WASHINGTON – The true impact of advanced fibrosis and cirrhosis advancing to serious hepatic and nonhepatic complications in nonalcoholic fatty liver disease remains somewhat a mystery, but a multinational prospective cohort study has found that patients with bridging fibrosis are at risk of nonhepatic malignancies and vascular problems while patients with cirrhosis are prone to predominantly liver-related complications that result in higher rates of death and liver transplant, according to a report presented at the annual meeting of the American Association for the Study of Liver Diseases.

“NAFLD patients with biopsy-proven cirrhosis have a higher mortality and liver-related complications than those with bridging fibrosis, whereas vascular events and nonhepatic malignancies are the commonest complications in those with bridging fibrosis,” said Eduardo Vilar-Gomez, MD, PhD, of Indiana University, Indianapolis. “Among compensated cirrhotic patients, those with Child-Pugh (CP) A6 are at highest risk of liver-related outcomes and mortality.”

WASHINGTON – The true impact of advanced fibrosis and cirrhosis advancing to serious hepatic and nonhepatic complications in nonalcoholic fatty liver disease remains somewhat a mystery, but a multinational prospective cohort study has found that patients with bridging fibrosis are at risk of nonhepatic malignancies and vascular problems while patients with cirrhosis are prone to predominantly liver-related complications that result in higher rates of death and liver transplant, according to a report presented at the annual meeting of the American Association for the Study of Liver Diseases.

“NAFLD patients with biopsy-proven cirrhosis have a higher mortality and liver-related complications than those with bridging fibrosis, whereas vascular events and nonhepatic malignancies are the commonest complications in those with bridging fibrosis,” said Eduardo Vilar-Gomez, MD, PhD, of Indiana University, Indianapolis. “Among compensated cirrhotic patients, those with Child-Pugh (CP) A6 are at highest risk of liver-related outcomes and mortality.”

WASHINGTON – The true impact of advanced fibrosis and cirrhosis advancing to serious hepatic and nonhepatic complications in nonalcoholic fatty liver disease remains somewhat a mystery, but a multinational prospective cohort study has found that patients with bridging fibrosis are at risk of nonhepatic malignancies and vascular problems while patients with cirrhosis are prone to predominantly liver-related complications that result in higher rates of death and liver transplant, according to a report presented at the annual meeting of the American Association for the Study of Liver Diseases.

“NAFLD patients with biopsy-proven cirrhosis have a higher mortality and liver-related complications than those with bridging fibrosis, whereas vascular events and nonhepatic malignancies are the commonest complications in those with bridging fibrosis,” said Eduardo Vilar-Gomez, MD, PhD, of Indiana University, Indianapolis. “Among compensated cirrhotic patients, those with Child-Pugh (CP) A6 are at highest risk of liver-related outcomes and mortality.”

Opiates are overused, and acute analgesics with high-quality evidence may be underused, for the treatment of migraine, according to research published online ahead of print June 26 in Cephalalgia. In addition, migraine may be undertreated with preventive medications. These prescribing patterns do not significantly differ by patients’ race, however.

Analyzing Nationally Representative Data

In the US, racial disparities in migraine burden have been reported. Migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life, compared with migraine in non-Hispanic whites. Lower-quality medication treatment for migraine may explain this difference, but little is known about the quality of migraine prescribing patterns in the US or whether racial differences exist.

Dr. Charleston and James F. Burke, MD, Associate Professor of Neurology at the University of Michigan Medical School, hypothesized that racial differences in the use of high-quality abortive, prophylactic medications would exist in ambulatory care settings, and that the quality of medical treatment for migraine disorders would be suboptimal in minority populations. To test these hypotheses, they analyzed all headache visits for patients over age 18 in the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2013.

The investigators defined quality of migraine care by using the American Academy of Neurology Headache Quality Measure Set. Researchers then assigned patients to one of three race or ethnicity categories—non-Hispanic white, African American, and Hispanic. Patients who reported other races or ethnicities were excluded.

The researchers assigned patients to one of four abortive agent categories—no abortive agent prescribed, all high-quality abortive agents (ie, triptans or dihydroergotamine), some low-quality abortive agents, or any opiate agent. In addition, the investigators assigned patients to one of four prophylactic agent categories—no prophylactic agent, all high-quality prophylaxis, some low-quality prophylaxis, or all low-quality prophylaxis. Finally, researchers made racial comparisons using descriptive statistics after applying NAMCS survey weights.

Prophylactic Agents Are Likely Underused

A total of 2,860 visits were included in the study, representing approximately 50 million migraine visits in the US from 2006 to 2013; 76% of patients were non-Hispanic white, 10% were African American, and 10% were Hispanic. Hispanic patients were more likely to be seen in a given practice for the first time, compared with non-Hispanic whites or African Americans. Researchers also observed a trend toward less private insurance and more Medicaid among African American and Hispanic patients, compared with non-Hispanic white patients.

Although overall migraine prescribing patterns were suboptimal, researchers did not find any major differences by race. “It is possible, though, that more modest racial differences in abortive prescribing exist, but that we lacked statistical power to identify those differences,” said Drs. Charleston and Burke.

In all, 41.3% of African Americans, 40.8% of non-Hispanic whites, and 41.2% of Hispanic patients received no prophylactic treatment. A total of 18.8% of African Americans, 11.9% of non-Hispanic whites, and 6.9% of Hispanic patients received exclusively Level A prophylaxis.

Forty-seven percent of African Americans, 38.2% of non-Hispanic whites, and 36.3% of Hispanic patients received no abortive treatments. In all, 15.3% of African Americans, 19.4% of non-Hispanic whites, and 17.7% of Hispanic patients received exclusively Level A abortive agents. About 15.2% of patients had a prescription for opiates, but no racial differences were observed.

In addition, African Americans were 4% less likely to receive all high-quality abortive agents, and Hispanic patients were 5% less likely to receive all high-quality prophylactic agents, compared with non-Hispanic whites. Neither of these differences was statistically significant, said the researchers.

“Understanding what drives these prescribing patterns and improving overall migraine prescribing should be a central concern for headache care practitioners and quality-improvement initiatives, and a target of future interventions,” said Drs. Charleston and Burke.

One limitation of this study was that researchers had no details on headache severity or duration. Another limitation was that the researchers did not control for socioeconomic status.

—Erica Tricarico

Suggested Reading

Charleston IV L, Burke JF. Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care? Cephalalgia. 2017 Jun 26 [Epub ahead of print].

Opiates are overused, and acute analgesics with high-quality evidence may be underused, for the treatment of migraine, according to research published online ahead of print June 26 in Cephalalgia. In addition, migraine may be undertreated with preventive medications. These prescribing patterns do not significantly differ by patients’ race, however.

Analyzing Nationally Representative Data

In the US, racial disparities in migraine burden have been reported. Migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life, compared with migraine in non-Hispanic whites. Lower-quality medication treatment for migraine may explain this difference, but little is known about the quality of migraine prescribing patterns in the US or whether racial differences exist.

Dr. Charleston and James F. Burke, MD, Associate Professor of Neurology at the University of Michigan Medical School, hypothesized that racial differences in the use of high-quality abortive, prophylactic medications would exist in ambulatory care settings, and that the quality of medical treatment for migraine disorders would be suboptimal in minority populations. To test these hypotheses, they analyzed all headache visits for patients over age 18 in the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2013.

The investigators defined quality of migraine care by using the American Academy of Neurology Headache Quality Measure Set. Researchers then assigned patients to one of three race or ethnicity categories—non-Hispanic white, African American, and Hispanic. Patients who reported other races or ethnicities were excluded.

The researchers assigned patients to one of four abortive agent categories—no abortive agent prescribed, all high-quality abortive agents (ie, triptans or dihydroergotamine), some low-quality abortive agents, or any opiate agent. In addition, the investigators assigned patients to one of four prophylactic agent categories—no prophylactic agent, all high-quality prophylaxis, some low-quality prophylaxis, or all low-quality prophylaxis. Finally, researchers made racial comparisons using descriptive statistics after applying NAMCS survey weights.

Prophylactic Agents Are Likely Underused

A total of 2,860 visits were included in the study, representing approximately 50 million migraine visits in the US from 2006 to 2013; 76% of patients were non-Hispanic white, 10% were African American, and 10% were Hispanic. Hispanic patients were more likely to be seen in a given practice for the first time, compared with non-Hispanic whites or African Americans. Researchers also observed a trend toward less private insurance and more Medicaid among African American and Hispanic patients, compared with non-Hispanic white patients.

