was novel, revolutionary, and striving to establish a newly effective and efficient way to provide patient services. It is useful to keep these roots in perspective – hospital medicine over the arc of time – from what WAS, to what IS and eventually what WILL BE. The cleverness of hospitalist leaders has been their capacity to understand this evolution and work with it. Hospitalist medicine built opportunities in response to high costs, the lack of continuity of care, and problems of communication. It was a solution.
How might you diagnose your burnout – and that of others with whom you work – in order to build solutions? Is it a phenomenon that involves just several individuals or is it characteristic of your group as a whole? What are the causes? What are the symptoms and what are the core issues? Some are system problems in which expectations for performance – and the resources to meet those objectives – are not reasonably aligned. There is a cost for trying to reduce costs on the backs of overworked clinicians.
If this is more than an individual problem, systematically ask the question and seek systematic answers. The better you document root causes and implications, the better are you able to make a data-driven case for change. Interview, survey, and with all this, you demonstrate your concern for staff, their work, and their work experience.
Showing that you care about the professional and personal well-being and balance of your workforce, in and of itself, is the beginning of an intervention. Be honest with yourself about your own experience. And then be open to the experiences of others. As a leader, your colleagues may suggest changes you make in your own leadership that could ameliorate some of that burnout. Better communication? Improved organization? Enhanced flexibility as appropriate? These are problems you can fix.
Other solutions must be negotiated with others on the systems level. With documentation in hand, build your case for the necessary changes, whatever that might entail. Hospitalist leaders negotiated their way into respected and productive positions in the health care system. Similarly, they must negotiate the right balance now to ensure the quality, morale, and reasonable productivity of their departments and workforce.
As a hospitalist leader, you know that each day will bring its complexities, challenges, and at times, its burdens. Your objective is to encourage – for yourself, for your colleagues, and for your system – resilience that is both personal and organizational. That resilience – the ability to take a hit and bounce back – is an encouraging signal of hope and recovery, for your workforce as well as the people for whom you care. The principles of swarm leadership – reinvigorated for your group – could very well provide signposts on that everyday quest for personal and group resilience.
Leonard J. Marcus, PhD, is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].
Proinflammatory diet may increase colorectal cancer risk
by increasing inflammation, new research suggests.
In the Jan. 18 online edition of JAMA Oncology, Fred K. Tabung, PhD, from the department of nutrition at the Harvard T.H. Chan School of Public Health, Boston, and coauthors presented analysis of data from 46,804 men in the Health Professionals Follow-up Study and 74,246 women in the Nurses’ Health Study, examining the relationship between proinflammatory diets and colorectal cancer.
The effect was more pronounced in men with highly inflammatory diets, who had a 44% higher risk of colorectal cancer, compared with those whose diets had low inflammatory potential (95% CI, 1.19-1.74; P less than .001). Women in the highest quintile had a 22% higher risk of colorectal cancer, compared with those in lowest quintile (95% CI, 1.02-1.45; P = .007). These increases in risk were seen even after adjusting for potential confounders such as age, family history of cancer, physical activity, smoking, NSAID use, and menopause status (JAMA Oncology. 2018 Jan 18. doi: 10.1001/jamaoncol.2017.4844).
Overall, there were 2,699 cases of incident colorectal cancer over 2,571,831 person-years of follow-up. Researchers noted 38 more incidents of colorectal cancer per 100,000 person-years among men in the highest quintile, and 12 more among women in the highest quintile, compared with men and women in the lowest quintiles.
The score used in the study looks at intake of foods such as processed, red, and organ meat; fish, vegetables other than green leafy or dark yellow vegetables, refined grains, high-energy and low-energy drinks, and tomatoes, which are all positively related to concentrations of the inflammatory markers. Foods linked to low concentrations of inflammatory markers include beer, wine, tea, coffee, dark yellow vegetables, green leafy vegetables, snacks, fruit juice, and pizza.
The association between proinflammatory diet and colorectal cancer risk was found in all anatomic locations, including the proximal and distal colon. The only exception was for rectal cancer in women, where dietary inflammatory potential did not significantly change cancer risk.
“It is not entirely clear why associations for rectal cancer were stronger in men than in women but are unlikely to be due to chance given the large significant heterogeneity by sex,” wrote Dr. Tabung and coauthors. They suggested the difference in risk pattern for rectal cancer may relate to broader differences in risk patterns between sexes.
“For example, higher body weight strongly predisposes men to higher risk of proximal colon cancer, distal colon cancer, and rectal cancer, and predisposes women to mainly higher risk of distal colon cancer but not rectal cancer.”
This was also evident when the authors looked at subgroup effects based on body mass index and alcohol intake. Men who were overweight or obese and who were on the most proinflammatory diet had a significant, 48% higher risk of colorectal cancer, compared with the lowest quintile. The same effect was not seen in overweight or obese women.
When alcohol intake was examined, researchers saw a significant 62% higher risk of colorectal cancer among men who were in the highest quintile for dietary inflammatory potential, but who did not drink alcohol, compared with teetotalers in the lowest quintile. In women, there was a 33% higher risk in the highest quintile, compared with the lowest in those who did not drink.
A similar trend was evident in individuals who drank up to one alcoholic drink a day, but it was only borderline significant, and there was no significant effect seen in individuals who drank more than one alcoholic drink a day, despite the fact that a high intake of alcohol has been associated with cancer risk in both men and women.
“It is possible that the adverse effects of alcohol intake through other mechanisms may be more dominant than those of its effect on the EDIP and may partially explain the stronger associations among men and women not consuming alcohol than among alcohol consumers.”
The Health Professionals Follow-up Study and Nurses’ Health Study are supported by the National Institutes of Health. Three authors were also supported by grants from the National Institutes of Health, and one also received support from the Friends of the Dana-Farber Cancer Institute and the Dana-Farber Harvard Cancer Center. No conflicts of interest were declared.
SOURCE: Tabung FK et al. JAMA Oncology. 2018 Jan 18. doi: 10.1001/jamaoncol.2017.4844
by increasing inflammation, new research suggests.
In the Jan. 18 online edition of JAMA Oncology, Fred K. Tabung, PhD, from the department of nutrition at the Harvard T.H. Chan School of Public Health, Boston, and coauthors presented analysis of data from 46,804 men in the Health Professionals Follow-up Study and 74,246 women in the Nurses’ Health Study, examining the relationship between proinflammatory diets and colorectal cancer.
The effect was more pronounced in men with highly inflammatory diets, who had a 44% higher risk of colorectal cancer, compared with those whose diets had low inflammatory potential (95% CI, 1.19-1.74; P less than .001). Women in the highest quintile had a 22% higher risk of colorectal cancer, compared with those in lowest quintile (95% CI, 1.02-1.45; P = .007). These increases in risk were seen even after adjusting for potential confounders such as age, family history of cancer, physical activity, smoking, NSAID use, and menopause status (JAMA Oncology. 2018 Jan 18. doi: 10.1001/jamaoncol.2017.4844).
Overall, there were 2,699 cases of incident colorectal cancer over 2,571,831 person-years of follow-up. Researchers noted 38 more incidents of colorectal cancer per 100,000 person-years among men in the highest quintile, and 12 more among women in the highest quintile, compared with men and women in the lowest quintiles.
The score used in the study looks at intake of foods such as processed, red, and organ meat; fish, vegetables other than green leafy or dark yellow vegetables, refined grains, high-energy and low-energy drinks, and tomatoes, which are all positively related to concentrations of the inflammatory markers. Foods linked to low concentrations of inflammatory markers include beer, wine, tea, coffee, dark yellow vegetables, green leafy vegetables, snacks, fruit juice, and pizza.
The association between proinflammatory diet and colorectal cancer risk was found in all anatomic locations, including the proximal and distal colon. The only exception was for rectal cancer in women, where dietary inflammatory potential did not significantly change cancer risk.