Although overall migraine prescribing patterns were suboptimal, researchers did not find any major differences by race. “It is possible, though, that more modest racial differences in abortive prescribing exist, but that we lacked statistical power to identify those differences,” said Drs. Charleston and Burke.

In all, 41.3% of African Americans, 40.8% of non-Hispanic whites, and 41.2% of Hispanic patients received no prophylactic treatment. A total of 18.8% of African Americans, 11.9% of non-Hispanic whites, and 6.9% of Hispanic patients received exclusively Level A prophylaxis.

Forty-seven percent of African Americans, 38.2% of non-Hispanic whites, and 36.3% of Hispanic patients received no abortive treatments. In all, 15.3% of African Americans, 19.4% of non-Hispanic whites, and 17.7% of Hispanic patients received exclusively Level A abortive agents. About 15.2% of patients had a prescription for opiates, but no racial differences were observed.

In addition, African Americans were 4% less likely to receive all high-quality abortive agents, and Hispanic patients were 5% less likely to receive all high-quality prophylactic agents, compared with non-Hispanic whites. Neither of these differences was statistically significant, said the researchers.

“Understanding what drives these prescribing patterns and improving overall migraine prescribing should be a central concern for headache care practitioners and quality-improvement initiatives, and a target of future interventions,” said Drs. Charleston and Burke.

One limitation of this study was that researchers had no details on headache severity or duration. Another limitation was that the researchers did not control for socioeconomic status.

—Erica Tricarico

Suggested Reading

Charleston IV L, Burke JF. Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care? Cephalalgia. 2017 Jun 26 [Epub ahead of print].

Opiates are overused, and acute analgesics with high-quality evidence may be underused, for the treatment of migraine, according to research published online ahead of print June 26 in Cephalalgia. In addition, migraine may be undertreated with preventive medications. These prescribing patterns do not significantly differ by patients’ race, however.

Analyzing Nationally Representative Data

In the US, racial disparities in migraine burden have been reported. Migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life, compared with migraine in non-Hispanic whites. Lower-quality medication treatment for migraine may explain this difference, but little is known about the quality of migraine prescribing patterns in the US or whether racial differences exist.

Dr. Charleston and James F. Burke, MD, Associate Professor of Neurology at the University of Michigan Medical School, hypothesized that racial differences in the use of high-quality abortive, prophylactic medications would exist in ambulatory care settings, and that the quality of medical treatment for migraine disorders would be suboptimal in minority populations. To test these hypotheses, they analyzed all headache visits for patients over age 18 in the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2013.

The investigators defined quality of migraine care by using the American Academy of Neurology Headache Quality Measure Set. Researchers then assigned patients to one of three race or ethnicity categories—non-Hispanic white, African American, and Hispanic. Patients who reported other races or ethnicities were excluded.

The researchers assigned patients to one of four abortive agent categories—no abortive agent prescribed, all high-quality abortive agents (ie, triptans or dihydroergotamine), some low-quality abortive agents, or any opiate agent. In addition, the investigators assigned patients to one of four prophylactic agent categories—no prophylactic agent, all high-quality prophylaxis, some low-quality prophylaxis, or all low-quality prophylaxis. Finally, researchers made racial comparisons using descriptive statistics after applying NAMCS survey weights.

Prophylactic Agents Are Likely Underused

A total of 2,860 visits were included in the study, representing approximately 50 million migraine visits in the US from 2006 to 2013; 76% of patients were non-Hispanic white, 10% were African American, and 10% were Hispanic. Hispanic patients were more likely to be seen in a given practice for the first time, compared with non-Hispanic whites or African Americans. Researchers also observed a trend toward less private insurance and more Medicaid among African American and Hispanic patients, compared with non-Hispanic white patients.

Although overall migraine prescribing patterns were suboptimal, researchers did not find any major differences by race. “It is possible, though, that more modest racial differences in abortive prescribing exist, but that we lacked statistical power to identify those differences,” said Drs. Charleston and Burke.

In all, 41.3% of African Americans, 40.8% of non-Hispanic whites, and 41.2% of Hispanic patients received no prophylactic treatment. A total of 18.8% of African Americans, 11.9% of non-Hispanic whites, and 6.9% of Hispanic patients received exclusively Level A prophylaxis.

Forty-seven percent of African Americans, 38.2% of non-Hispanic whites, and 36.3% of Hispanic patients received no abortive treatments. In all, 15.3% of African Americans, 19.4% of non-Hispanic whites, and 17.7% of Hispanic patients received exclusively Level A abortive agents. About 15.2% of patients had a prescription for opiates, but no racial differences were observed.

In addition, African Americans were 4% less likely to receive all high-quality abortive agents, and Hispanic patients were 5% less likely to receive all high-quality prophylactic agents, compared with non-Hispanic whites. Neither of these differences was statistically significant, said the researchers.

“Understanding what drives these prescribing patterns and improving overall migraine prescribing should be a central concern for headache care practitioners and quality-improvement initiatives, and a target of future interventions,” said Drs. Charleston and Burke.

One limitation of this study was that researchers had no details on headache severity or duration. Another limitation was that the researchers did not control for socioeconomic status.

—Erica Tricarico

Suggested Reading

Charleston IV L, Burke JF. Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care? Cephalalgia. 2017 Jun 26 [Epub ahead of print].

Editor’s note: Each month, Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

What are the requirements to become a Master in Hospital Medicine, and how has this designation been beneficial to your career?

I have been an SHM member since the early years (early 2000s, I think), and I became a Master in Hospital Medicine (MHM) in 2013. I see the MHM designation as recognizing accomplishments that have been critical in advancing the field of hospital medicine and SHM as a society.

I would guess that my contributions to the SHM Board, being SHM president, cofounding (with others) the Academic Hospitalist Academy, founding (with others) the Quality Safety Educators Academy, and being the founding chair of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine pathway were probably what led to my induction.

The salient question probably isn’t “How has this designation been beneficial to my career?” but, rather, “How, after receiving the MHM designation, has my career benefited hospital medicine and SHM?” To my mind, there are some awards in life that recognize excellence in the completion of a task. They herald the end of a finite game: a “best research project” award, for example. But then there are a special few recognitions that, while they recognize past contributions, focus more upon the future than the past. They are infinite recognitions, because implicitly, they are recognitions of “promise” as much as achievement. They convey the organization’s trust in, and high expectations for, the recipient. In sum, they are simultaneously an honor and an obligation … an obligation and an expectation that the recipient will continue to do even more. In academic parlance, being “tenured” is a good example; for the Society of Hospital Medicine, the equivalent is the MHM recognition. I have done a lot for SHM, but the MHM designation obligates me to do even more. Honoring that obligation is what I plan to do with my career.
 

How did you become involved with SHM’s Leadership Academy, and how has the program developed over the years?

I started doing a 1-hour talk when the Mastering Teamwork course started. I did that for a couple of years but, as my career was evolving into higher-level institutional and hospital leadership, there was much more to talk about than I could fit into 1 hour.

The core of my leadership message is based in the “character ethic” (being better than who you are) and not the popular “personality ethic” (looking better than you are). So it’s that … plus all of the leadership mistakes I have made along the way. And that’s a lot of mistakes … enough to fill 9 hours of Mastering Teamwork.
 

In your opinion, what are some of the main takeaways for those who participate in SHM’s Leadership Academy?

Two of the three core components of great leadership are having a mission and purpose and being sincere. Leadership Academy can’t deliver the first two, so participants do have to come prepared to be trained.

Understanding people is the third core component, and mastering that skill is really complex. It is not something you can do with a clever slogan and a new lapel pin. It comes in many forms: teamwork, communication, networking, dealing with crisis, orchestrating change, etc. But at its core, Leadership Academy is all about training future leaders in how to understand people … and to develop the skills to inspire, motivate, and move their team to greater heights. Because at its core, leadership is about getting people to go places they otherwise didn’t want to go and to do things that they didn’t already want to do. And, to do that, you have to understand people.
 

As an active SHM member of many years, what advice do you have for members who wish to get more involved?

You have to start somewhere, and you have to see the entry level years as investing in yourself. There will be sacrifice involved, so don’t expect immediate returns on the investment, and the first few years might not be that fun.

Every year, there is a call for committee membership, and you need to get involved in one or more of those committees. Find the most senior hospitalist, who is the most involved in SHM, and tell her that you want to be on an SHM committee, and could she nominate you? If you do not have that luxury, then pay attention at the SHM annual conference. The SHM president-elect is responsible for building out the SHM committee nominees; as president, you are always looking to find enthusiastic people to be on the committees. Receiving emails from enthusiastic members is more welcome than you might think. As soon as that person is announced, find her email and start making the request to be on a committee. Be open to the assignment: Even if it is not your favorite committee, being there is more important than not.

But remember, networking and reputation are “two tailed.” You can improve your reputation by meaningful and consistent participation on a committee (leading to higher and better leadership opportunities), but you can also tarnish it by being assigned to a committee and not doing anything. You do that once, and there is a high probability that you will not be asked back again.

Great strategy, at the end of the day, is always putting yourself in a position with the maximum number of options. The key to personal development strategy is networking. The more people you know, the higher the probability that your email box will light up with the “Hey, do you want to collaborate on this project together?” sort of emails. Attend the annual conferences, attend the SHM Academies (Leadership, Quality and Safety Educators Academy, Academic Hospitalist Academy, etc.). Build genuine relationships with the people you meet there, and the rest will work out just fine.
 

Ms. Steele is the marketing communications specialist at the Society of Hospital Medicine.

Editor’s note: Each month, Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

What are the requirements to become a Master in Hospital Medicine, and how has this designation been beneficial to your career?

I have been an SHM member since the early years (early 2000s, I think), and I became a Master in Hospital Medicine (MHM) in 2013. I see the MHM designation as recognizing accomplishments that have been critical in advancing the field of hospital medicine and SHM as a society.

I would guess that my contributions to the SHM Board, being SHM president, cofounding (with others) the Academic Hospitalist Academy, founding (with others) the Quality Safety Educators Academy, and being the founding chair of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine pathway were probably what led to my induction.

The salient question probably isn’t “How has this designation been beneficial to my career?” but, rather, “How, after receiving the MHM designation, has my career benefited hospital medicine and SHM?” To my mind, there are some awards in life that recognize excellence in the completion of a task. They herald the end of a finite game: a “best research project” award, for example. But then there are a special few recognitions that, while they recognize past contributions, focus more upon the future than the past. They are infinite recognitions, because implicitly, they are recognitions of “promise” as much as achievement. They convey the organization’s trust in, and high expectations for, the recipient. In sum, they are simultaneously an honor and an obligation … an obligation and an expectation that the recipient will continue to do even more. In academic parlance, being “tenured” is a good example; for the Society of Hospital Medicine, the equivalent is the MHM recognition. I have done a lot for SHM, but the MHM designation obligates me to do even more. Honoring that obligation is what I plan to do with my career.
 

How did you become involved with SHM’s Leadership Academy, and how has the program developed over the years?

I started doing a 1-hour talk when the Mastering Teamwork course started. I did that for a couple of years but, as my career was evolving into higher-level institutional and hospital leadership, there was much more to talk about than I could fit into 1 hour.

The core of my leadership message is based in the “character ethic” (being better than who you are) and not the popular “personality ethic” (looking better than you are). So it’s that … plus all of the leadership mistakes I have made along the way. And that’s a lot of mistakes … enough to fill 9 hours of Mastering Teamwork.
 

In your opinion, what are some of the main takeaways for those who participate in SHM’s Leadership Academy?

Two of the three core components of great leadership are having a mission and purpose and being sincere. Leadership Academy can’t deliver the first two, so participants do have to come prepared to be trained.

Understanding people is the third core component, and mastering that skill is really complex. It is not something you can do with a clever slogan and a new lapel pin. It comes in many forms: teamwork, communication, networking, dealing with crisis, orchestrating change, etc. But at its core, Leadership Academy is all about training future leaders in how to understand people … and to develop the skills to inspire, motivate, and move their team to greater heights. Because at its core, leadership is about getting people to go places they otherwise didn’t want to go and to do things that they didn’t already want to do. And, to do that, you have to understand people.
 

As an active SHM member of many years, what advice do you have for members who wish to get more involved?

You have to start somewhere, and you have to see the entry level years as investing in yourself. There will be sacrifice involved, so don’t expect immediate returns on the investment, and the first few years might not be that fun.

Every year, there is a call for committee membership, and you need to get involved in one or more of those committees. Find the most senior hospitalist, who is the most involved in SHM, and tell her that you want to be on an SHM committee, and could she nominate you? If you do not have that luxury, then pay attention at the SHM annual conference. The SHM president-elect is responsible for building out the SHM committee nominees; as president, you are always looking to find enthusiastic people to be on the committees. Receiving emails from enthusiastic members is more welcome than you might think. As soon as that person is announced, find her email and start making the request to be on a committee. Be open to the assignment: Even if it is not your favorite committee, being there is more important than not.

But remember, networking and reputation are “two tailed.” You can improve your reputation by meaningful and consistent participation on a committee (leading to higher and better leadership opportunities), but you can also tarnish it by being assigned to a committee and not doing anything. You do that once, and there is a high probability that you will not be asked back again.

Great strategy, at the end of the day, is always putting yourself in a position with the maximum number of options. The key to personal development strategy is networking. The more people you know, the higher the probability that your email box will light up with the “Hey, do you want to collaborate on this project together?” sort of emails. Attend the annual conferences, attend the SHM Academies (Leadership, Quality and Safety Educators Academy, Academic Hospitalist Academy, etc.). Build genuine relationships with the people you meet there, and the rest will work out just fine.
 

Ms. Steele is the marketing communications specialist at the Society of Hospital Medicine.

Editor’s note: Each month, Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

What are the requirements to become a Master in Hospital Medicine, and how has this designation been beneficial to your career?

I have been an SHM member since the early years (early 2000s, I think), and I became a Master in Hospital Medicine (MHM) in 2013. I see the MHM designation as recognizing accomplishments that have been critical in advancing the field of hospital medicine and SHM as a society.

I would guess that my contributions to the SHM Board, being SHM president, cofounding (with others) the Academic Hospitalist Academy, founding (with others) the Quality Safety Educators Academy, and being the founding chair of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine pathway were probably what led to my induction.

The salient question probably isn’t “How has this designation been beneficial to my career?” but, rather, “How, after receiving the MHM designation, has my career benefited hospital medicine and SHM?” To my mind, there are some awards in life that recognize excellence in the completion of a task. They herald the end of a finite game: a “best research project” award, for example. But then there are a special few recognitions that, while they recognize past contributions, focus more upon the future than the past. They are infinite recognitions, because implicitly, they are recognitions of “promise” as much as achievement. They convey the organization’s trust in, and high expectations for, the recipient. In sum, they are simultaneously an honor and an obligation … an obligation and an expectation that the recipient will continue to do even more. In academic parlance, being “tenured” is a good example; for the Society of Hospital Medicine, the equivalent is the MHM recognition. I have done a lot for SHM, but the MHM designation obligates me to do even more. Honoring that obligation is what I plan to do with my career.
 

How did you become involved with SHM’s Leadership Academy, and how has the program developed over the years?

I started doing a 1-hour talk when the Mastering Teamwork course started. I did that for a couple of years but, as my career was evolving into higher-level institutional and hospital leadership, there was much more to talk about than I could fit into 1 hour.

The core of my leadership message is based in the “character ethic” (being better than who you are) and not the popular “personality ethic” (looking better than you are). So it’s that … plus all of the leadership mistakes I have made along the way. And that’s a lot of mistakes … enough to fill 9 hours of Mastering Teamwork.
 

In your opinion, what are some of the main takeaways for those who participate in SHM’s Leadership Academy?

Two of the three core components of great leadership are having a mission and purpose and being sincere. Leadership Academy can’t deliver the first two, so participants do have to come prepared to be trained.

Understanding people is the third core component, and mastering that skill is really complex. It is not something you can do with a clever slogan and a new lapel pin. It comes in many forms: teamwork, communication, networking, dealing with crisis, orchestrating change, etc. But at its core, Leadership Academy is all about training future leaders in how to understand people … and to develop the skills to inspire, motivate, and move their team to greater heights. Because at its core, leadership is about getting people to go places they otherwise didn’t want to go and to do things that they didn’t already want to do. And, to do that, you have to understand people.
 

As an active SHM member of many years, what advice do you have for members who wish to get more involved?

You have to start somewhere, and you have to see the entry level years as investing in yourself. There will be sacrifice involved, so don’t expect immediate returns on the investment, and the first few years might not be that fun.