“It is not entirely clear why associations for rectal cancer were stronger in men than in women but are unlikely to be due to chance given the large significant heterogeneity by sex,” wrote Dr. Tabung and coauthors. They suggested the difference in risk pattern for rectal cancer may relate to broader differences in risk patterns between sexes.
“For example, higher body weight strongly predisposes men to higher risk of proximal colon cancer, distal colon cancer, and rectal cancer, and predisposes women to mainly higher risk of distal colon cancer but not rectal cancer.”
This was also evident when the authors looked at subgroup effects based on body mass index and alcohol intake. Men who were overweight or obese and who were on the most proinflammatory diet had a significant, 48% higher risk of colorectal cancer, compared with the lowest quintile. The same effect was not seen in overweight or obese women.
When alcohol intake was examined, researchers saw a significant 62% higher risk of colorectal cancer among men who were in the highest quintile for dietary inflammatory potential, but who did not drink alcohol, compared with teetotalers in the lowest quintile. In women, there was a 33% higher risk in the highest quintile, compared with the lowest in those who did not drink.
A similar trend was evident in individuals who drank up to one alcoholic drink a day, but it was only borderline significant, and there was no significant effect seen in individuals who drank more than one alcoholic drink a day, despite the fact that a high intake of alcohol has been associated with cancer risk in both men and women.
“It is possible that the adverse effects of alcohol intake through other mechanisms may be more dominant than those of its effect on the EDIP and may partially explain the stronger associations among men and women not consuming alcohol than among alcohol consumers.”
The Health Professionals Follow-up Study and Nurses’ Health Study are supported by the National Institutes of Health. Three authors were also supported by grants from the National Institutes of Health, and one also received support from the Friends of the Dana-Farber Cancer Institute and the Dana-Farber Harvard Cancer Center. No conflicts of interest were declared.
SOURCE: Tabung FK et al. JAMA Oncology. 2018 Jan 18. doi: 10.1001/jamaoncol.2017.4844
by increasing inflammation, new research suggests.
In the Jan. 18 online edition of JAMA Oncology, Fred K. Tabung, PhD, from the department of nutrition at the Harvard T.H. Chan School of Public Health, Boston, and coauthors presented analysis of data from 46,804 men in the Health Professionals Follow-up Study and 74,246 women in the Nurses’ Health Study, examining the relationship between proinflammatory diets and colorectal cancer.
The effect was more pronounced in men with highly inflammatory diets, who had a 44% higher risk of colorectal cancer, compared with those whose diets had low inflammatory potential (95% CI, 1.19-1.74; P less than .001). Women in the highest quintile had a 22% higher risk of colorectal cancer, compared with those in lowest quintile (95% CI, 1.02-1.45; P = .007). These increases in risk were seen even after adjusting for potential confounders such as age, family history of cancer, physical activity, smoking, NSAID use, and menopause status (JAMA Oncology. 2018 Jan 18. doi: 10.1001/jamaoncol.2017.4844).
Overall, there were 2,699 cases of incident colorectal cancer over 2,571,831 person-years of follow-up. Researchers noted 38 more incidents of colorectal cancer per 100,000 person-years among men in the highest quintile, and 12 more among women in the highest quintile, compared with men and women in the lowest quintiles.
The score used in the study looks at intake of foods such as processed, red, and organ meat; fish, vegetables other than green leafy or dark yellow vegetables, refined grains, high-energy and low-energy drinks, and tomatoes, which are all positively related to concentrations of the inflammatory markers. Foods linked to low concentrations of inflammatory markers include beer, wine, tea, coffee, dark yellow vegetables, green leafy vegetables, snacks, fruit juice, and pizza.
The association between proinflammatory diet and colorectal cancer risk was found in all anatomic locations, including the proximal and distal colon. The only exception was for rectal cancer in women, where dietary inflammatory potential did not significantly change cancer risk.
“It is not entirely clear why associations for rectal cancer were stronger in men than in women but are unlikely to be due to chance given the large significant heterogeneity by sex,” wrote Dr. Tabung and coauthors. They suggested the difference in risk pattern for rectal cancer may relate to broader differences in risk patterns between sexes.
“For example, higher body weight strongly predisposes men to higher risk of proximal colon cancer, distal colon cancer, and rectal cancer, and predisposes women to mainly higher risk of distal colon cancer but not rectal cancer.”
This was also evident when the authors looked at subgroup effects based on body mass index and alcohol intake. Men who were overweight or obese and who were on the most proinflammatory diet had a significant, 48% higher risk of colorectal cancer, compared with the lowest quintile. The same effect was not seen in overweight or obese women.
When alcohol intake was examined, researchers saw a significant 62% higher risk of colorectal cancer among men who were in the highest quintile for dietary inflammatory potential, but who did not drink alcohol, compared with teetotalers in the lowest quintile. In women, there was a 33% higher risk in the highest quintile, compared with the lowest in those who did not drink.
A similar trend was evident in individuals who drank up to one alcoholic drink a day, but it was only borderline significant, and there was no significant effect seen in individuals who drank more than one alcoholic drink a day, despite the fact that a high intake of alcohol has been associated with cancer risk in both men and women.
“It is possible that the adverse effects of alcohol intake through other mechanisms may be more dominant than those of its effect on the EDIP and may partially explain the stronger associations among men and women not consuming alcohol than among alcohol consumers.”
The Health Professionals Follow-up Study and Nurses’ Health Study are supported by the National Institutes of Health. Three authors were also supported by grants from the National Institutes of Health, and one also received support from the Friends of the Dana-Farber Cancer Institute and the Dana-Farber Harvard Cancer Center. No conflicts of interest were declared.
SOURCE: Tabung FK et al. JAMA Oncology. 2018 Jan 18. doi: 10.1001/jamaoncol.2017.4844
FROM JAMA ONCOLOGY
Key clinical point: A diet high in foods such as processed meats, refined grains, and soda may increase the risk of colorectal cancer by promoting inflammation.
Major finding: People in the highest quintile of dietary inflammatory score had a 32% higher risk of developing colorectal cancer, compared with those in the lowest quintile.
Data source: Analysis of data from 46,804 men in the Health Professionals Follow-up Study, and 74,246 women in the Nurses’ Health Study.
Disclosures: The Health Professionals Follow-up Study and Nurses’ Health Study are supported by the National Institutes of Health. Three authors were supported by grants from the National Institutes of Health, and one also received support from the Friends of the Dana-Farber Cancer Institute, and the Dana-Farber Harvard Cancer Center. No conflicts of interest were declared.
Source: JAMA Oncology. 2018 Jan 18. doi: 10.1001/jamaoncol.2017.4844
Listen up: Acoustic device useful for diabetic foot ulcers
The Food & Drug Administration has approved the marketing of a device that uses acoustic shock waves to boost wound closure in patients with diabetic foot ulcers (DFUs), an especially stubborn and dangerous condition.
The treatment is experimental, and only limited research into its effectiveness has been published. Still, representatives of its manufacturer say the device, known as dermaPACE, has produced promising results as a secondary treatment in stubborn cases.
A wound care specialist said in an interview that the shock wave technology appears to hold promise.
“A shortcoming in the field of wound care is that providers are typically not trained in a standardized fashion on when and how to a perform meticulous excisional sharp debridement of a wound,” said Bill Tettelbach, MD, systems medical director of Wound Care & Hyperbaric Medicine Services at Intermountain Healthcare in Salt Lake City. “In the majority of cases, the better the debridement, the more rapidly the patient will obtain wound closure.”
This new therapy may provide a benefit as a secondary treatment, especially when the patient cannot tolerate extensive sharp debridement, he said. It also could potentially improve biofilm penetration of antimicrobial topical treatments, he said.
DFUs are believed to affect as many as 1 in 4 people with diabetes over the course of their lifetimes. A 2014 report estimated that care of these wounds costs insurers as much as $13 billion a year in the U.S. alone (Diabetes Care. 2014 Mar;37[3]:651-8).