Every year, there is a call for committee membership, and you need to get involved in one or more of those committees. Find the most senior hospitalist, who is the most involved in SHM, and tell her that you want to be on an SHM committee, and could she nominate you? If you do not have that luxury, then pay attention at the SHM annual conference. The SHM president-elect is responsible for building out the SHM committee nominees; as president, you are always looking to find enthusiastic people to be on the committees. Receiving emails from enthusiastic members is more welcome than you might think. As soon as that person is announced, find her email and start making the request to be on a committee. Be open to the assignment: Even if it is not your favorite committee, being there is more important than not.

But remember, networking and reputation are “two tailed.” You can improve your reputation by meaningful and consistent participation on a committee (leading to higher and better leadership opportunities), but you can also tarnish it by being assigned to a committee and not doing anything. You do that once, and there is a high probability that you will not be asked back again.

Great strategy, at the end of the day, is always putting yourself in a position with the maximum number of options. The key to personal development strategy is networking. The more people you know, the higher the probability that your email box will light up with the “Hey, do you want to collaborate on this project together?” sort of emails. Attend the annual conferences, attend the SHM Academies (Leadership, Quality and Safety Educators Academy, Academic Hospitalist Academy, etc.). Build genuine relationships with the people you meet there, and the rest will work out just fine.
 

Ms. Steele is the marketing communications specialist at the Society of Hospital Medicine.

BARCELONA – Atrial fibrillation is at least as strong a risk factor for venous thromboembolism as for ischemic stroke, Bjorn Hornestam, MD, asserted at the annual congress of the European Society of Cardiology.

This novel finding from a Swedish national registry study suggests it’s time for thoughtful consideration of a revision of risk scores in patients with atrial fibrillation (AF), according to Dr. Hornestam, director of cardiology at Sahlgrenska University Hospital in Gothenburg, Sweden.

“VTE risk is not included as an outcome in the CHA₂DS₂-VASc score, so we underestimate the total thromboembolic risk in AF patients,” he said.

Dr. Hornestam presented a Swedish registry study of 1.36 million patients, including 470,738 patients with new-onset AF and no previous diagnosis of VTE or ischemic stroke and twice as many controls without AF who were matched to the AF patients by age, gender, and county.

[email protected]

BARCELONA – Atrial fibrillation is at least as strong a risk factor for venous thromboembolism as for ischemic stroke, Bjorn Hornestam, MD, asserted at the annual congress of the European Society of Cardiology.

This novel finding from a Swedish national registry study suggests it’s time for thoughtful consideration of a revision of risk scores in patients with atrial fibrillation (AF), according to Dr. Hornestam, director of cardiology at Sahlgrenska University Hospital in Gothenburg, Sweden.

“VTE risk is not included as an outcome in the CHA₂DS₂-VASc score, so we underestimate the total thromboembolic risk in AF patients,” he said.

Dr. Hornestam presented a Swedish registry study of 1.36 million patients, including 470,738 patients with new-onset AF and no previous diagnosis of VTE or ischemic stroke and twice as many controls without AF who were matched to the AF patients by age, gender, and county.

[email protected]

BARCELONA – Atrial fibrillation is at least as strong a risk factor for venous thromboembolism as for ischemic stroke, Bjorn Hornestam, MD, asserted at the annual congress of the European Society of Cardiology.

This novel finding from a Swedish national registry study suggests it’s time for thoughtful consideration of a revision of risk scores in patients with atrial fibrillation (AF), according to Dr. Hornestam, director of cardiology at Sahlgrenska University Hospital in Gothenburg, Sweden.

“VTE risk is not included as an outcome in the CHA₂DS₂-VASc score, so we underestimate the total thromboembolic risk in AF patients,” he said.

Dr. Hornestam presented a Swedish registry study of 1.36 million patients, including 470,738 patients with new-onset AF and no previous diagnosis of VTE or ischemic stroke and twice as many controls without AF who were matched to the AF patients by age, gender, and county.

[email protected]

You are an important source of sexual and reproductive information for adolescents, and can be instrumental in preventing unintended pregnancies and sexually transmitted infections as well as promoting healthy relationships. A new clinical report from the American Academy of Pediatrics’ Committee on Adolescence provides a variety of tools and techniques to help you with these discussions with your patients.

Confidentiality and consent are two of the most important factors to consider when discussing sexual health with adolescents, according to Arik V. Marcell, MD, and Gale R. Burstein, MD, coauthors of the report (Pediatrics. 2017. doi: 10.1542/peds.2017-2858). As confidentiality is promoted over the course of time, adolescents are more likely to return for care. Promoting a confidential environment also allows adolescent patients to feel free to communicate about sensitive topics such as sexual behaviors, partners, or gender. This is especially true for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth, who may need more social indications that you and your office are sympathetic to sensitive issues. One way to do this is to post an office policy that details the confidential services you provide and ensure that the post is visible to all parents and adolescents. Explain this information at the beginning of the visit, starting at age 11-14 years. State laws regarding consent and confidentiality vary from state to state. The Guttmacher Institute and the Center for Adolescent Health and the Law provide resources summarizing laws for each state.

Clear and effective communication is another important feature in providing sexual health care to adolescents. Adolescence is a time of great change, and many adolescents may not feel comfortable asking questions, even though they want them answered. The AAP report recommends utilizing several interview techniques to get solid answers from adolescents.

Asking direct but open-ended questions is a great way to get useful answers from adolescents and it avoids yes/no answers. After listening to a patient’s response, use a reflection response, or one that mirrors the feeling of the patient. This allows the patient to feel that he or she is being heard. Restating and summarizing the interview also is an effective tool and allows the patient to understand what has been discussed. Asking questions that provide insight into the patient allows you to better understand the patient as a person. The use of reassuring and supportive statements is important to support patients and allow them to feel more comfortable, according to the report.

javi_indy/ Thinkstock

[email protected]

You are an important source of sexual and reproductive information for adolescents, and can be instrumental in preventing unintended pregnancies and sexually transmitted infections as well as promoting healthy relationships. A new clinical report from the American Academy of Pediatrics’ Committee on Adolescence provides a variety of tools and techniques to help you with these discussions with your patients.

Confidentiality and consent are two of the most important factors to consider when discussing sexual health with adolescents, according to Arik V. Marcell, MD, and Gale R. Burstein, MD, coauthors of the report (Pediatrics. 2017. doi: 10.1542/peds.2017-2858). As confidentiality is promoted over the course of time, adolescents are more likely to return for care. Promoting a confidential environment also allows adolescent patients to feel free to communicate about sensitive topics such as sexual behaviors, partners, or gender. This is especially true for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth, who may need more social indications that you and your office are sympathetic to sensitive issues. One way to do this is to post an office policy that details the confidential services you provide and ensure that the post is visible to all parents and adolescents. Explain this information at the beginning of the visit, starting at age 11-14 years. State laws regarding consent and confidentiality vary from state to state. The Guttmacher Institute and the Center for Adolescent Health and the Law provide resources summarizing laws for each state.

Clear and effective communication is another important feature in providing sexual health care to adolescents. Adolescence is a time of great change, and many adolescents may not feel comfortable asking questions, even though they want them answered. The AAP report recommends utilizing several interview techniques to get solid answers from adolescents.

Asking direct but open-ended questions is a great way to get useful answers from adolescents and it avoids yes/no answers. After listening to a patient’s response, use a reflection response, or one that mirrors the feeling of the patient. This allows the patient to feel that he or she is being heard. Restating and summarizing the interview also is an effective tool and allows the patient to understand what has been discussed. Asking questions that provide insight into the patient allows you to better understand the patient as a person. The use of reassuring and supportive statements is important to support patients and allow them to feel more comfortable, according to the report.

javi_indy/ Thinkstock

[email protected]

You are an important source of sexual and reproductive information for adolescents, and can be instrumental in preventing unintended pregnancies and sexually transmitted infections as well as promoting healthy relationships. A new clinical report from the American Academy of Pediatrics’ Committee on Adolescence provides a variety of tools and techniques to help you with these discussions with your patients.

Confidentiality and consent are two of the most important factors to consider when discussing sexual health with adolescents, according to Arik V. Marcell, MD, and Gale R. Burstein, MD, coauthors of the report (Pediatrics. 2017. doi: 10.1542/peds.2017-2858). As confidentiality is promoted over the course of time, adolescents are more likely to return for care. Promoting a confidential environment also allows adolescent patients to feel free to communicate about sensitive topics such as sexual behaviors, partners, or gender. This is especially true for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth, who may need more social indications that you and your office are sympathetic to sensitive issues. One way to do this is to post an office policy that details the confidential services you provide and ensure that the post is visible to all parents and adolescents. Explain this information at the beginning of the visit, starting at age 11-14 years. State laws regarding consent and confidentiality vary from state to state. The Guttmacher Institute and the Center for Adolescent Health and the Law provide resources summarizing laws for each state.

Clear and effective communication is another important feature in providing sexual health care to adolescents. Adolescence is a time of great change, and many adolescents may not feel comfortable asking questions, even though they want them answered. The AAP report recommends utilizing several interview techniques to get solid answers from adolescents.

Asking direct but open-ended questions is a great way to get useful answers from adolescents and it avoids yes/no answers. After listening to a patient’s response, use a reflection response, or one that mirrors the feeling of the patient. This allows the patient to feel that he or she is being heard. Restating and summarizing the interview also is an effective tool and allows the patient to understand what has been discussed. Asking questions that provide insight into the patient allows you to better understand the patient as a person. The use of reassuring and supportive statements is important to support patients and allow them to feel more comfortable, according to the report.

javi_indy/ Thinkstock

[email protected]

CHICAGO – Maral Skelsey, MD, doesn’t get flowers from her patients very often. But, she said, a big bouquet recently landed on her desk after she had performed a nail biopsy on a patient. The note from the patient read, “That wasn’t as bad as I thought it would be!”

The patient’s relief after the procedure highlights the apprehension that both patients and dermatologists can feel when a nail biopsy becomes necessary, said Dr. Skelsey, director of dermatologic surgery at Georgetown University, Washington, D.C.

Speaking at the summer meeting of the American Academy of Dermatology, Dr. Skelsey said that the most important advice she can give about the nail biopsy is, “Do it early and often.”

Dr. Skelsey reminded the audience that the musician Bob Marley died of malignant melanoma; the first sign of his cancer was a longitudinal melanonychia that went unbiopsied. “The biggest mistake we make is not doing it,” she said.

In performing a nail biopsy, said Dr. Skelsey, the goals are, first and foremost, to optimize the pathologic diagnosis. Correct technique can help avoid complications such as bleeding, infection, and nail dystrophy; the right approach can minimize pain and anxiety, she added.

In preparing for a biopsy for melanonychia, “dermoscopy can be very helpful” in assessing the location of the pigment and fine-tuning planning for the biopsy, said Dr. Skelsey. Also, if the streak of melanonychia has reached the distal nail, sending the clipping for pathology can be useful as well.

For dorsal pigmentation, the proximal nail matrix should be biopsied.

“Do not use a punch biopsy on the nail fold to diagnose melanoma – you will get a false negative,” Dr. Skelsey said. It’s not possible to get an accurate diagnosis going through the nail plate to the nail bed, she said.

The preoperative assessment is usually straightforward. Pertinent items in the patient’s history include any medication allergies, current anticoagulation, and any history of prior trauma to the digit to be biopsied. Occasionally, imaging may be helpful, and patients should always be assessed for vascular insufficiency, she noted.

Preoperatively, she asks her patients to remove nail polish and pretreat the area with povidone iodine for 2 days prior to the procedure. Patients need to have a ride home after the procedure, and should be prepared to elevate the affected extremity for 48 hours post procedure. If a toenail is biopsied, they’re advised to come with a postop shoe.

Her patients receive a 5-minute isopropyl alcohol wash of the area to be biopsied just before the procedure, followed by air drying and a 5-minute scrub with 7.5% povidone iodine, which then is wiped off preprocedure.

For hemostasis, a tourniquet can be improvised with a sterile glove finger and a hemostat; there are also dedicated finger cots available that work well for this purpose, she said. In addition to nail nippers and a nail elevator, an English nail splitter can be helpful, said Dr. Skelsey.

For anesthesia, she said she ordinarily uses a 30 gauge needle with buffered lidocaine and epinephrine at room temperature to deliver a wing block. Beginning about 1 cm proximal and lateral to the junction of the proximal and lateral nail fold, the dermatologist can slowly inject about 1.5 cc per side. As the block takes effect, the lateral nail fold will blanch distally in a wing-shaped pattern. This technique, she said, also has the benefit of acting as a volumetric tourniquet.

“To avulse or not to avulse?” asked Dr. Skelsey. “I used to avulse almost everything,” she said, but noted that a complete avulsion is a “pretty traumatic” procedure. Now, unless a full avulsion is required for complete and accurate pathology, she will usually perform a partial nail plate avulsion.

A partial avulsion can reduce pain and morbidity, and can be done by two different methods: the partial proximal avulsion, and the “trap door” avulsion. In a trap door avulsion, she said, the distal matrix is primarily visualized, so this may be a good option for a longitudinal melanonychia arising from the distal matrix. A Freer elevator is used to detach the nail plate from the bed and the matrix, after which the nail plate can be lifted with a hemostat.

In a partial proximal avulsion, the proximal nail fold is reflected, so it’s a better option when the proximal nail matrix needs evaluation, she said.

After the avulsion has been done, “the matrix has been exposed. Now what? Punch or shave?” asked Dr. Skelsey. She noted that she used to perform punch biopsies on “everything,” and that it’s a good option if the pigmented area spans 3 mm or less. One issue, though, is that the specimen can get stuck in the puncher, and extraction can make it difficult to deliver an intact specimen.

Shave biopsies, Dr. Skelsey said, are effective in dealing with nail matrix lesions. They can yield an accurate pathologic diagnosis, and the biopsied digits healed without nail dystrophy in about three quarters of the cases in one study, she said. Potential recurrence of pigmentation is one drawback of the shave technique, she said.

With a shave biopsy, she performs tangential incisions of the proximal and lateral nail folds, and scores and reflects the nail. Then, the band of pigment is shaved tangentially. She cauterizes the area, and sometimes will use a bit of an absorbable gelatin sponge (Gelfoam) as well. Then the proximal nail fold and nail plate are sutured.

Replacing the nail plate results in better cosmesis and is much more comfortable for the patient, she said. An 18-gauge needle can be used to bore a hole through the avulsed nail plate, which may be held in an antiseptic solution soak during the biopsy. The sutures should then be placed from skin to nail plate, so nail fragments aren’t driven into the skin during the suturing process. Finally, specimen margins should be inked, and separate labeled formalin jars are needed for the nail plate, nail bed, and the matrix.

Dr. Skelsey reported that she had no conflicts of interest.
 

[email protected]

On Twitter @karioakes

CHICAGO – Maral Skelsey, MD, doesn’t get flowers from her patients very often. But, she said, a big bouquet recently landed on her desk after she had performed a nail biopsy on a patient. The note from the patient read, “That wasn’t as bad as I thought it would be!”

The patient’s relief after the procedure highlights the apprehension that both patients and dermatologists can feel when a nail biopsy becomes necessary, said Dr. Skelsey, director of dermatologic surgery at Georgetown University, Washington, D.C.

Speaking at the summer meeting of the American Academy of Dermatology, Dr. Skelsey said that the most important advice she can give about the nail biopsy is, “Do it early and often.”

Dr. Skelsey reminded the audience that the musician Bob Marley died of malignant melanoma; the first sign of his cancer was a longitudinal melanonychia that went unbiopsied. “The biggest mistake we make is not doing it,” she said.

In performing a nail biopsy, said Dr. Skelsey, the goals are, first and foremost, to optimize the pathologic diagnosis. Correct technique can help avoid complications such as bleeding, infection, and nail dystrophy; the right approach can minimize pain and anxiety, she added.

In preparing for a biopsy for melanonychia, “dermoscopy can be very helpful” in assessing the location of the pigment and fine-tuning planning for the biopsy, said Dr. Skelsey. Also, if the streak of melanonychia has reached the distal nail, sending the clipping for pathology can be useful as well.

For dorsal pigmentation, the proximal nail matrix should be biopsied.

“Do not use a punch biopsy on the nail fold to diagnose melanoma – you will get a false negative,” Dr. Skelsey said. It’s not possible to get an accurate diagnosis going through the nail plate to the nail bed, she said.

The preoperative assessment is usually straightforward. Pertinent items in the patient’s history include any medication allergies, current anticoagulation, and any history of prior trauma to the digit to be biopsied. Occasionally, imaging may be helpful, and patients should always be assessed for vascular insufficiency, she noted.

Preoperatively, she asks her patients to remove nail polish and pretreat the area with povidone iodine for 2 days prior to the procedure. Patients need to have a ride home after the procedure, and should be prepared to elevate the affected extremity for 48 hours post procedure. If a toenail is biopsied, they’re advised to come with a postop shoe.