Treatment options include debridement and, in more extreme cases, hyperbaric oxygen treatment. Amputation can be required if treatment is unsuccessful.
According to Mr. Stegagno, the shock wave device is about the size of a desktop computer from a decade ago. A high-voltage generator box is connected to a handheld therapy head and delivers an acoustic pulse to the patient. The system “is like a spark plug that you see in your automobile,” he said. “It’s pretty much the same technology as lithotripsy, just downsized significantly. The key part is a highly focused, high-energy pulse.”
In a news release, the FDA said it examined the results of two studies of patients with diabetes who received usual DFU care along with either the shock wave therapy or a sham therapy. A total of 336 patients took part in the multicenter, randomized, double-blind studies.
According to the FDA, the studies found a 44% wound closure rate at 24 weeks in patients who had undergone 1-7 shock wave treatments, compared with the 30% wound closure rate in those who received the sham treatment.
Side effects included pain while the device was applied, bruising and numbness, migraines, nausea, fainting, wound infection, fever, and infection beyond the wound such as cellulitis and osteomyelitis.
“There were no meaningful statistical differences in the adverse event rates between the dermaPACE-treated patients and the sham-control group,” Mr. Stegagno said. “There were no issues regarding the tolerability of the treatment, which suggests that a second course of treatment, if needed, is a clinically viable option.”
Mr. Stegagno said the FDA expressed concern about “increased incidences of osteomyelitis at later points in the trials, particularly at the 10-week mark and later.” In response to the agency’s concerns, warning statements were added to labeling, he said.
According to Mr. Stegagno, only one study into the shock wave treatment for DFU has been published, although research has been released through posters and abstracts. The small published study favorably compared shock wave therapy with hyperbaric oxygen therapy. (Diabetes Res Clin Pract. 2011 May;92[2]:187-93)
“Sanuwave will be sponsoring additional studies later this year in the [United States] as follow-on studies to the just-completed DFU trials,” Mr. Stegagno said.
The FDA says the device is intended to be used in adults aged 22 and up with certain types of chronic DFUs. The Sanuwave company says patients should be treated with 4-8 applications over 2-10 weeks.
The shock wave process appears to boost healing through a process that leads to inflammatory responses and oxygenation, Mr. Stegagno said, by first creating an initial compression phase that “squeezes the cell and creates a microtrauma.”
“The cell wakes up and says, ‘Something just punched me,’ ” he said. “This tissue and cellular disruption is believed to initiate the cellular signaling for growth factors and other proteins noted in studies.”
The effects of negative pressure also play a role in stimulation of the wound, he said.
The shock wave therapy will cost an estimated $3,000-$4,000 per protocol of 8 treatments, said Kevin A. Richardson II, the CEO and chairman of the board at Sanuwave, in an interview. The initial plan is for the company to place the devices with doctors while the firm still owns the machines, he said.
The FDA approved the marketing of the device as part of its de novo premarket review pathway, which allows certain new types of devices to be approved when approved similar devices don’t yet exist for the purposes of comparison.
Mr. Stegagno and Mr. Richardson work for Sanuwave. Dr. Tettelbach reported no relevant disclosures.
The Food & Drug Administration has approved the marketing of a device that uses acoustic shock waves to boost wound closure in patients with diabetic foot ulcers (DFUs), an especially stubborn and dangerous condition.
The treatment is experimental, and only limited research into its effectiveness has been published. Still, representatives of its manufacturer say the device, known as dermaPACE, has produced promising results as a secondary treatment in stubborn cases.
A wound care specialist said in an interview that the shock wave technology appears to hold promise.
“A shortcoming in the field of wound care is that providers are typically not trained in a standardized fashion on when and how to a perform meticulous excisional sharp debridement of a wound,” said Bill Tettelbach, MD, systems medical director of Wound Care & Hyperbaric Medicine Services at Intermountain Healthcare in Salt Lake City. “In the majority of cases, the better the debridement, the more rapidly the patient will obtain wound closure.”
This new therapy may provide a benefit as a secondary treatment, especially when the patient cannot tolerate extensive sharp debridement, he said. It also could potentially improve biofilm penetration of antimicrobial topical treatments, he said.
DFUs are believed to affect as many as 1 in 4 people with diabetes over the course of their lifetimes. A 2014 report estimated that care of these wounds costs insurers as much as $13 billion a year in the U.S. alone (Diabetes Care. 2014 Mar;37[3]:651-8).
Treatment options include debridement and, in more extreme cases, hyperbaric oxygen treatment. Amputation can be required if treatment is unsuccessful.
According to Mr. Stegagno, the shock wave device is about the size of a desktop computer from a decade ago. A high-voltage generator box is connected to a handheld therapy head and delivers an acoustic pulse to the patient. The system “is like a spark plug that you see in your automobile,” he said. “It’s pretty much the same technology as lithotripsy, just downsized significantly. The key part is a highly focused, high-energy pulse.”
In a news release, the FDA said it examined the results of two studies of patients with diabetes who received usual DFU care along with either the shock wave therapy or a sham therapy. A total of 336 patients took part in the multicenter, randomized, double-blind studies.
According to the FDA, the studies found a 44% wound closure rate at 24 weeks in patients who had undergone 1-7 shock wave treatments, compared with the 30% wound closure rate in those who received the sham treatment.
Side effects included pain while the device was applied, bruising and numbness, migraines, nausea, fainting, wound infection, fever, and infection beyond the wound such as cellulitis and osteomyelitis.
“There were no meaningful statistical differences in the adverse event rates between the dermaPACE-treated patients and the sham-control group,” Mr. Stegagno said. “There were no issues regarding the tolerability of the treatment, which suggests that a second course of treatment, if needed, is a clinically viable option.”
Mr. Stegagno said the FDA expressed concern about “increased incidences of osteomyelitis at later points in the trials, particularly at the 10-week mark and later.” In response to the agency’s concerns, warning statements were added to labeling, he said.
According to Mr. Stegagno, only one study into the shock wave treatment for DFU has been published, although research has been released through posters and abstracts. The small published study favorably compared shock wave therapy with hyperbaric oxygen therapy. (Diabetes Res Clin Pract. 2011 May;92[2]:187-93)
“Sanuwave will be sponsoring additional studies later this year in the [United States] as follow-on studies to the just-completed DFU trials,” Mr. Stegagno said.
The FDA says the device is intended to be used in adults aged 22 and up with certain types of chronic DFUs. The Sanuwave company says patients should be treated with 4-8 applications over 2-10 weeks.
The shock wave process appears to boost healing through a process that leads to inflammatory responses and oxygenation, Mr. Stegagno said, by first creating an initial compression phase that “squeezes the cell and creates a microtrauma.”
“The cell wakes up and says, ‘Something just punched me,’ ” he said. “This tissue and cellular disruption is believed to initiate the cellular signaling for growth factors and other proteins noted in studies.”
The effects of negative pressure also play a role in stimulation of the wound, he said.
The shock wave therapy will cost an estimated $3,000-$4,000 per protocol of 8 treatments, said Kevin A. Richardson II, the CEO and chairman of the board at Sanuwave, in an interview. The initial plan is for the company to place the devices with doctors while the firm still owns the machines, he said.
The FDA approved the marketing of the device as part of its de novo premarket review pathway, which allows certain new types of devices to be approved when approved similar devices don’t yet exist for the purposes of comparison.
Mr. Stegagno and Mr. Richardson work for Sanuwave. Dr. Tettelbach reported no relevant disclosures.
The Food & Drug Administration has approved the marketing of a device that uses acoustic shock waves to boost wound closure in patients with diabetic foot ulcers (DFUs), an especially stubborn and dangerous condition.
The treatment is experimental, and only limited research into its effectiveness has been published. Still, representatives of its manufacturer say the device, known as dermaPACE, has produced promising results as a secondary treatment in stubborn cases.