Her patients receive a 5-minute isopropyl alcohol wash of the area to be biopsied just before the procedure, followed by air drying and a 5-minute scrub with 7.5% povidone iodine, which then is wiped off preprocedure.

For hemostasis, a tourniquet can be improvised with a sterile glove finger and a hemostat; there are also dedicated finger cots available that work well for this purpose, she said. In addition to nail nippers and a nail elevator, an English nail splitter can be helpful, said Dr. Skelsey.

For anesthesia, she said she ordinarily uses a 30 gauge needle with buffered lidocaine and epinephrine at room temperature to deliver a wing block. Beginning about 1 cm proximal and lateral to the junction of the proximal and lateral nail fold, the dermatologist can slowly inject about 1.5 cc per side. As the block takes effect, the lateral nail fold will blanch distally in a wing-shaped pattern. This technique, she said, also has the benefit of acting as a volumetric tourniquet.

“To avulse or not to avulse?” asked Dr. Skelsey. “I used to avulse almost everything,” she said, but noted that a complete avulsion is a “pretty traumatic” procedure. Now, unless a full avulsion is required for complete and accurate pathology, she will usually perform a partial nail plate avulsion.

A partial avulsion can reduce pain and morbidity, and can be done by two different methods: the partial proximal avulsion, and the “trap door” avulsion. In a trap door avulsion, she said, the distal matrix is primarily visualized, so this may be a good option for a longitudinal melanonychia arising from the distal matrix. A Freer elevator is used to detach the nail plate from the bed and the matrix, after which the nail plate can be lifted with a hemostat.

In a partial proximal avulsion, the proximal nail fold is reflected, so it’s a better option when the proximal nail matrix needs evaluation, she said.

After the avulsion has been done, “the matrix has been exposed. Now what? Punch or shave?” asked Dr. Skelsey. She noted that she used to perform punch biopsies on “everything,” and that it’s a good option if the pigmented area spans 3 mm or less. One issue, though, is that the specimen can get stuck in the puncher, and extraction can make it difficult to deliver an intact specimen.

Shave biopsies, Dr. Skelsey said, are effective in dealing with nail matrix lesions. They can yield an accurate pathologic diagnosis, and the biopsied digits healed without nail dystrophy in about three quarters of the cases in one study, she said. Potential recurrence of pigmentation is one drawback of the shave technique, she said.

With a shave biopsy, she performs tangential incisions of the proximal and lateral nail folds, and scores and reflects the nail. Then, the band of pigment is shaved tangentially. She cauterizes the area, and sometimes will use a bit of an absorbable gelatin sponge (Gelfoam) as well. Then the proximal nail fold and nail plate are sutured.

Replacing the nail plate results in better cosmesis and is much more comfortable for the patient, she said. An 18-gauge needle can be used to bore a hole through the avulsed nail plate, which may be held in an antiseptic solution soak during the biopsy. The sutures should then be placed from skin to nail plate, so nail fragments aren’t driven into the skin during the suturing process. Finally, specimen margins should be inked, and separate labeled formalin jars are needed for the nail plate, nail bed, and the matrix.

Dr. Skelsey reported that she had no conflicts of interest.
 

[email protected]

On Twitter @karioakes

CHICAGO – Maral Skelsey, MD, doesn’t get flowers from her patients very often. But, she said, a big bouquet recently landed on her desk after she had performed a nail biopsy on a patient. The note from the patient read, “That wasn’t as bad as I thought it would be!”

The patient’s relief after the procedure highlights the apprehension that both patients and dermatologists can feel when a nail biopsy becomes necessary, said Dr. Skelsey, director of dermatologic surgery at Georgetown University, Washington, D.C.

Speaking at the summer meeting of the American Academy of Dermatology, Dr. Skelsey said that the most important advice she can give about the nail biopsy is, “Do it early and often.”

Dr. Skelsey reminded the audience that the musician Bob Marley died of malignant melanoma; the first sign of his cancer was a longitudinal melanonychia that went unbiopsied. “The biggest mistake we make is not doing it,” she said.

In performing a nail biopsy, said Dr. Skelsey, the goals are, first and foremost, to optimize the pathologic diagnosis. Correct technique can help avoid complications such as bleeding, infection, and nail dystrophy; the right approach can minimize pain and anxiety, she added.

In preparing for a biopsy for melanonychia, “dermoscopy can be very helpful” in assessing the location of the pigment and fine-tuning planning for the biopsy, said Dr. Skelsey. Also, if the streak of melanonychia has reached the distal nail, sending the clipping for pathology can be useful as well.

For dorsal pigmentation, the proximal nail matrix should be biopsied.

“Do not use a punch biopsy on the nail fold to diagnose melanoma – you will get a false negative,” Dr. Skelsey said. It’s not possible to get an accurate diagnosis going through the nail plate to the nail bed, she said.

The preoperative assessment is usually straightforward. Pertinent items in the patient’s history include any medication allergies, current anticoagulation, and any history of prior trauma to the digit to be biopsied. Occasionally, imaging may be helpful, and patients should always be assessed for vascular insufficiency, she noted.

Preoperatively, she asks her patients to remove nail polish and pretreat the area with povidone iodine for 2 days prior to the procedure. Patients need to have a ride home after the procedure, and should be prepared to elevate the affected extremity for 48 hours post procedure. If a toenail is biopsied, they’re advised to come with a postop shoe.

Her patients receive a 5-minute isopropyl alcohol wash of the area to be biopsied just before the procedure, followed by air drying and a 5-minute scrub with 7.5% povidone iodine, which then is wiped off preprocedure.

For hemostasis, a tourniquet can be improvised with a sterile glove finger and a hemostat; there are also dedicated finger cots available that work well for this purpose, she said. In addition to nail nippers and a nail elevator, an English nail splitter can be helpful, said Dr. Skelsey.

For anesthesia, she said she ordinarily uses a 30 gauge needle with buffered lidocaine and epinephrine at room temperature to deliver a wing block. Beginning about 1 cm proximal and lateral to the junction of the proximal and lateral nail fold, the dermatologist can slowly inject about 1.5 cc per side. As the block takes effect, the lateral nail fold will blanch distally in a wing-shaped pattern. This technique, she said, also has the benefit of acting as a volumetric tourniquet.

“To avulse or not to avulse?” asked Dr. Skelsey. “I used to avulse almost everything,” she said, but noted that a complete avulsion is a “pretty traumatic” procedure. Now, unless a full avulsion is required for complete and accurate pathology, she will usually perform a partial nail plate avulsion.

A partial avulsion can reduce pain and morbidity, and can be done by two different methods: the partial proximal avulsion, and the “trap door” avulsion. In a trap door avulsion, she said, the distal matrix is primarily visualized, so this may be a good option for a longitudinal melanonychia arising from the distal matrix. A Freer elevator is used to detach the nail plate from the bed and the matrix, after which the nail plate can be lifted with a hemostat.

In a partial proximal avulsion, the proximal nail fold is reflected, so it’s a better option when the proximal nail matrix needs evaluation, she said.

After the avulsion has been done, “the matrix has been exposed. Now what? Punch or shave?” asked Dr. Skelsey. She noted that she used to perform punch biopsies on “everything,” and that it’s a good option if the pigmented area spans 3 mm or less. One issue, though, is that the specimen can get stuck in the puncher, and extraction can make it difficult to deliver an intact specimen.

Shave biopsies, Dr. Skelsey said, are effective in dealing with nail matrix lesions. They can yield an accurate pathologic diagnosis, and the biopsied digits healed without nail dystrophy in about three quarters of the cases in one study, she said. Potential recurrence of pigmentation is one drawback of the shave technique, she said.

With a shave biopsy, she performs tangential incisions of the proximal and lateral nail folds, and scores and reflects the nail. Then, the band of pigment is shaved tangentially. She cauterizes the area, and sometimes will use a bit of an absorbable gelatin sponge (Gelfoam) as well. Then the proximal nail fold and nail plate are sutured.

Replacing the nail plate results in better cosmesis and is much more comfortable for the patient, she said. An 18-gauge needle can be used to bore a hole through the avulsed nail plate, which may be held in an antiseptic solution soak during the biopsy. The sutures should then be placed from skin to nail plate, so nail fragments aren’t driven into the skin during the suturing process. Finally, specimen margins should be inked, and separate labeled formalin jars are needed for the nail plate, nail bed, and the matrix.

Dr. Skelsey reported that she had no conflicts of interest.
 

[email protected]

On Twitter @karioakes

TORONTO – Extracorporeal membrane oxygenation (ECMO) is associated with lung recovery rates as high as 90% in pediatric patients with near-fatal asthma, but the risk of complications was also high and the cannulation technique employed made a significant difference to outcomes, according to a study presented at the CHEST annual meeting.

“ECMO for near-fatal asthma is a potentially life-saving intervention, however, clinicians should be aware of the potentially severe complications, particularly with veno-arterial cannulation in this population,” said Rebecca Kohlberg-Davis, MD, a pediatric resident at Connecticut Children’s Medical Center, Hartford.

Debra L. Beck/Frontline Medical News

TORONTO – Extracorporeal membrane oxygenation (ECMO) is associated with lung recovery rates as high as 90% in pediatric patients with near-fatal asthma, but the risk of complications was also high and the cannulation technique employed made a significant difference to outcomes, according to a study presented at the CHEST annual meeting.

“ECMO for near-fatal asthma is a potentially life-saving intervention, however, clinicians should be aware of the potentially severe complications, particularly with veno-arterial cannulation in this population,” said Rebecca Kohlberg-Davis, MD, a pediatric resident at Connecticut Children’s Medical Center, Hartford.

Debra L. Beck/Frontline Medical News

TORONTO – Extracorporeal membrane oxygenation (ECMO) is associated with lung recovery rates as high as 90% in pediatric patients with near-fatal asthma, but the risk of complications was also high and the cannulation technique employed made a significant difference to outcomes, according to a study presented at the CHEST annual meeting.

“ECMO for near-fatal asthma is a potentially life-saving intervention, however, clinicians should be aware of the potentially severe complications, particularly with veno-arterial cannulation in this population,” said Rebecca Kohlberg-Davis, MD, a pediatric resident at Connecticut Children’s Medical Center, Hartford.

Debra L. Beck/Frontline Medical News

TORONTO – A test that only requires a maximum 2-hour wait for results was highly accurate at detecting influenza and respiratory syncytial virus infection in lung transplant patients, according to research presented at the CHEST annual meeting on Oct. 30.

This rapid and highly accurate test for detecting three common respiratory viruses has dramatically cut the need for empiric treatments and the risk for causing nosocomial infections in lung transplant patients who develop severe upper respiratory infections, Macé M. Schuurmans, MD, noted during the presentation.

This study involved 100 consecutive lung transplant patients who presented at Zurich University Hospital with signs of severe upper respiratory infection. The researchers ran the rapid and standard diagnostic tests for each patient and found that, relative to the standard test, the rapid test had positive and negative predictive values of 95%.

The number of empiric treatments with oseltamivir (Tamiflu) and ribavirin to treat a suspected influenza or respiratory syncytial virus infection (RSV) has “strongly diminished” by about two-thirds, noted Dr. Schuurmans, who is a pulmonologist at the hospital.

Until the rapid test became available, Dr. Shuurmans and his associates used a standard polymerase chain reaction test that takes 36-48 hours to yield a result. Using this test made treating patients empirically with oseltamivir and oral antibiotics for a couple of days a necessity, he said in a video interview. The older test also required isolating patients to avoid the potential spread of influenza or RSV in the hospital.

The rapid test, which became available for U.S. use in early 2017, covers influenza A and B and RSV in a single test with a single mouth-swab specimen.

“We now routinely use the rapid test and don’t prescribe empiric antivirals or antibiotics as often,” Dr. Schuurmans said. “There is much less drug cost and fewer potential adverse effects from empiric treatment.” Specimens still also undergo conventional testing, however, because that can identify eight additional viruses that the rapid test doesn’t cover.

Dr. Schuurmans acknowledged that further study needs to assess the cost-benefit of the rapid test to confirm that its added expense is offset by reduced expenses for empiric treatment and hospital isolation.

He had no disclosures. The study received no commercial support.

[email protected]

On Twitter @mitchelzoler

TORONTO – A test that only requires a maximum 2-hour wait for results was highly accurate at detecting influenza and respiratory syncytial virus infection in lung transplant patients, according to research presented at the CHEST annual meeting on Oct. 30.

This rapid and highly accurate test for detecting three common respiratory viruses has dramatically cut the need for empiric treatments and the risk for causing nosocomial infections in lung transplant patients who develop severe upper respiratory infections, Macé M. Schuurmans, MD, noted during the presentation.

This study involved 100 consecutive lung transplant patients who presented at Zurich University Hospital with signs of severe upper respiratory infection. The researchers ran the rapid and standard diagnostic tests for each patient and found that, relative to the standard test, the rapid test had positive and negative predictive values of 95%.

The number of empiric treatments with oseltamivir (Tamiflu) and ribavirin to treat a suspected influenza or respiratory syncytial virus infection (RSV) has “strongly diminished” by about two-thirds, noted Dr. Schuurmans, who is a pulmonologist at the hospital.

Until the rapid test became available, Dr. Shuurmans and his associates used a standard polymerase chain reaction test that takes 36-48 hours to yield a result. Using this test made treating patients empirically with oseltamivir and oral antibiotics for a couple of days a necessity, he said in a video interview. The older test also required isolating patients to avoid the potential spread of influenza or RSV in the hospital.

The rapid test, which became available for U.S. use in early 2017, covers influenza A and B and RSV in a single test with a single mouth-swab specimen.

“We now routinely use the rapid test and don’t prescribe empiric antivirals or antibiotics as often,” Dr. Schuurmans said. “There is much less drug cost and fewer potential adverse effects from empiric treatment.” Specimens still also undergo conventional testing, however, because that can identify eight additional viruses that the rapid test doesn’t cover.

Dr. Schuurmans acknowledged that further study needs to assess the cost-benefit of the rapid test to confirm that its added expense is offset by reduced expenses for empiric treatment and hospital isolation.

He had no disclosures. The study received no commercial support.

[email protected]

On Twitter @mitchelzoler

TORONTO – A test that only requires a maximum 2-hour wait for results was highly accurate at detecting influenza and respiratory syncytial virus infection in lung transplant patients, according to research presented at the CHEST annual meeting on Oct. 30.

This rapid and highly accurate test for detecting three common respiratory viruses has dramatically cut the need for empiric treatments and the risk for causing nosocomial infections in lung transplant patients who develop severe upper respiratory infections, Macé M. Schuurmans, MD, noted during the presentation.

This study involved 100 consecutive lung transplant patients who presented at Zurich University Hospital with signs of severe upper respiratory infection. The researchers ran the rapid and standard diagnostic tests for each patient and found that, relative to the standard test, the rapid test had positive and negative predictive values of 95%.

The number of empiric treatments with oseltamivir (Tamiflu) and ribavirin to treat a suspected influenza or respiratory syncytial virus infection (RSV) has “strongly diminished” by about two-thirds, noted Dr. Schuurmans, who is a pulmonologist at the hospital.

Until the rapid test became available, Dr. Shuurmans and his associates used a standard polymerase chain reaction test that takes 36-48 hours to yield a result. Using this test made treating patients empirically with oseltamivir and oral antibiotics for a couple of days a necessity, he said in a video interview. The older test also required isolating patients to avoid the potential spread of influenza or RSV in the hospital.

The rapid test, which became available for U.S. use in early 2017, covers influenza A and B and RSV in a single test with a single mouth-swab specimen.

“We now routinely use the rapid test and don’t prescribe empiric antivirals or antibiotics as often,” Dr. Schuurmans said. “There is much less drug cost and fewer potential adverse effects from empiric treatment.” Specimens still also undergo conventional testing, however, because that can identify eight additional viruses that the rapid test doesn’t cover.

Dr. Schuurmans acknowledged that further study needs to assess the cost-benefit of the rapid test to confirm that its added expense is offset by reduced expenses for empiric treatment and hospital isolation.

He had no disclosures. The study received no commercial support.

[email protected]

On Twitter @mitchelzoler

WASHINGTON – Fewer than half of studied hepatocellular carcinoma patients born between 1945 and 1965 were eligible for transplant, despite a 58% increase in HCC rate during the past decade, according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases 2017.

This disparity is a cause for concern given that this cohort constitutes nearly 75% of hepatitis C virus (HCV) infections in the United States.

“Understanding hepatocellular carcinoma trends among the 1945-1965 birth cohort is particularly important given the increasing number of chronic liver diseases in that group,” said presenter Ann Robinson, MD, of Highland Hospital, Oakland, Calif.