A wound care specialist said in an interview that the shock wave technology appears to hold promise.
“A shortcoming in the field of wound care is that providers are typically not trained in a standardized fashion on when and how to a perform meticulous excisional sharp debridement of a wound,” said Bill Tettelbach, MD, systems medical director of Wound Care & Hyperbaric Medicine Services at Intermountain Healthcare in Salt Lake City. “In the majority of cases, the better the debridement, the more rapidly the patient will obtain wound closure.”
This new therapy may provide a benefit as a secondary treatment, especially when the patient cannot tolerate extensive sharp debridement, he said. It also could potentially improve biofilm penetration of antimicrobial topical treatments, he said.
DFUs are believed to affect as many as 1 in 4 people with diabetes over the course of their lifetimes. A 2014 report estimated that care of these wounds costs insurers as much as $13 billion a year in the U.S. alone (Diabetes Care. 2014 Mar;37[3]:651-8).
Treatment options include debridement and, in more extreme cases, hyperbaric oxygen treatment. Amputation can be required if treatment is unsuccessful.
According to Mr. Stegagno, the shock wave device is about the size of a desktop computer from a decade ago. A high-voltage generator box is connected to a handheld therapy head and delivers an acoustic pulse to the patient. The system “is like a spark plug that you see in your automobile,” he said. “It’s pretty much the same technology as lithotripsy, just downsized significantly. The key part is a highly focused, high-energy pulse.”
In a news release, the FDA said it examined the results of two studies of patients with diabetes who received usual DFU care along with either the shock wave therapy or a sham therapy. A total of 336 patients took part in the multicenter, randomized, double-blind studies.
According to the FDA, the studies found a 44% wound closure rate at 24 weeks in patients who had undergone 1-7 shock wave treatments, compared with the 30% wound closure rate in those who received the sham treatment.
Side effects included pain while the device was applied, bruising and numbness, migraines, nausea, fainting, wound infection, fever, and infection beyond the wound such as cellulitis and osteomyelitis.
“There were no meaningful statistical differences in the adverse event rates between the dermaPACE-treated patients and the sham-control group,” Mr. Stegagno said. “There were no issues regarding the tolerability of the treatment, which suggests that a second course of treatment, if needed, is a clinically viable option.”
Mr. Stegagno said the FDA expressed concern about “increased incidences of osteomyelitis at later points in the trials, particularly at the 10-week mark and later.” In response to the agency’s concerns, warning statements were added to labeling, he said.
According to Mr. Stegagno, only one study into the shock wave treatment for DFU has been published, although research has been released through posters and abstracts. The small published study favorably compared shock wave therapy with hyperbaric oxygen therapy. (Diabetes Res Clin Pract. 2011 May;92[2]:187-93)
“Sanuwave will be sponsoring additional studies later this year in the [United States] as follow-on studies to the just-completed DFU trials,” Mr. Stegagno said.
The FDA says the device is intended to be used in adults aged 22 and up with certain types of chronic DFUs. The Sanuwave company says patients should be treated with 4-8 applications over 2-10 weeks.
The shock wave process appears to boost healing through a process that leads to inflammatory responses and oxygenation, Mr. Stegagno said, by first creating an initial compression phase that “squeezes the cell and creates a microtrauma.”
“The cell wakes up and says, ‘Something just punched me,’ ” he said. “This tissue and cellular disruption is believed to initiate the cellular signaling for growth factors and other proteins noted in studies.”
The effects of negative pressure also play a role in stimulation of the wound, he said.
The shock wave therapy will cost an estimated $3,000-$4,000 per protocol of 8 treatments, said Kevin A. Richardson II, the CEO and chairman of the board at Sanuwave, in an interview. The initial plan is for the company to place the devices with doctors while the firm still owns the machines, he said.
The FDA approved the marketing of the device as part of its de novo premarket review pathway, which allows certain new types of devices to be approved when approved similar devices don’t yet exist for the purposes of comparison.
Mr. Stegagno and Mr. Richardson work for Sanuwave. Dr. Tettelbach reported no relevant disclosures.
A Sore Subject
For several years, a 60-year-old woman has had a nonhealing, asymptomatic “sore” on her upper right cheek. The lesion causes no pain or discomfort; it bothers her simply because it will not go away. It does occasionally bleed.
Several attempts at treatment—including antibiotic ointment, peroxide, and topical alcohol— have failed. A dermatologist once treated the lesion with cryotherapy; this initially reduced its size, but the effect didn’t last.
The patient admits to “worshipping the sun” as a youngster, tanning at every opportunity. Several family members, including her sister and mother, have had skin cancer.
EXAMINATION
A 6.5-mm, round, red nodule is located on the mid-upper right cheek, below the eye. On closer inspection, it appears glassy and translucent, with several obvious telangiectasias. It is surprisingly firm on palpation, though not at all tender to touch.
Elsewhere, the patient’s fair skin has abundant evidence of sun damage, including wrinkles, discoloration, and focal telangiectasias. No other lesions are seen. No nodes are palpable in her head or neck.
With the patient’s permission, and after discussion of the indications, procedure, alternatives, and risks, the lesion is removed by curettement. It is quite friable and shallow, allowing complete removal. The area is left to heal by secondary intention, and the specimen is submitted to pathology.
What is the diagnosis?
The pathology report confirmed the suspected diagnosis: noduloulcerative basal cell carcinoma (BCC). By far the most common type of skin cancer in the world, noduloulcerative BCCs are caused by overexposure to the sun.
As obvious as this diagnosis seemed to be, biopsy was warranted to confirm it and to rule out several other items in the differential. The latter include squamous cell carcinoma (which has far more harmful potential than BCC), sebaceous carcinoma, Merkel cell carcinoma, and melanoma.
Not all BCCs are created equal—certain clinical and histologic characteristics predict a more aggressive course. While most BCCs require surgical excision, other treatment options do exist. In this patient’s case, the size and location of the lesion lent it to curettement and healing by secondary intention. Other methods could have included immunotherapy with imiquimod, antitumor creams (eg, 5-fluorouracil), or even radiation therapy. Her lesion was small and well-defined enough that Mohs surgery was not indicated—though some might disagree with that assessment.
TAKE-HOME LEARNING POINTS
- Like all basal cell carcinomas (BCCs), ulcerative BCC—the most common type—is caused by overexposure to the sun.
- BCCs are often mistaken for infection or other sore, which delays the diagnosis.
- Nonhealing lesions should be considered cancerous until proven otherwise.
- Though this diagnosis was fairly obvious, biopsy is necessary to rule out other items in the differential—some of which (ie, Merkel cell carcinoma, melanoma) are potentially fatal.
For several years, a 60-year-old woman has had a nonhealing, asymptomatic “sore” on her upper right cheek. The lesion causes no pain or discomfort; it bothers her simply because it will not go away. It does occasionally bleed.
Several attempts at treatment—including antibiotic ointment, peroxide, and topical alcohol— have failed. A dermatologist once treated the lesion with cryotherapy; this initially reduced its size, but the effect didn’t last.
The patient admits to “worshipping the sun” as a youngster, tanning at every opportunity. Several family members, including her sister and mother, have had skin cancer.
EXAMINATION
A 6.5-mm, round, red nodule is located on the mid-upper right cheek, below the eye. On closer inspection, it appears glassy and translucent, with several obvious telangiectasias. It is surprisingly firm on palpation, though not at all tender to touch.
Elsewhere, the patient’s fair skin has abundant evidence of sun damage, including wrinkles, discoloration, and focal telangiectasias. No other lesions are seen. No nodes are palpable in her head or neck.
With the patient’s permission, and after discussion of the indications, procedure, alternatives, and risks, the lesion is removed by curettement. It is quite friable and shallow, allowing complete removal. The area is left to heal by secondary intention, and the specimen is submitted to pathology.
What is the diagnosis?
The pathology report confirmed the suspected diagnosis: noduloulcerative basal cell carcinoma (BCC). By far the most common type of skin cancer in the world, noduloulcerative BCCs are caused by overexposure to the sun.
As obvious as this diagnosis seemed to be, biopsy was warranted to confirm it and to rule out several other items in the differential. The latter include squamous cell carcinoma (which has far more harmful potential than BCC), sebaceous carcinoma, Merkel cell carcinoma, and melanoma.
Not all BCCs are created equal—certain clinical and histologic characteristics predict a more aggressive course. While most BCCs require surgical excision, other treatment options do exist. In this patient’s case, the size and location of the lesion lent it to curettement and healing by secondary intention. Other methods could have included immunotherapy with imiquimod, antitumor creams (eg, 5-fluorouracil), or even radiation therapy. Her lesion was small and well-defined enough that Mohs surgery was not indicated—though some might disagree with that assessment.
TAKE-HOME LEARNING POINTS
- Like all basal cell carcinomas (BCCs), ulcerative BCC—the most common type—is caused by overexposure to the sun.
- BCCs are often mistaken for infection or other sore, which delays the diagnosis.
- Nonhealing lesions should be considered cancerous until proven otherwise.
- Though this diagnosis was fairly obvious, biopsy is necessary to rule out other items in the differential—some of which (ie, Merkel cell carcinoma, melanoma) are potentially fatal.
For several years, a 60-year-old woman has had a nonhealing, asymptomatic “sore” on her upper right cheek. The lesion causes no pain or discomfort; it bothers her simply because it will not go away. It does occasionally bleed.
Several attempts at treatment—including antibiotic ointment, peroxide, and topical alcohol— have failed. A dermatologist once treated the lesion with cryotherapy; this initially reduced its size, but the effect didn’t last.
The patient admits to “worshipping the sun” as a youngster, tanning at every opportunity. Several family members, including her sister and mother, have had skin cancer.
EXAMINATION
A 6.5-mm, round, red nodule is located on the mid-upper right cheek, below the eye. On closer inspection, it appears glassy and translucent, with several obvious telangiectasias. It is surprisingly firm on palpation, though not at all tender to touch.
Elsewhere, the patient’s fair skin has abundant evidence of sun damage, including wrinkles, discoloration, and focal telangiectasias. No other lesions are seen. No nodes are palpable in her head or neck.
With the patient’s permission, and after discussion of the indications, procedure, alternatives, and risks, the lesion is removed by curettement. It is quite friable and shallow, allowing complete removal. The area is left to heal by secondary intention, and the specimen is submitted to pathology.
What is the diagnosis?
The pathology report confirmed the suspected diagnosis: noduloulcerative basal cell carcinoma (BCC). By far the most common type of skin cancer in the world, noduloulcerative BCCs are caused by overexposure to the sun.
As obvious as this diagnosis seemed to be, biopsy was warranted to confirm it and to rule out several other items in the differential. The latter include squamous cell carcinoma (which has far more harmful potential than BCC), sebaceous carcinoma, Merkel cell carcinoma, and melanoma.
Not all BCCs are created equal—certain clinical and histologic characteristics predict a more aggressive course. While most BCCs require surgical excision, other treatment options do exist. In this patient’s case, the size and location of the lesion lent it to curettement and healing by secondary intention. Other methods could have included immunotherapy with imiquimod, antitumor creams (eg, 5-fluorouracil), or even radiation therapy. Her lesion was small and well-defined enough that Mohs surgery was not indicated—though some might disagree with that assessment.
TAKE-HOME LEARNING POINTS
- Like all basal cell carcinomas (BCCs), ulcerative BCC—the most common type—is caused by overexposure to the sun.
- BCCs are often mistaken for infection or other sore, which delays the diagnosis.
- Nonhealing lesions should be considered cancerous until proven otherwise.
- Though this diagnosis was fairly obvious, biopsy is necessary to rule out other items in the differential—some of which (ie, Merkel cell carcinoma, melanoma) are potentially fatal.
Gastric bypass T2D benefit can fade over time
but the effect diminished over time, according to findings published Jan. 16 in JAMA.
In a randomized study of 113 obese patients with diabetes, about 50% of those who received gastric bypass in addition to lifestyle and medical management achieved the composite endpoint of a hemoglobin A1c (HbA1c) value of less than 7%, an LDL cholesterol level of less than 100 mg/dL, and a systolic blood pressure of less than 130 mm Hg after 1 year, reported Sayeed Ikramuddin, MD, FACS, of the department of surgery at the University of Minnesota, Minneapolis, and his coauthors. For comparison, just 16% in the lifestyle/medical management group achieved the endpoint (difference, 34%; 95% confidence interval, 14%-54%; P = .003) .
At 5 years’ follow-up, about 23% of patients in the gastric bypass group and 4% in the lifestyle/medical management group achieved the composite triple endpoint (difference, 19%; 95% CI, 4%-34%; P = .01), the authors reported.
The study included 120 patients at four sites in the United States and Taiwan, 7 of whom either died or were lost to follow-up before completion of the study. Participants had an HbA1c level of 8% or higher and a body mass index between 30 and 39.9 kg/m2.
Patients were randomized to receive either 2 years of lifestyle and medical management alone or in conjunction with standardized Roux-en-Y gastric bypass. During the first 2 years of intervention, patients were told to record weight, exercise, and food intake and were prescribed 325 minutes of physical activity per week. Participants also met regularly with a trained interventionist and an endocrinologist and were given pharmacologic therapy for hyperglycemia, cholesterol, and hypertension, the authors said. Aside from usual visits with a primary physician, all study interventions ceased after the initial 2-year period.
At baseline, the group that received only lifestyle/medical management had a mean BMI of 34.4 and HbA1c level of 9.6%, compared with a mean BMI of 34.9 and HbA1c level of 9.6% in the gastric bypass group.
Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group, but it remained stable from year 3 through year 5, Dr. Ikramuddin and his coauthors said in the report.
Overall, 26% of patients who had gastric bypass surgery during the first year achieved the triple endpoint at 5 years, compared with 8% of those who did not have surgery (difference, 18%; 95% CI, 6%-32%; P = .04).
The mean weight loss for participants in the gastric bypass group was 21.8% at 5 years, compared with 9.6% in the lifestyle/medical management group (difference, 12.2%; 95% CI, 8.9%-15.5%).
The results suggest that “gastric bypass provides significant benefit but with a smaller and less durable effect size than what is seen in the evaluation of glycemic control alone,” the authors wrote.
“Because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement,” Dr. Ikramuddin and his colleagues concluded.
Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics.
SOURCE: Ikramuddin S. JAMA. 2018;319(3):266-278.
but the effect diminished over time, according to findings published Jan. 16 in JAMA.
In a randomized study of 113 obese patients with diabetes, about 50% of those who received gastric bypass in addition to lifestyle and medical management achieved the composite endpoint of a hemoglobin A1c (HbA1c) value of less than 7%, an LDL cholesterol level of less than 100 mg/dL, and a systolic blood pressure of less than 130 mm Hg after 1 year, reported Sayeed Ikramuddin, MD, FACS, of the department of surgery at the University of Minnesota, Minneapolis, and his coauthors. For comparison, just 16% in the lifestyle/medical management group achieved the endpoint (difference, 34%; 95% confidence interval, 14%-54%; P = .003) .
At 5 years’ follow-up, about 23% of patients in the gastric bypass group and 4% in the lifestyle/medical management group achieved the composite triple endpoint (difference, 19%; 95% CI, 4%-34%; P = .01), the authors reported.
The study included 120 patients at four sites in the United States and Taiwan, 7 of whom either died or were lost to follow-up before completion of the study. Participants had an HbA1c level of 8% or higher and a body mass index between 30 and 39.9 kg/m2.
Patients were randomized to receive either 2 years of lifestyle and medical management alone or in conjunction with standardized Roux-en-Y gastric bypass. During the first 2 years of intervention, patients were told to record weight, exercise, and food intake and were prescribed 325 minutes of physical activity per week. Participants also met regularly with a trained interventionist and an endocrinologist and were given pharmacologic therapy for hyperglycemia, cholesterol, and hypertension, the authors said. Aside from usual visits with a primary physician, all study interventions ceased after the initial 2-year period.
At baseline, the group that received only lifestyle/medical management had a mean BMI of 34.4 and HbA1c level of 9.6%, compared with a mean BMI of 34.9 and HbA1c level of 9.6% in the gastric bypass group.
Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group, but it remained stable from year 3 through year 5, Dr. Ikramuddin and his coauthors said in the report.
Overall, 26% of patients who had gastric bypass surgery during the first year achieved the triple endpoint at 5 years, compared with 8% of those who did not have surgery (difference, 18%; 95% CI, 6%-32%; P = .04).
The mean weight loss for participants in the gastric bypass group was 21.8% at 5 years, compared with 9.6% in the lifestyle/medical management group (difference, 12.2%; 95% CI, 8.9%-15.5%).
The results suggest that “gastric bypass provides significant benefit but with a smaller and less durable effect size than what is seen in the evaluation of glycemic control alone,” the authors wrote.
“Because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement,” Dr. Ikramuddin and his colleagues concluded.
Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics.
SOURCE: Ikramuddin S. JAMA. 2018;319(3):266-278.
but the effect diminished over time, according to findings published Jan. 16 in JAMA.
In a randomized study of 113 obese patients with diabetes, about 50% of those who received gastric bypass in addition to lifestyle and medical management achieved the composite endpoint of a hemoglobin A1c (HbA1c) value of less than 7%, an LDL cholesterol level of less than 100 mg/dL, and a systolic blood pressure of less than 130 mm Hg after 1 year, reported Sayeed Ikramuddin, MD, FACS, of the department of surgery at the University of Minnesota, Minneapolis, and his coauthors. For comparison, just 16% in the lifestyle/medical management group achieved the endpoint (difference, 34%; 95% confidence interval, 14%-54%; P = .003) .
At 5 years’ follow-up, about 23% of patients in the gastric bypass group and 4% in the lifestyle/medical management group achieved the composite triple endpoint (difference, 19%; 95% CI, 4%-34%; P = .01), the authors reported.
The study included 120 patients at four sites in the United States and Taiwan, 7 of whom either died or were lost to follow-up before completion of the study. Participants had an HbA1c level of 8% or higher and a body mass index between 30 and 39.9 kg/m2.
Patients were randomized to receive either 2 years of lifestyle and medical management alone or in conjunction with standardized Roux-en-Y gastric bypass. During the first 2 years of intervention, patients were told to record weight, exercise, and food intake and were prescribed 325 minutes of physical activity per week. Participants also met regularly with a trained interventionist and an endocrinologist and were given pharmacologic therapy for hyperglycemia, cholesterol, and hypertension, the authors said. Aside from usual visits with a primary physician, all study interventions ceased after the initial 2-year period.
At baseline, the group that received only lifestyle/medical management had a mean BMI of 34.4 and HbA1c level of 9.6%, compared with a mean BMI of 34.9 and HbA1c level of 9.6% in the gastric bypass group.
Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group, but it remained stable from year 3 through year 5, Dr. Ikramuddin and his coauthors said in the report.
Overall, 26% of patients who had gastric bypass surgery during the first year achieved the triple endpoint at 5 years, compared with 8% of those who did not have surgery (difference, 18%; 95% CI, 6%-32%; P = .04).
The mean weight loss for participants in the gastric bypass group was 21.8% at 5 years, compared with 9.6% in the lifestyle/medical management group (difference, 12.2%; 95% CI, 8.9%-15.5%).
The results suggest that “gastric bypass provides significant benefit but with a smaller and less durable effect size than what is seen in the evaluation of glycemic control alone,” the authors wrote.
“Because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement,” Dr. Ikramuddin and his colleagues concluded.
Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics.
SOURCE: Ikramuddin S. JAMA. 2018;319(3):266-278.
FROM JAMA
Key clinical point: Adding gastric bypass surgery to lifestyle and medical management improves diabetes outcomes – but with diminished effect over time.
Major finding: Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group.
Data source: A randomized study of 113 patients at four sites in the United States and Taiwan with a HbA1c level of 8% or higher and a BMI of 30-39.9 kg/m2.
Disclosures: Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics
SOURCE: Ikramuddin S et al. JAMA. 2018;319(3):266-278.
Risk-stratification tool predicts severe hypoglycemia
Background: Severe hypoglycemia caused by glucose-lowering medications is a known public health and patient safety issue. Identifying patients with T2D at risk of severe hypoglycemia might facilitate interventions to offset that risk.
Study design: Prospective cohort.
Setting: Kaiser Permanente Northern California (derivation and internal validation cohort); Veterans Affairs Diabetes Epidemiology Cohort and Group Health Cooperative (external validation cohorts).
Synopsis: Through EHR data, 206,435 eligible patients with T2D were randomly split into derivation (80%) and internal validation (20%) samples. EHR data were reviewed for preselected clinical risk factors for hypoglycemia with a primary outcome of ED visit or hospital admission with a primary diagnosis of hypoglycemia over the ensuing year. A predictive tool was built based on six variables: prior hypoglycemia episodes, number of ED encounters for any reason in the prior year, insulin use, sulfonylurea use, presence of severe or end-stage kidney disease, and age. Predicted 12-month risk was categorized as high (greater than 5%), intermediate (1%-5%) or low (less than 1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% of patients were categorized as high, intermediate, and low risk, respectively. Observed 12-month hypoglycemia-related health care utilization rates were 6.7%, 1.4%, and 0.2%, respectively. The external validation cohorts performed similarly.
Bottom line: A simple tool using readily available data can be used to estimate the 12-month risk of severe hypoglycemia in patients with T2D.
Citation: Karter AJ et al. Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use. JAMA Intern Med. 2017 Oct 1;177(10):1461-70.
Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine.
Background: Severe hypoglycemia caused by glucose-lowering medications is a known public health and patient safety issue. Identifying patients with T2D at risk of severe hypoglycemia might facilitate interventions to offset that risk.
Study design: Prospective cohort.
Setting: Kaiser Permanente Northern California (derivation and internal validation cohort); Veterans Affairs Diabetes Epidemiology Cohort and Group Health Cooperative (external validation cohorts).
Synopsis: Through EHR data, 206,435 eligible patients with T2D were randomly split into derivation (80%) and internal validation (20%) samples. EHR data were reviewed for preselected clinical risk factors for hypoglycemia with a primary outcome of ED visit or hospital admission with a primary diagnosis of hypoglycemia over the ensuing year. A predictive tool was built based on six variables: prior hypoglycemia episodes, number of ED encounters for any reason in the prior year, insulin use, sulfonylurea use, presence of severe or end-stage kidney disease, and age. Predicted 12-month risk was categorized as high (greater than 5%), intermediate (1%-5%) or low (less than 1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% of patients were categorized as high, intermediate, and low risk, respectively. Observed 12-month hypoglycemia-related health care utilization rates were 6.7%, 1.4%, and 0.2%, respectively. The external validation cohorts performed similarly.
Bottom line: A simple tool using readily available data can be used to estimate the 12-month risk of severe hypoglycemia in patients with T2D.
Citation: Karter AJ et al. Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use. JAMA Intern Med. 2017 Oct 1;177(10):1461-70.
Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine.
Background: Severe hypoglycemia caused by glucose-lowering medications is a known public health and patient safety issue. Identifying patients with T2D at risk of severe hypoglycemia might facilitate interventions to offset that risk.
Study design: Prospective cohort.
Setting: Kaiser Permanente Northern California (derivation and internal validation cohort); Veterans Affairs Diabetes Epidemiology Cohort and Group Health Cooperative (external validation cohorts).
Synopsis: Through EHR data, 206,435 eligible patients with T2D were randomly split into derivation (80%) and internal validation (20%) samples. EHR data were reviewed for preselected clinical risk factors for hypoglycemia with a primary outcome of ED visit or hospital admission with a primary diagnosis of hypoglycemia over the ensuing year. A predictive tool was built based on six variables: prior hypoglycemia episodes, number of ED encounters for any reason in the prior year, insulin use, sulfonylurea use, presence of severe or end-stage kidney disease, and age. Predicted 12-month risk was categorized as high (greater than 5%), intermediate (1%-5%) or low (less than 1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% of patients were categorized as high, intermediate, and low risk, respectively. Observed 12-month hypoglycemia-related health care utilization rates were 6.7%, 1.4%, and 0.2%, respectively. The external validation cohorts performed similarly.
Bottom line: A simple tool using readily available data can be used to estimate the 12-month risk of severe hypoglycemia in patients with T2D.
Citation: Karter AJ et al. Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use. JAMA Intern Med. 2017 Oct 1;177(10):1461-70.
Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine.
Five pearls target wound healing
MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.
In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
Avoid opioids for postoperative pain
“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”
“The take-home message is that for the first time we have patient-oriented data that suggests that opioids impair healing,” Dr. Kirsner said. “So avoid opioids if at all possible.”
The precise mechanism remains unknown. The most likely explanation, he said, is that opioids inhibit substance P, a peptide that promotes healing in animal models. Interestingly, he added, adding the opioid antagonist naltrexone in animal studies improves healing.
Consider skipping epidermal sutures in some cases
Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”
A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.
“Forget epidermal sutures if you’re brave enough,” he said.
Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”
And speaking of wound edges …
When debriding a nonhealing wound ...
There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.
“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
If a patient is unusually anxious or stressed
Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.
“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.
“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.
“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
Two technologies still look good for scarless donor sites
Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.
With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”
As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.
Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.
“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”
An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”
Dr. Kirsner said he had no relevant financial disclosures.
MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.
In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
Avoid opioids for postoperative pain
“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”
“The take-home message is that for the first time we have patient-oriented data that suggests that opioids impair healing,” Dr. Kirsner said. “So avoid opioids if at all possible.”
The precise mechanism remains unknown. The most likely explanation, he said, is that opioids inhibit substance P, a peptide that promotes healing in animal models. Interestingly, he added, adding the opioid antagonist naltrexone in animal studies improves healing.
Consider skipping epidermal sutures in some cases
Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”
A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.
“Forget epidermal sutures if you’re brave enough,” he said.
Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”
And speaking of wound edges …
When debriding a nonhealing wound ...
There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.
“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
If a patient is unusually anxious or stressed
Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.
“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.
“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.
“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
Two technologies still look good for scarless donor sites
Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.
With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”
As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.
Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.
“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”
An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”
Dr. Kirsner said he had no relevant financial disclosures.
MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.
In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
Avoid opioids for postoperative pain
“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”
“The take-home message is that for the first time we have patient-oriented data that suggests that opioids impair healing,” Dr. Kirsner said. “So avoid opioids if at all possible.”
The precise mechanism remains unknown. The most likely explanation, he said, is that opioids inhibit substance P, a peptide that promotes healing in animal models. Interestingly, he added, adding the opioid antagonist naltrexone in animal studies improves healing.
Consider skipping epidermal sutures in some cases
Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”
A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.
“Forget epidermal sutures if you’re brave enough,” he said.
Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”
And speaking of wound edges …
When debriding a nonhealing wound ...
There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.
“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
If a patient is unusually anxious or stressed
Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.
“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.
“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.
“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
Two technologies still look good for scarless donor sites
Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.
With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”
As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.
Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.
“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”
An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”
Dr. Kirsner said he had no relevant financial disclosures.
EXPERT ANALYSIS FROM ODAC 2018
Hospitalist movers and shakers – Jan. 2018
Michael Rader, MD, has been named the chief medical officer of the Department of Veterans Affairs New York/New Jersey Health Care Network. The network serves upward of a half-million veterans in 76 counties in New York, New Jersey, and Pennsylvania. Dr. Rader’s appointment began on Oct. 15, 2017.
Previously, Dr. Rader was chief medical officer at Prospect East Orange (N.J.) General. In his new position, the 35-year veteran will be charged with overseeing care at VA facilities in Albany Stratton, Bath, Canandaigua, and Syracuse in New York, as well as the VA Western New York Health System, the New York Harbor Health System, the New Jersey Health Care System, Hudson Valley Healthcare System, the James J. Peters and Northport VA Medical Centers, as well as 66 community-based outpatient clinics.
The Rhode Island Medical Society has elected Bradley Collins, MD, as its new president. An internist and hospitalist, Dr. Collins practices at Miriam Hospital in Providence, R.I., where he started in 2006 as a staff hospitalist. He’s now the medical director of appeals for Lifespan at Miriam.
Dr. Collins is an assistant professor of clinical medicine at Brown University’s Alpert Medical School, while also serving as a fellow for the Society of Hospital Medicine.
Tracy Cardin, ACNP, SFHM, has been named associate director of clinical integration at Adfinitas Health, a private hospitalist company based in Maryland that serves more than 50 hospitals and post-acute care centers across the Mid-Atlantic region. Cardin is responsible for advancing the company’s training and onboarding infrastructure to support the full integration of physicians, nurse practitioners, and physician assistants into the Adfinitas care delivery model.
Jeffrey Millard, MD, has been named Patient Experience Provider of the Year by the employees and staff at Hardin Memorial Health (Elizabethtown, Ky.). Dr. Millard has been a hospitalist at Hardin Memorial Hospital since 2012.
The Patient Experience Provider of the Year award recognizes a provider who exceeds the company’s mission and vision with patients and their families, as well as with the hospital’s staff. Dr. Millard was chosen from a list of more than 800 nominations.
Benjamin Keidan, MD, has been appointed as chief medical officer for Boulder (Colo.) Community Health. Dr. Keidan advances from his previous role as medical director of quality and population health for outpatient primary care and specialty clinics.
Dr. Keidan is a former internist and hospitalist for BCH and has worked in Boulder County for the past 12 years. He is only the second CMO in BCH’s history.
Dinesh Bande, MD, has been selected as the new chair of the department of internal medicine at the University of North Dakota, Grand Forks. Dr. Bande is a clinical associate professor at the school and a hospitalist with Sanford Health.
Dr. Bande has been the clerkship director for third-year medical students at UND for the past 2 years. As chair of internal medicine, he will oversee education, research, clinical care, training, and service programs within the department.
Vicki Iannotti, MD, has been named chief medical officer at the Elizabeth Ann Seton Pediatric Center in Yonkers, N.Y. Dr. Iannotti joins Seton after spending 12 years as associate chief of pediatrics and pediatric hospital medicine at Maria Fareri Children’s Hospital in Valhalla, N.Y.
At Seton, Dr. Iannotti will oversee 100 medical professionals at the 201,000-square-foot facility, which is the largest provider of children’s acute care in the United States.
Business moves
Management Service Organization Continuum Health (Marlton, N.J.) has signed an agreement with the Mid-Atlantic region’s largest private hospitalist group, Adfinitas Health (Hanover, Md.), to be its revenue management cycle partner. Founded in 1999, Continuum Health now serves more than 1,500 providers in more than 400 locations.
Colquitt Regional Medical Center in Moultrie, Ga., has expanded its hospitalist program, adding 5 physicians to increase its total to 10 on-staff hospitalists. Colquitt Regional’s program began in 2012 with four hospitalists.
In the past, Colquitt Regional has shared hospitalists with surrounding hospitals to meet the demand for care. With the addition of the five new physicians, the hospital can provide full-time hospital medicine care with physicians employed by Colquitt Regional.
Michael Rader, MD, has been named the chief medical officer of the Department of Veterans Affairs New York/New Jersey Health Care Network. The network serves upward of a half-million veterans in 76 counties in New York, New Jersey, and Pennsylvania. Dr. Rader’s appointment began on Oct. 15, 2017.
Previously, Dr. Rader was chief medical officer at Prospect East Orange (N.J.) General. In his new position, the 35-year veteran will be charged with overseeing care at VA facilities in Albany Stratton, Bath, Canandaigua, and Syracuse in New York, as well as the VA Western New York Health System, the New York Harbor Health System, the New Jersey Health Care System, Hudson Valley Healthcare System, the James J. Peters and Northport VA Medical Centers, as well as 66 community-based outpatient clinics.
The Rhode Island Medical Society has elected Bradley Collins, MD, as its new president. An internist and hospitalist, Dr. Collins practices at Miriam Hospital in Providence, R.I., where he started in 2006 as a staff hospitalist. He’s now the medical director of appeals for Lifespan at Miriam.
Dr. Collins is an assistant professor of clinical medicine at Brown University’s Alpert Medical School, while also serving as a fellow for the Society of Hospital Medicine.
Tracy Cardin, ACNP, SFHM, has been named associate director of clinical integration at Adfinitas Health, a private hospitalist company based in Maryland that serves more than 50 hospitals and post-acute care centers across the Mid-Atlantic region. Cardin is responsible for advancing the company’s training and onboarding infrastructure to support the full integration of physicians, nurse practitioners, and physician assistants into the Adfinitas care delivery model.
Jeffrey Millard, MD, has been named Patient Experience Provider of the Year by the employees and staff at Hardin Memorial Health (Elizabethtown, Ky.). Dr. Millard has been a hospitalist at Hardin Memorial Hospital since 2012.
The Patient Experience Provider of the Year award recognizes a provider who exceeds the company’s mission and vision with patients and their families, as well as with the hospital’s staff. Dr. Millard was chosen from a list of more than 800 nominations.
Benjamin Keidan, MD, has been appointed as chief medical officer for Boulder (Colo.) Community Health. Dr. Keidan advances from his previous role as medical director of quality and population health for outpatient primary care and specialty clinics.
Dr. Keidan is a former internist and hospitalist for BCH and has worked in Boulder County for the past 12 years. He is only the second CMO in BCH’s history.
Dinesh Bande, MD, has been selected as the new chair of the department of internal medicine at the University of North Dakota, Grand Forks. Dr. Bande is a clinical associate professor at the school and a hospitalist with Sanford Health.
Dr. Bande has been the clerkship director for third-year medical students at UND for the past 2 years. As chair of internal medicine, he will oversee education, research, clinical care, training, and service programs within the department.
Vicki Iannotti, MD, has been named chief medical officer at the Elizabeth Ann Seton Pediatric Center in Yonkers, N.Y. Dr. Iannotti joins Seton after spending 12 years as associate chief of pediatrics and pediatric hospital medicine at Maria Fareri Children’s Hospital in Valhalla, N.Y.
At Seton, Dr. Iannotti will oversee 100 medical professionals at the 201,000-square-foot facility, which is the largest provider of children’s acute care in the United States.
Business moves
Management Service Organization Continuum Health (Marlton, N.J.) has signed an agreement with the Mid-Atlantic region’s largest private hospitalist group, Adfinitas Health (Hanover, Md.), to be its revenue management cycle partner. Founded in 1999, Continuum Health now serves more than 1,500 providers in more than 400 locations.
Colquitt Regional Medical Center in Moultrie, Ga., has expanded its hospitalist program, adding 5 physicians to increase its total to 10 on-staff hospitalists. Colquitt Regional’s program began in 2012 with four hospitalists.
In the past, Colquitt Regional has shared hospitalists with surrounding hospitals to meet the demand for care. With the addition of the five new physicians, the hospital can provide full-time hospital medicine care with physicians employed by Colquitt Regional.
Michael Rader, MD, has been named the chief medical officer of the Department of Veterans Affairs New York/New Jersey Health Care Network. The network serves upward of a half-million veterans in 76 counties in New York, New Jersey, and Pennsylvania. Dr. Rader’s appointment began on Oct. 15, 2017.
Previously, Dr. Rader was chief medical officer at Prospect East Orange (N.J.) General. In his new position, the 35-year veteran will be charged with overseeing care at VA facilities in Albany Stratton, Bath, Canandaigua, and Syracuse in New York, as well as the VA Western New York Health System, the New York Harbor Health System, the New Jersey Health Care System, Hudson Valley Healthcare System, the James J. Peters and Northport VA Medical Centers, as well as 66 community-based outpatient clinics.
The Rhode Island Medical Society has elected Bradley Collins, MD, as its new president. An internist and hospitalist, Dr. Collins practices at Miriam Hospital in Providence, R.I., where he started in 2006 as a staff hospitalist. He’s now the medical director of appeals for Lifespan at Miriam.
Dr. Collins is an assistant professor of clinical medicine at Brown University’s Alpert Medical School, while also serving as a fellow for the Society of Hospital Medicine.
Tracy Cardin, ACNP, SFHM, has been named associate director of clinical integration at Adfinitas Health, a private hospitalist company based in Maryland that serves more than 50 hospitals and post-acute care centers across the Mid-Atlantic region. Cardin is responsible for advancing the company’s training and onboarding infrastructure to support the full integration of physicians, nurse practitioners, and physician assistants into the Adfinitas care delivery model.
Jeffrey Millard, MD, has been named Patient Experience Provider of the Year by the employees and staff at Hardin Memorial Health (Elizabethtown, Ky.). Dr. Millard has been a hospitalist at Hardin Memorial Hospital since 2012.
The Patient Experience Provider of the Year award recognizes a provider who exceeds the company’s mission and vision with patients and their families, as well as with the hospital’s staff. Dr. Millard was chosen from a list of more than 800 nominations.
Benjamin Keidan, MD, has been appointed as chief medical officer for Boulder (Colo.) Community Health. Dr. Keidan advances from his previous role as medical director of quality and population health for outpatient primary care and specialty clinics.
Dr. Keidan is a former internist and hospitalist for BCH and has worked in Boulder County for the past 12 years. He is only the second CMO in BCH’s history.
Dinesh Bande, MD, has been selected as the new chair of the department of internal medicine at the University of North Dakota, Grand Forks. Dr. Bande is a clinical associate professor at the school and a hospitalist with Sanford Health.
Dr. Bande has been the clerkship director for third-year medical students at UND for the past 2 years. As chair of internal medicine, he will oversee education, research, clinical care, training, and service programs within the department.
Vicki Iannotti, MD, has been named chief medical officer at the Elizabeth Ann Seton Pediatric Center in Yonkers, N.Y. Dr. Iannotti joins Seton after spending 12 years as associate chief of pediatrics and pediatric hospital medicine at Maria Fareri Children’s Hospital in Valhalla, N.Y.
At Seton, Dr. Iannotti will oversee 100 medical professionals at the 201,000-square-foot facility, which is the largest provider of children’s acute care in the United States.
Business moves
Management Service Organization Continuum Health (Marlton, N.J.) has signed an agreement with the Mid-Atlantic region’s largest private hospitalist group, Adfinitas Health (Hanover, Md.), to be its revenue management cycle partner. Founded in 1999, Continuum Health now serves more than 1,500 providers in more than 400 locations.
Colquitt Regional Medical Center in Moultrie, Ga., has expanded its hospitalist program, adding 5 physicians to increase its total to 10 on-staff hospitalists. Colquitt Regional’s program began in 2012 with four hospitalists.
In the past, Colquitt Regional has shared hospitalists with surrounding hospitals to meet the demand for care. With the addition of the five new physicians, the hospital can provide full-time hospital medicine care with physicians employed by Colquitt Regional.