In a retrospective study, researchers evaluated 38,045 patients born between 1945 and 1965 and who were on the Surveillance, Epidemiology, and End Results (SEER) registry and diagnosed with HCC between 2004 and 2014.

Patients were predominantly male (81.6%), white (50%), insured by Medicare or private insurance (66.2%), and diagnosed with localized tumors (52%).

White and Hispanic patients displayed the largest increase in HCC diagnoses during the study period, growing by 67.6% and 66.1%, respectively, followed by Native American and African American patients, whose HCC diagnoses increased by 61% and 57.2%, respectively.

Overall, 57.2% of patients studied did not meet the Milan criteria, according to Dr. Robinson.

Disparities in patients’ meeting the Milan criteria were apparent once researchers adjusted for patients’ sex, race, insurance status, or cancer subtype.

The largest disparity was seen among patients who were uninsured or on Medicaid, who were half as likely to meet Milan criteria at time of diagnosis, compared with insured patients (odds ratio, less than 0.5; P less than .001).

African Americans also saw lower odds of eligibility for transplantation (OR, less than 0.75; P less than .001), compared with white patients.

While the difference between men and women was statistically significant (OR, 0.875; P = .022), the difference in odds was not as prominent as that of uninsured patients or African American patients was.

These disparities may have to do with a lack of patient knowledge or less frequent screening among these patients, as well as an overall rise in nonalcoholic fatty liver disease, according to Dr. Robinson and her fellow investigators.

“It’s been well documented in prior studies that there is an underutilization of screenings both for one-time hepatitis and baby boomer population, despite recommendations by the CDC [Centers for Disease Control and Prevention]” said Dr. Robinson. Other factors may include whether patients know they should be receive these screenings, whether providers have educated their patients about this, and how much the provider knows about the screening guidelines.

The number of patients who meet the Milan criteria are growing, however, according to investigators. In 2013-2014, 46.3% of baby boomers met the Milan criteria, compared with 36.4% in 2004-2006.

Identifying vulnerabilities within these cohorts and increasing education for both providers and patients will help narrow the gap even further, explained Dr. Robinson.

“Looking at etiology-specific differences to know which populations are not receiving screening, [focusing on] things that can help us communicate this with patients, as well as distribute this information among care providers, and breaking down barriers to treatment,” are all important factors, according to Dr. Robinson.

Investigators were limited by SEER’s exclusion of etiology of HCC and comorbidities. Additionally, the researchers were unaware whether patients were receiving surveillance that was within practice guidelines.

Presenters reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

WASHINGTON – Fewer than half of studied hepatocellular carcinoma patients born between 1945 and 1965 were eligible for transplant, despite a 58% increase in HCC rate during the past decade, according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases 2017.

This disparity is a cause for concern given that this cohort constitutes nearly 75% of hepatitis C virus (HCV) infections in the United States.

“Understanding hepatocellular carcinoma trends among the 1945-1965 birth cohort is particularly important given the increasing number of chronic liver diseases in that group,” said presenter Ann Robinson, MD, of Highland Hospital, Oakland, Calif.

In a retrospective study, researchers evaluated 38,045 patients born between 1945 and 1965 and who were on the Surveillance, Epidemiology, and End Results (SEER) registry and diagnosed with HCC between 2004 and 2014.

Patients were predominantly male (81.6%), white (50%), insured by Medicare or private insurance (66.2%), and diagnosed with localized tumors (52%).

White and Hispanic patients displayed the largest increase in HCC diagnoses during the study period, growing by 67.6% and 66.1%, respectively, followed by Native American and African American patients, whose HCC diagnoses increased by 61% and 57.2%, respectively.

Overall, 57.2% of patients studied did not meet the Milan criteria, according to Dr. Robinson.

Disparities in patients’ meeting the Milan criteria were apparent once researchers adjusted for patients’ sex, race, insurance status, or cancer subtype.

The largest disparity was seen among patients who were uninsured or on Medicaid, who were half as likely to meet Milan criteria at time of diagnosis, compared with insured patients (odds ratio, less than 0.5; P less than .001).

African Americans also saw lower odds of eligibility for transplantation (OR, less than 0.75; P less than .001), compared with white patients.

While the difference between men and women was statistically significant (OR, 0.875; P = .022), the difference in odds was not as prominent as that of uninsured patients or African American patients was.

These disparities may have to do with a lack of patient knowledge or less frequent screening among these patients, as well as an overall rise in nonalcoholic fatty liver disease, according to Dr. Robinson and her fellow investigators.

“It’s been well documented in prior studies that there is an underutilization of screenings both for one-time hepatitis and baby boomer population, despite recommendations by the CDC [Centers for Disease Control and Prevention]” said Dr. Robinson. Other factors may include whether patients know they should be receive these screenings, whether providers have educated their patients about this, and how much the provider knows about the screening guidelines.

The number of patients who meet the Milan criteria are growing, however, according to investigators. In 2013-2014, 46.3% of baby boomers met the Milan criteria, compared with 36.4% in 2004-2006.

Identifying vulnerabilities within these cohorts and increasing education for both providers and patients will help narrow the gap even further, explained Dr. Robinson.

“Looking at etiology-specific differences to know which populations are not receiving screening, [focusing on] things that can help us communicate this with patients, as well as distribute this information among care providers, and breaking down barriers to treatment,” are all important factors, according to Dr. Robinson.

Investigators were limited by SEER’s exclusion of etiology of HCC and comorbidities. Additionally, the researchers were unaware whether patients were receiving surveillance that was within practice guidelines.

Presenters reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

WASHINGTON – Fewer than half of studied hepatocellular carcinoma patients born between 1945 and 1965 were eligible for transplant, despite a 58% increase in HCC rate during the past decade, according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases 2017.

This disparity is a cause for concern given that this cohort constitutes nearly 75% of hepatitis C virus (HCV) infections in the United States.

“Understanding hepatocellular carcinoma trends among the 1945-1965 birth cohort is particularly important given the increasing number of chronic liver diseases in that group,” said presenter Ann Robinson, MD, of Highland Hospital, Oakland, Calif.

In a retrospective study, researchers evaluated 38,045 patients born between 1945 and 1965 and who were on the Surveillance, Epidemiology, and End Results (SEER) registry and diagnosed with HCC between 2004 and 2014.

Patients were predominantly male (81.6%), white (50%), insured by Medicare or private insurance (66.2%), and diagnosed with localized tumors (52%).

White and Hispanic patients displayed the largest increase in HCC diagnoses during the study period, growing by 67.6% and 66.1%, respectively, followed by Native American and African American patients, whose HCC diagnoses increased by 61% and 57.2%, respectively.

Overall, 57.2% of patients studied did not meet the Milan criteria, according to Dr. Robinson.

Disparities in patients’ meeting the Milan criteria were apparent once researchers adjusted for patients’ sex, race, insurance status, or cancer subtype.

The largest disparity was seen among patients who were uninsured or on Medicaid, who were half as likely to meet Milan criteria at time of diagnosis, compared with insured patients (odds ratio, less than 0.5; P less than .001).

African Americans also saw lower odds of eligibility for transplantation (OR, less than 0.75; P less than .001), compared with white patients.

While the difference between men and women was statistically significant (OR, 0.875; P = .022), the difference in odds was not as prominent as that of uninsured patients or African American patients was.

These disparities may have to do with a lack of patient knowledge or less frequent screening among these patients, as well as an overall rise in nonalcoholic fatty liver disease, according to Dr. Robinson and her fellow investigators.

“It’s been well documented in prior studies that there is an underutilization of screenings both for one-time hepatitis and baby boomer population, despite recommendations by the CDC [Centers for Disease Control and Prevention]” said Dr. Robinson. Other factors may include whether patients know they should be receive these screenings, whether providers have educated their patients about this, and how much the provider knows about the screening guidelines.

The number of patients who meet the Milan criteria are growing, however, according to investigators. In 2013-2014, 46.3% of baby boomers met the Milan criteria, compared with 36.4% in 2004-2006.

Identifying vulnerabilities within these cohorts and increasing education for both providers and patients will help narrow the gap even further, explained Dr. Robinson.

“Looking at etiology-specific differences to know which populations are not receiving screening, [focusing on] things that can help us communicate this with patients, as well as distribute this information among care providers, and breaking down barriers to treatment,” are all important factors, according to Dr. Robinson.

Investigators were limited by SEER’s exclusion of etiology of HCC and comorbidities. Additionally, the researchers were unaware whether patients were receiving surveillance that was within practice guidelines.

Presenters reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets