EXPERT COMMENTARY

 A 2013 report from the Women’s Health Initiative (WHI), the large National Institutes of Health–funded placebo-controlledrandomized trial of postmenopausal hormone therapy (HT) with oral estrogen (for women with hysterectomy) or estrogen-progestin (for women with an intact uterus), with 13 years of cumulative follow-up, documented the safety of systemic HT when initiated by women younger than 60 years of age or within 10 years of menopause onset.¹ Now, with 18 years of cumulative follow-up data available (intervention and extended postintervention phases), the WHI investigators present all-cause and cause-specific mortality outcomes from the 2 HT trials.

Related article:
2017 Update on menopause

Details of the study

A total of 27,347 WHI participants (baseline mean age, 63.4 years; 80.6% white) used oral estrogen-progestin therapy (EPT) or placebo for a median of 5.6 years (n = 16,608) or estrogen-only therapy (ET) or placebo for a median of 7.2 years (n = 10,739). Each hazard ratio (HR) reported below refers to 18-year cumulative follow-up.

All-cause mortality. In the overall pooled cohort (EPT and ET groups), all-cause mortality was similar, with a rate of 27.1% in the HT group and 27.6% in the placebo group (HR, 0.99; 95% confidence interval [CI], 0.94–1.03). The mortality end points included deaths from all causes; cardiovascular disease (coronary heart disease, stroke, and other cardiovascular diseases); cancer (breast, colorectal, and other cancers); and other (Alzheimer disease, other dementia, chronic obstructive pulmonary disease, injuries and accidents, and other).

Stratifying by baseline participant age (comparing women aged 50–59 years with those aged 70–79 years), the HR for all-cause mortality in the pooled cohort during the intervention phase was 0.61 (95% CI, 0.43–0.87), and during the cumulative 18-year follow-up, the HR was 0.87 (95% CI, 0.76–1.00).

Cause-specific mortality. Neither cardiovascular disease mortality nor total cancer mortality was significantly impacted by HT use. In the pooled cohort, cardiovascular disease mortality was 8.9% in the HT group and 9.0% in the placebo group (HR, 1.00; 95% CI, 0.92–1.08), with no differences between the EPT and the ET trials. Cancer mortality rates in the pooled cohort also were similar, with 8.2% in the HT group and 8.0% in the placebo group (HR, 1.03; 95% CI, 0.95–1.12).

With respect to breast cancer mortality, the impact of HT diverged for EPT and ET. For the EPT group, the HR for breast cancer mortality was 1.44 (95% CI, 0.97–2.15; P = .07), while for the ET group the HR was 0.55 (95% CI, 0.33–0.92; P = .02).

Related articles:
Does the discontinuation of menopausal hormone therapy affect a woman’s cardiovascular risk?

Study strengths and weaknesses

The WHI represents the largest randomized placebo-controlled trials of HT. The current WHI trials report provides new, cumulative 18-year follow-up data on all-cause and cause-specific mortality in women treated with HT or placebo.

The authors noted, however, that the use of only one HT dose, formulation, and route of administration in each trial may limit the generalizability of the study results to other HT preparations. For example, the WHI did not examine the transdermal route of estrogen administration. Likewise, the WHI did not examine use of progestational agents other than medroxyprogesterone acetate. In addition, while almost all cohort deaths were captured through the National Death Index for the data analyses, specificity of cause of death may vary across outcomes. Further, since multiple outcomes and subgroups were examined, clinicians should interpret cause-specific mortality rates with caution.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

 A 2013 report from the Women’s Health Initiative (WHI), the large National Institutes of Health–funded placebo-controlledrandomized trial of postmenopausal hormone therapy (HT) with oral estrogen (for women with hysterectomy) or estrogen-progestin (for women with an intact uterus), with 13 years of cumulative follow-up, documented the safety of systemic HT when initiated by women younger than 60 years of age or within 10 years of menopause onset.¹ Now, with 18 years of cumulative follow-up data available (intervention and extended postintervention phases), the WHI investigators present all-cause and cause-specific mortality outcomes from the 2 HT trials.

Related article:
2017 Update on menopause

Details of the study

A total of 27,347 WHI participants (baseline mean age, 63.4 years; 80.6% white) used oral estrogen-progestin therapy (EPT) or placebo for a median of 5.6 years (n = 16,608) or estrogen-only therapy (ET) or placebo for a median of 7.2 years (n = 10,739). Each hazard ratio (HR) reported below refers to 18-year cumulative follow-up.

All-cause mortality. In the overall pooled cohort (EPT and ET groups), all-cause mortality was similar, with a rate of 27.1% in the HT group and 27.6% in the placebo group (HR, 0.99; 95% confidence interval [CI], 0.94–1.03). The mortality end points included deaths from all causes; cardiovascular disease (coronary heart disease, stroke, and other cardiovascular diseases); cancer (breast, colorectal, and other cancers); and other (Alzheimer disease, other dementia, chronic obstructive pulmonary disease, injuries and accidents, and other).

Stratifying by baseline participant age (comparing women aged 50–59 years with those aged 70–79 years), the HR for all-cause mortality in the pooled cohort during the intervention phase was 0.61 (95% CI, 0.43–0.87), and during the cumulative 18-year follow-up, the HR was 0.87 (95% CI, 0.76–1.00).

Cause-specific mortality. Neither cardiovascular disease mortality nor total cancer mortality was significantly impacted by HT use. In the pooled cohort, cardiovascular disease mortality was 8.9% in the HT group and 9.0% in the placebo group (HR, 1.00; 95% CI, 0.92–1.08), with no differences between the EPT and the ET trials. Cancer mortality rates in the pooled cohort also were similar, with 8.2% in the HT group and 8.0% in the placebo group (HR, 1.03; 95% CI, 0.95–1.12).

With respect to breast cancer mortality, the impact of HT diverged for EPT and ET. For the EPT group, the HR for breast cancer mortality was 1.44 (95% CI, 0.97–2.15; P = .07), while for the ET group the HR was 0.55 (95% CI, 0.33–0.92; P = .02).

Related articles:
Does the discontinuation of menopausal hormone therapy affect a woman’s cardiovascular risk?

Study strengths and weaknesses

The WHI represents the largest randomized placebo-controlled trials of HT. The current WHI trials report provides new, cumulative 18-year follow-up data on all-cause and cause-specific mortality in women treated with HT or placebo.

The authors noted, however, that the use of only one HT dose, formulation, and route of administration in each trial may limit the generalizability of the study results to other HT preparations. For example, the WHI did not examine the transdermal route of estrogen administration. Likewise, the WHI did not examine use of progestational agents other than medroxyprogesterone acetate. In addition, while almost all cohort deaths were captured through the National Death Index for the data analyses, specificity of cause of death may vary across outcomes. Further, since multiple outcomes and subgroups were examined, clinicians should interpret cause-specific mortality rates with caution.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

 A 2013 report from the Women’s Health Initiative (WHI), the large National Institutes of Health–funded placebo-controlledrandomized trial of postmenopausal hormone therapy (HT) with oral estrogen (for women with hysterectomy) or estrogen-progestin (for women with an intact uterus), with 13 years of cumulative follow-up, documented the safety of systemic HT when initiated by women younger than 60 years of age or within 10 years of menopause onset.¹ Now, with 18 years of cumulative follow-up data available (intervention and extended postintervention phases), the WHI investigators present all-cause and cause-specific mortality outcomes from the 2 HT trials.

Related article:
2017 Update on menopause

Details of the study

A total of 27,347 WHI participants (baseline mean age, 63.4 years; 80.6% white) used oral estrogen-progestin therapy (EPT) or placebo for a median of 5.6 years (n = 16,608) or estrogen-only therapy (ET) or placebo for a median of 7.2 years (n = 10,739). Each hazard ratio (HR) reported below refers to 18-year cumulative follow-up.

All-cause mortality. In the overall pooled cohort (EPT and ET groups), all-cause mortality was similar, with a rate of 27.1% in the HT group and 27.6% in the placebo group (HR, 0.99; 95% confidence interval [CI], 0.94–1.03). The mortality end points included deaths from all causes; cardiovascular disease (coronary heart disease, stroke, and other cardiovascular diseases); cancer (breast, colorectal, and other cancers); and other (Alzheimer disease, other dementia, chronic obstructive pulmonary disease, injuries and accidents, and other).

Stratifying by baseline participant age (comparing women aged 50–59 years with those aged 70–79 years), the HR for all-cause mortality in the pooled cohort during the intervention phase was 0.61 (95% CI, 0.43–0.87), and during the cumulative 18-year follow-up, the HR was 0.87 (95% CI, 0.76–1.00).

Cause-specific mortality. Neither cardiovascular disease mortality nor total cancer mortality was significantly impacted by HT use. In the pooled cohort, cardiovascular disease mortality was 8.9% in the HT group and 9.0% in the placebo group (HR, 1.00; 95% CI, 0.92–1.08), with no differences between the EPT and the ET trials. Cancer mortality rates in the pooled cohort also were similar, with 8.2% in the HT group and 8.0% in the placebo group (HR, 1.03; 95% CI, 0.95–1.12).

With respect to breast cancer mortality, the impact of HT diverged for EPT and ET. For the EPT group, the HR for breast cancer mortality was 1.44 (95% CI, 0.97–2.15; P = .07), while for the ET group the HR was 0.55 (95% CI, 0.33–0.92; P = .02).

Related articles:
Does the discontinuation of menopausal hormone therapy affect a woman’s cardiovascular risk?

Study strengths and weaknesses

The WHI represents the largest randomized placebo-controlled trials of HT. The current WHI trials report provides new, cumulative 18-year follow-up data on all-cause and cause-specific mortality in women treated with HT or placebo.

The authors noted, however, that the use of only one HT dose, formulation, and route of administration in each trial may limit the generalizability of the study results to other HT preparations. For example, the WHI did not examine the transdermal route of estrogen administration. Likewise, the WHI did not examine use of progestational agents other than medroxyprogesterone acetate. In addition, while almost all cohort deaths were captured through the National Death Index for the data analyses, specificity of cause of death may vary across outcomes. Further, since multiple outcomes and subgroups were examined, clinicians should interpret cause-specific mortality rates with caution.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

LONDON—Transient epileptic amnesia (TEA) does not appear to increase the risk of Alzheimer’s disease, according to a study presented at the 2017 Alzheimer’s Association International Conference. Persistent memory problems are common in patients with TEA, but the prevalence of dementia in these patients may not exceed that in the general population, the researchers noted.

TEA is a type of adult-onset temporal lobe epilepsy characterized by recurring amnestic seizures. Interictal memory deficits, such as autobiographic amnesia and accelerated long-term forgetting, are common. Short-term follow-up after initiating anticonvulsant medication suggests good seizure control and stable cognition. Recent case reports, however, have raised concerns that TEA may be a prodrome of Alzheimer’s disease.

Investigating Clinical and Cognitive Outcomes

To evaluate the basis for these concerns, Sharon A. Savage, PhD, Lecturer in Aging and Dementia at the University of Exeter Medical School in the United Kingdom, and colleagues investigated clinical and cognitive outcomes of patients with TEA over 10 to 20 years. They also assessed evidence of increased risk of Alzheimer’s disease.

The researchers studied two cohorts of patients with TEA. The first cohort included 10 patients followed up at 10 years and 20 years. The second cohort included 42 patients followed up at 10 years. At baseline, both cohorts were compared with age- and IQ-matched healthy controls. Researchers also recorded Alzheimer’s disease diagnoses among participants with TEA and compared the prevalence of Alzheimer’s disease in the study populations with published prevalence rates.

In a subset of patients, Dr. Savage and colleagues assessed cognitive ability using the National Adult Reading Test or the Wechsler Abbreviated Scale of Intelligence. They assessed objective memory using the Logical Memory story 1, Rey Complex Figure, and the Recognition Memory Test. Additional testing examined naming, verbal fluency, and problem solving.

Fifty patients completed neuropsychologic review (mean age at baseline, 66). At last follow-up, clinical information was available for nine patients from Cohort 1 and 37 patients from Cohort 2.

Controls Performed Similarly to TEA Cohorts

At 20 years, no cases of Alzheimer’s disease were reported in Cohort 1. One participant in that group developed vascular dementia, and four died. Four patients in Cohort 2 had Alzheimer’s disease at 10 years, and 15 patients died, including one patient with Alzheimer’s disease.

When TEA data were compared with data from healthy controls, general cognitive ability among patients with TEA was above average with no decline at 10 and 20 years. In addition, significant change from baseline was observed at 10 years for story recall, recognition memory, verbal fluency, and problem solving. Overall, approximately one-third of patients with TEA remained stable or improved on individual test scores at 10 years.

At 20 years, general cognitive ability remained above average for patients with TEA, compared with controls. Performance was not significantly reduced on more than one memory measure per participant.

Researchers concluded that memory problems may continue in TEA despite effective cessation of seizures. Some patients may remain stable over 10 to 20 years, and others may decline. Additional changes in executive function may also develop over time in some patients, the researchers added.

“The prognosis of TEA appears relatively benign,” said Dr. Savage and colleagues. Patients in both TEA cohorts performed similarly to healthy controls on the majority of tests. In addition, life expectancy did not appear to decrease, and seizures were generally well controlled.

—Erica Tricarico

LONDON—Transient epileptic amnesia (TEA) does not appear to increase the risk of Alzheimer’s disease, according to a study presented at the 2017 Alzheimer’s Association International Conference. Persistent memory problems are common in patients with TEA, but the prevalence of dementia in these patients may not exceed that in the general population, the researchers noted.

TEA is a type of adult-onset temporal lobe epilepsy characterized by recurring amnestic seizures. Interictal memory deficits, such as autobiographic amnesia and accelerated long-term forgetting, are common. Short-term follow-up after initiating anticonvulsant medication suggests good seizure control and stable cognition. Recent case reports, however, have raised concerns that TEA may be a prodrome of Alzheimer’s disease.

Investigating Clinical and Cognitive Outcomes

To evaluate the basis for these concerns, Sharon A. Savage, PhD, Lecturer in Aging and Dementia at the University of Exeter Medical School in the United Kingdom, and colleagues investigated clinical and cognitive outcomes of patients with TEA over 10 to 20 years. They also assessed evidence of increased risk of Alzheimer’s disease.

The researchers studied two cohorts of patients with TEA. The first cohort included 10 patients followed up at 10 years and 20 years. The second cohort included 42 patients followed up at 10 years. At baseline, both cohorts were compared with age- and IQ-matched healthy controls. Researchers also recorded Alzheimer’s disease diagnoses among participants with TEA and compared the prevalence of Alzheimer’s disease in the study populations with published prevalence rates.

In a subset of patients, Dr. Savage and colleagues assessed cognitive ability using the National Adult Reading Test or the Wechsler Abbreviated Scale of Intelligence. They assessed objective memory using the Logical Memory story 1, Rey Complex Figure, and the Recognition Memory Test. Additional testing examined naming, verbal fluency, and problem solving.

Fifty patients completed neuropsychologic review (mean age at baseline, 66). At last follow-up, clinical information was available for nine patients from Cohort 1 and 37 patients from Cohort 2.

Controls Performed Similarly to TEA Cohorts

At 20 years, no cases of Alzheimer’s disease were reported in Cohort 1. One participant in that group developed vascular dementia, and four died. Four patients in Cohort 2 had Alzheimer’s disease at 10 years, and 15 patients died, including one patient with Alzheimer’s disease.

When TEA data were compared with data from healthy controls, general cognitive ability among patients with TEA was above average with no decline at 10 and 20 years. In addition, significant change from baseline was observed at 10 years for story recall, recognition memory, verbal fluency, and problem solving. Overall, approximately one-third of patients with TEA remained stable or improved on individual test scores at 10 years.

At 20 years, general cognitive ability remained above average for patients with TEA, compared with controls. Performance was not significantly reduced on more than one memory measure per participant.

Researchers concluded that memory problems may continue in TEA despite effective cessation of seizures. Some patients may remain stable over 10 to 20 years, and others may decline. Additional changes in executive function may also develop over time in some patients, the researchers added.

“The prognosis of TEA appears relatively benign,” said Dr. Savage and colleagues. Patients in both TEA cohorts performed similarly to healthy controls on the majority of tests. In addition, life expectancy did not appear to decrease, and seizures were generally well controlled.

—Erica Tricarico

LONDON—Transient epileptic amnesia (TEA) does not appear to increase the risk of Alzheimer’s disease, according to a study presented at the 2017 Alzheimer’s Association International Conference. Persistent memory problems are common in patients with TEA, but the prevalence of dementia in these patients may not exceed that in the general population, the researchers noted.

TEA is a type of adult-onset temporal lobe epilepsy characterized by recurring amnestic seizures. Interictal memory deficits, such as autobiographic amnesia and accelerated long-term forgetting, are common. Short-term follow-up after initiating anticonvulsant medication suggests good seizure control and stable cognition. Recent case reports, however, have raised concerns that TEA may be a prodrome of Alzheimer’s disease.

Investigating Clinical and Cognitive Outcomes

To evaluate the basis for these concerns, Sharon A. Savage, PhD, Lecturer in Aging and Dementia at the University of Exeter Medical School in the United Kingdom, and colleagues investigated clinical and cognitive outcomes of patients with TEA over 10 to 20 years. They also assessed evidence of increased risk of Alzheimer’s disease.

The researchers studied two cohorts of patients with TEA. The first cohort included 10 patients followed up at 10 years and 20 years. The second cohort included 42 patients followed up at 10 years. At baseline, both cohorts were compared with age- and IQ-matched healthy controls. Researchers also recorded Alzheimer’s disease diagnoses among participants with TEA and compared the prevalence of Alzheimer’s disease in the study populations with published prevalence rates.

In a subset of patients, Dr. Savage and colleagues assessed cognitive ability using the National Adult Reading Test or the Wechsler Abbreviated Scale of Intelligence. They assessed objective memory using the Logical Memory story 1, Rey Complex Figure, and the Recognition Memory Test. Additional testing examined naming, verbal fluency, and problem solving.

Fifty patients completed neuropsychologic review (mean age at baseline, 66). At last follow-up, clinical information was available for nine patients from Cohort 1 and 37 patients from Cohort 2.

Controls Performed Similarly to TEA Cohorts

At 20 years, no cases of Alzheimer’s disease were reported in Cohort 1. One participant in that group developed vascular dementia, and four died. Four patients in Cohort 2 had Alzheimer’s disease at 10 years, and 15 patients died, including one patient with Alzheimer’s disease.

When TEA data were compared with data from healthy controls, general cognitive ability among patients with TEA was above average with no decline at 10 and 20 years. In addition, significant change from baseline was observed at 10 years for story recall, recognition memory, verbal fluency, and problem solving. Overall, approximately one-third of patients with TEA remained stable or improved on individual test scores at 10 years.

At 20 years, general cognitive ability remained above average for patients with TEA, compared with controls. Performance was not significantly reduced on more than one memory measure per participant.

Researchers concluded that memory problems may continue in TEA despite effective cessation of seizures. Some patients may remain stable over 10 to 20 years, and others may decline. Additional changes in executive function may also develop over time in some patients, the researchers added.

“The prognosis of TEA appears relatively benign,” said Dr. Savage and colleagues. Patients in both TEA cohorts performed similarly to healthy controls on the majority of tests. In addition, life expectancy did not appear to decrease, and seizures were generally well controlled.

—Erica Tricarico

Endoscopists who performed endoscopic retrograde cholangiopancreatography (ERCP) at high-volume centers had a 60% greater odds of procedure success compared with those at low-volume centers, according to the results of a systematic review and meta-analysis.

High-volume endoscopists also had a 30% lower odds of performing ERCP that led to adverse events such as pancreatitis, perforation, and bleeding, reported Rajesh N. Keswani, MD, MS, of Northwestern University, Chicago, and his associates. High-volume centers themselves also were associated with a significantly higher odds of successful ERCP (odds ratio, 2.0; 95% CI, 1.6 to 2.5), although they were not associated with a significantly lower risk of adverse events, the reviewers wrote. The study was published in the December issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.06.002).

Diagnostic ERCP has fallen sevenfold in the past 30 years while therapeutic use has increased 30-fold, the researchers noted. Therapeutic use spans several complex pancreaticobiliary conditions, including chronic pancreatitis, malignant jaundice, and complications of liver transplantation. This shift from diagnostic to therapeutic has naturally increased the complexity of ERCP, the need for expert endoscopy, and the potential risk of adverse events. “As health care continues to shift toward rewarding value rather than volume, it will be increasingly important to deliver care that is effective and efficient,” the reviewers wrote. “Thus, understanding factors associated with unsuccessful interventions, such as a failed ERCP, will be of critical importance to payers and patients (Clin Gastroenterol Hepatol. 2017 Jun 7;218:237-45).

Therefore, they searched MEDLINE, EMBASE, and the Cochrane register of controlled trials for prospective and retrospective studies published through January 2017. In all, the researchers identified 13 studies that stratified outcomes by volume per endoscopist or center. These studies comprised 59,437 procedures and patients. Definitions of low volume varied by study, ranging from less than 25 to less than 156 annual ERCPs per endoscopist and from less than 87 to less than 200 annual ERCPs per center. Endoscopists who achieved this threshold were significantly more likely to perform successful ERCPs than were low-volume endoscopists (OR, 1.6; 95% CI, 1.2 to 2.1), and were significantly less likely to have patients develop pancreatitis, perforation, or bleeding after ERCP (OR, 0.7; 95% CI, 0.5 to 0.8).

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

“Given these compelling findings, we propose that providers and payers consider consolidating ERCP to high-volume endoscopists and centers to improve ERCP outcomes and value,” the reviewers wrote. Minimum thresholds for endoscopists and centers to maintain ERCP skills and optimize outcomes have not been defined, they noted. Intuitively, there is no “critical volume threshold” at which “outcomes suddenly improve,” but the studies in this analysis used widely varying definitions of low volume, they added. It also remains unclear whether a low-volume endoscopist can achieve optimal outcomes at a high-volume center, or vice versa, they said. They recommended studies to better define procedure success and the appropriate use of ERCP in therapeutic settings.

One reviewer acknowledged support from the University of Colorado Department of Medicine Outstanding Early Career Faculty Program. The reviewers reported having no conflicts of interest.

Endoscopists who performed endoscopic retrograde cholangiopancreatography (ERCP) at high-volume centers had a 60% greater odds of procedure success compared with those at low-volume centers, according to the results of a systematic review and meta-analysis.

High-volume endoscopists also had a 30% lower odds of performing ERCP that led to adverse events such as pancreatitis, perforation, and bleeding, reported Rajesh N. Keswani, MD, MS, of Northwestern University, Chicago, and his associates. High-volume centers themselves also were associated with a significantly higher odds of successful ERCP (odds ratio, 2.0; 95% CI, 1.6 to 2.5), although they were not associated with a significantly lower risk of adverse events, the reviewers wrote. The study was published in the December issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.06.002).

Diagnostic ERCP has fallen sevenfold in the past 30 years while therapeutic use has increased 30-fold, the researchers noted. Therapeutic use spans several complex pancreaticobiliary conditions, including chronic pancreatitis, malignant jaundice, and complications of liver transplantation. This shift from diagnostic to therapeutic has naturally increased the complexity of ERCP, the need for expert endoscopy, and the potential risk of adverse events. “As health care continues to shift toward rewarding value rather than volume, it will be increasingly important to deliver care that is effective and efficient,” the reviewers wrote. “Thus, understanding factors associated with unsuccessful interventions, such as a failed ERCP, will be of critical importance to payers and patients (Clin Gastroenterol Hepatol. 2017 Jun 7;218:237-45).

Therefore, they searched MEDLINE, EMBASE, and the Cochrane register of controlled trials for prospective and retrospective studies published through January 2017. In all, the researchers identified 13 studies that stratified outcomes by volume per endoscopist or center. These studies comprised 59,437 procedures and patients. Definitions of low volume varied by study, ranging from less than 25 to less than 156 annual ERCPs per endoscopist and from less than 87 to less than 200 annual ERCPs per center. Endoscopists who achieved this threshold were significantly more likely to perform successful ERCPs than were low-volume endoscopists (OR, 1.6; 95% CI, 1.2 to 2.1), and were significantly less likely to have patients develop pancreatitis, perforation, or bleeding after ERCP (OR, 0.7; 95% CI, 0.5 to 0.8).

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

“Given these compelling findings, we propose that providers and payers consider consolidating ERCP to high-volume endoscopists and centers to improve ERCP outcomes and value,” the reviewers wrote. Minimum thresholds for endoscopists and centers to maintain ERCP skills and optimize outcomes have not been defined, they noted. Intuitively, there is no “critical volume threshold” at which “outcomes suddenly improve,” but the studies in this analysis used widely varying definitions of low volume, they added. It also remains unclear whether a low-volume endoscopist can achieve optimal outcomes at a high-volume center, or vice versa, they said. They recommended studies to better define procedure success and the appropriate use of ERCP in therapeutic settings.

One reviewer acknowledged support from the University of Colorado Department of Medicine Outstanding Early Career Faculty Program. The reviewers reported having no conflicts of interest.

Endoscopists who performed endoscopic retrograde cholangiopancreatography (ERCP) at high-volume centers had a 60% greater odds of procedure success compared with those at low-volume centers, according to the results of a systematic review and meta-analysis.

High-volume endoscopists also had a 30% lower odds of performing ERCP that led to adverse events such as pancreatitis, perforation, and bleeding, reported Rajesh N. Keswani, MD, MS, of Northwestern University, Chicago, and his associates. High-volume centers themselves also were associated with a significantly higher odds of successful ERCP (odds ratio, 2.0; 95% CI, 1.6 to 2.5), although they were not associated with a significantly lower risk of adverse events, the reviewers wrote. The study was published in the December issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.06.002).

Diagnostic ERCP has fallen sevenfold in the past 30 years while therapeutic use has increased 30-fold, the researchers noted. Therapeutic use spans several complex pancreaticobiliary conditions, including chronic pancreatitis, malignant jaundice, and complications of liver transplantation. This shift from diagnostic to therapeutic has naturally increased the complexity of ERCP, the need for expert endoscopy, and the potential risk of adverse events. “As health care continues to shift toward rewarding value rather than volume, it will be increasingly important to deliver care that is effective and efficient,” the reviewers wrote. “Thus, understanding factors associated with unsuccessful interventions, such as a failed ERCP, will be of critical importance to payers and patients (Clin Gastroenterol Hepatol. 2017 Jun 7;218:237-45).

Therefore, they searched MEDLINE, EMBASE, and the Cochrane register of controlled trials for prospective and retrospective studies published through January 2017. In all, the researchers identified 13 studies that stratified outcomes by volume per endoscopist or center. These studies comprised 59,437 procedures and patients. Definitions of low volume varied by study, ranging from less than 25 to less than 156 annual ERCPs per endoscopist and from less than 87 to less than 200 annual ERCPs per center. Endoscopists who achieved this threshold were significantly more likely to perform successful ERCPs than were low-volume endoscopists (OR, 1.6; 95% CI, 1.2 to 2.1), and were significantly less likely to have patients develop pancreatitis, perforation, or bleeding after ERCP (OR, 0.7; 95% CI, 0.5 to 0.8).

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

“Given these compelling findings, we propose that providers and payers consider consolidating ERCP to high-volume endoscopists and centers to improve ERCP outcomes and value,” the reviewers wrote. Minimum thresholds for endoscopists and centers to maintain ERCP skills and optimize outcomes have not been defined, they noted. Intuitively, there is no “critical volume threshold” at which “outcomes suddenly improve,” but the studies in this analysis used widely varying definitions of low volume, they added. It also remains unclear whether a low-volume endoscopist can achieve optimal outcomes at a high-volume center, or vice versa, they said. They recommended studies to better define procedure success and the appropriate use of ERCP in therapeutic settings.

One reviewer acknowledged support from the University of Colorado Department of Medicine Outstanding Early Career Faculty Program. The reviewers reported having no conflicts of interest.

ORLANDO – Probiotics are safe and effective for treating functional abdominal pain in children, based on findings from a meta-analysis of 11 randomized studies with a total of 790 patients.

“We think there is pretty strong evidence” for the efficacy of probiotics, and “by any analysis you can throw at them probiotics are safe,” Gordon Morris, MD, said at the World Congress of Gastroenterology at ACG 2017. “The evidence is of moderate and high quality,” added Dr. Morris, a pediatric gastroenterologist at the University of Central Lancashire in Preston, England.

The most widely studied probiotic in the analysis was Lactobacillus reuteri, used in six of the studies with a total of 405 randomized patients. The next most commonly studied agent was Lactobacillus rhamnosus GG, the focus of four studies and tested in a total of 270 randomized patients. Both microbes showed statistically significant and clinically meaningful levels of pain reduction when compared with placebo in subgroup analyses, said Dr. Morris, who performed the meta-analysis as a Cochrane Review Groups systematic review.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

ORLANDO – Probiotics are safe and effective for treating functional abdominal pain in children, based on findings from a meta-analysis of 11 randomized studies with a total of 790 patients.

“We think there is pretty strong evidence” for the efficacy of probiotics, and “by any analysis you can throw at them probiotics are safe,” Gordon Morris, MD, said at the World Congress of Gastroenterology at ACG 2017. “The evidence is of moderate and high quality,” added Dr. Morris, a pediatric gastroenterologist at the University of Central Lancashire in Preston, England.

The most widely studied probiotic in the analysis was Lactobacillus reuteri, used in six of the studies with a total of 405 randomized patients. The next most commonly studied agent was Lactobacillus rhamnosus GG, the focus of four studies and tested in a total of 270 randomized patients. Both microbes showed statistically significant and clinically meaningful levels of pain reduction when compared with placebo in subgroup analyses, said Dr. Morris, who performed the meta-analysis as a Cochrane Review Groups systematic review.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

ORLANDO – Probiotics are safe and effective for treating functional abdominal pain in children, based on findings from a meta-analysis of 11 randomized studies with a total of 790 patients.

“We think there is pretty strong evidence” for the efficacy of probiotics, and “by any analysis you can throw at them probiotics are safe,” Gordon Morris, MD, said at the World Congress of Gastroenterology at ACG 2017. “The evidence is of moderate and high quality,” added Dr. Morris, a pediatric gastroenterologist at the University of Central Lancashire in Preston, England.

The most widely studied probiotic in the analysis was Lactobacillus reuteri, used in six of the studies with a total of 405 randomized patients. The next most commonly studied agent was Lactobacillus rhamnosus GG, the focus of four studies and tested in a total of 270 randomized patients. Both microbes showed statistically significant and clinically meaningful levels of pain reduction when compared with placebo in subgroup analyses, said Dr. Morris, who performed the meta-analysis as a Cochrane Review Groups systematic review.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

NIPT SCREENING FOR TWIN ZYGOSITY AND GENETIC RISK FACTORS

Building on its history as the only NIPT that can differentiate between the mother’s and the baby’s DNA, Panorama is now also the only NIPT to distinguish between each twin’s DNA, says Natera. Panorama’s unique technology enables it to determine zygosity and each twin’s gender while also allowing it to identify risk for more genetic conditions in twin pregnancies than other NIPTs, including monosomy X, sex chromosome trisomies, and 22q11.2 deletion syndrome.

FOR MORE INFORMATION, VISIT: http://www.panoramatest.com/panorama-test/

NEW DRUG FOR TREATING BACTERIAL VAGINOSIS

Symbiomix Therapeutics reported that FDA approval was supported by comprehensive studies that found the single-dose secnidazole 2g was efficacious. All treatment-emergent adverse effects were mild or moderate in intensity; no serious adverse events were reported. Solosec will be available to patients in the first quarter of 2018.

FOR MORE INFORMATION, VISIT: https://symbiomix.com/sym-1219/

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

NIPT SCREENING FOR TWIN ZYGOSITY AND GENETIC RISK FACTORS

Building on its history as the only NIPT that can differentiate between the mother’s and the baby’s DNA, Panorama is now also the only NIPT to distinguish between each twin’s DNA, says Natera. Panorama’s unique technology enables it to determine zygosity and each twin’s gender while also allowing it to identify risk for more genetic conditions in twin pregnancies than other NIPTs, including monosomy X, sex chromosome trisomies, and 22q11.2 deletion syndrome.

FOR MORE INFORMATION, VISIT: http://www.panoramatest.com/panorama-test/

NEW DRUG FOR TREATING BACTERIAL VAGINOSIS

Symbiomix Therapeutics reported that FDA approval was supported by comprehensive studies that found the single-dose secnidazole 2g was efficacious. All treatment-emergent adverse effects were mild or moderate in intensity; no serious adverse events were reported. Solosec will be available to patients in the first quarter of 2018.

FOR MORE INFORMATION, VISIT: https://symbiomix.com/sym-1219/

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

NIPT SCREENING FOR TWIN ZYGOSITY AND GENETIC RISK FACTORS

Building on its history as the only NIPT that can differentiate between the mother’s and the baby’s DNA, Panorama is now also the only NIPT to distinguish between each twin’s DNA, says Natera. Panorama’s unique technology enables it to determine zygosity and each twin’s gender while also allowing it to identify risk for more genetic conditions in twin pregnancies than other NIPTs, including monosomy X, sex chromosome trisomies, and 22q11.2 deletion syndrome.

FOR MORE INFORMATION, VISIT: http://www.panoramatest.com/panorama-test/

NEW DRUG FOR TREATING BACTERIAL VAGINOSIS

Symbiomix Therapeutics reported that FDA approval was supported by comprehensive studies that found the single-dose secnidazole 2g was efficacious. All treatment-emergent adverse effects were mild or moderate in intensity; no serious adverse events were reported. Solosec will be available to patients in the first quarter of 2018.

FOR MORE INFORMATION, VISIT: https://symbiomix.com/sym-1219/

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

ORLANDO – Evidence supports “backing off” from screening colonoscopies every 5 years for patients who had one or two nonadvanced adenomas removed during a prior colonoscopy, Thomas F. Imperiale, MD, AGAF, said at the World Congress of Gastroenterology at ACG 2017.

He reported findings from more than 66,000 U.S. veterans followed at any one of 13 Veterans Affairs medical centers for an average of more than 7 years. The 10,220 patients who underwent a second screening colonoscopy after an index colonoscopy that led to removal of one or two nonadvanced adenomas had 0.16% colorectal cancer mortality, compared with 0.13% among 8,718 patients with a similar history who did not receive follow-up colonoscopy. The rate of colorectal cancer death was 0.12% among 47,629 control veterans who had no adenomas removed during their index colonoscopy.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

ORLANDO – Evidence supports “backing off” from screening colonoscopies every 5 years for patients who had one or two nonadvanced adenomas removed during a prior colonoscopy, Thomas F. Imperiale, MD, AGAF, said at the World Congress of Gastroenterology at ACG 2017.

He reported findings from more than 66,000 U.S. veterans followed at any one of 13 Veterans Affairs medical centers for an average of more than 7 years. The 10,220 patients who underwent a second screening colonoscopy after an index colonoscopy that led to removal of one or two nonadvanced adenomas had 0.16% colorectal cancer mortality, compared with 0.13% among 8,718 patients with a similar history who did not receive follow-up colonoscopy. The rate of colorectal cancer death was 0.12% among 47,629 control veterans who had no adenomas removed during their index colonoscopy.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

ORLANDO – Evidence supports “backing off” from screening colonoscopies every 5 years for patients who had one or two nonadvanced adenomas removed during a prior colonoscopy, Thomas F. Imperiale, MD, AGAF, said at the World Congress of Gastroenterology at ACG 2017.

He reported findings from more than 66,000 U.S. veterans followed at any one of 13 Veterans Affairs medical centers for an average of more than 7 years. The 10,220 patients who underwent a second screening colonoscopy after an index colonoscopy that led to removal of one or two nonadvanced adenomas had 0.16% colorectal cancer mortality, compared with 0.13% among 8,718 patients with a similar history who did not receive follow-up colonoscopy. The rate of colorectal cancer death was 0.12% among 47,629 control veterans who had no adenomas removed during their index colonoscopy.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

Click here to download the PDF.

Click here to download the PDF.

Click here to download the PDF.

A risk score based on EEG variables and seizure history may quickly and accurately aid clinical judgment of seizure risk in patients who are critically ill, according to research published online ahead of print October 9 in JAMA Neurology.

Studies have detected a high incidence of subclinical seizures in patients with sepsis, traumatic brain injury, and other conditions, but no simple, validated method exists to assess a patient’s seizure risk using a combination of factors. Aaron F. Struck, MD, Assistant Professor of Neurology at the University of Wisconsin in Madison, and colleagues sought to create a simple scoring system associated with the probability of seizures in patients with acute illness.

Data From Three Centers

The investigators created the scoring system using data from a multicenter prospective database. The database included clinical and electrographic variables from patients who had more than six hours of uninterrupted EEG recordings for clinical indications other than epilepsy monitoring unit admissions. The continuous EEG sessions were recorded at Emory University Hospital in Atlanta, Brigham and Women’s Hospital in Boston, and Yale New Haven Hospital in Connecticut. In all, 5,427 continuous EEGs were performed on 4,772 patients (49.9% men; median age, 61).

To build their scoring model, the investigators used a machine-learning method, Risk-Calibrated Supersparse Linear Integer Model (RiskSLIM), that considered 24 candidate variables. The researchers used cross-validation to validate the model’s accuracy and risk calibration.

The final model, which the researchers called 2HELPS2B, had an area under the curve of 0.819 and an average calibration error of 2.7%. A patient’s score ranges from 0–7 and is based on the following six variables:

• brief (ictal) rhythmic discharges (B[I]RDS) (2 points)
• presence of lateralized periodic discharges, lateralized rhythmic delta activity, or bilateral independent periodic discharges (1 point)
• prior seizure (1 point)
• sporadic epileptiform discharges (1 point)
• frequency greater than 2.0 Hz for any periodic or rhythmic pattern (1 point)
• presence of “plus” features (ie, superimposed, rhythmic, sharp, or fast activity) (1 point).

The seizure risk associated with each score from 0–5 was 5%, 12%, 27%, 50%, 73%, and 88%, respectively. For a score of 6 or 7, the probable seizure risk was greater than 95%.

The large sample size and use of data from multiple centers are among the study’s strengths. Limitations of the study include that duration of EEG was not included in the database, and that no sessions of less than six hours were included in the study.

“The 2HELPS2B score is an easy-to-use tool to augment clinical judgment of the risk for seizures in individual patients,” Dr. Struck and colleagues said. “The simplicity of the system allows for easy integration into clinical workflow. With increasing familiarity, 2HELPS2B will improve communication between EEG interpreters and clinicians through the use of a quickly comprehensible single number to describe seizure risk for patients on continuous EEG.”

Questions Remain

The investigators designed “a simple scale with good accuracy, which can be easily used by clinicians to estimate seizure risk in their patients,” said Barry M. Czeisler, MD, Assistant Professor of Neurology and Neurosurgery at New York University School of Medicine, and Jan Claassen, MD, PhD, Associate Professor of Neurology at Columbia University College of Physicians and Surgeons in New York, in an accompanying editorial. Still, the score is unvalidated for prediction based on less than six hours of EEG recordings and should be validated in prospective studies, they said.

A seizure risk scale has the potential to inform clinical practice. “Certain patients may not need to stay on continuous EEG for a long time if their seizure risk is low,” but an acceptable level of risk remains unclear, said Drs. Czeisler and Claassen. In addition, the score potentially could guide which patterns of features warrant more aggressive treatment, such as with additional antiepileptic medication. “Appropriate risk stratification using 2HELPS2B may allow us to answer these questions adequately in the near future,” they said. “The development of adequate measurement tools is often necessary to appropriately study a condition, which in turn may allow for future optimization of treatment algorithms.”

—Jake Remaly

Suggested Reading

Czeisler BM, Claassen J. A novel clinical score to assess seizure risk. JAMA Neurology. 2017 Oct 9 [Epub ahead of print].

Struck AF, Ustun B, Rodriguez Ruiz A, et al. Association of an electroencephalography-based risk score with seizure probability in hospitalized patients. JAMA Neurology. 2017 Oct 9 [Epub ahead of print].

A risk score based on EEG variables and seizure history may quickly and accurately aid clinical judgment of seizure risk in patients who are critically ill, according to research published online ahead of print October 9 in JAMA Neurology.

Studies have detected a high incidence of subclinical seizures in patients with sepsis, traumatic brain injury, and other conditions, but no simple, validated method exists to assess a patient’s seizure risk using a combination of factors. Aaron F. Struck, MD, Assistant Professor of Neurology at the University of Wisconsin in Madison, and colleagues sought to create a simple scoring system associated with the probability of seizures in patients with acute illness.

Data From Three Centers

The investigators created the scoring system using data from a multicenter prospective database. The database included clinical and electrographic variables from patients who had more than six hours of uninterrupted EEG recordings for clinical indications other than epilepsy monitoring unit admissions. The continuous EEG sessions were recorded at Emory University Hospital in Atlanta, Brigham and Women’s Hospital in Boston, and Yale New Haven Hospital in Connecticut. In all, 5,427 continuous EEGs were performed on 4,772 patients (49.9% men; median age, 61).

To build their scoring model, the investigators used a machine-learning method, Risk-Calibrated Supersparse Linear Integer Model (RiskSLIM), that considered 24 candidate variables. The researchers used cross-validation to validate the model’s accuracy and risk calibration.

The final model, which the researchers called 2HELPS2B, had an area under the curve of 0.819 and an average calibration error of 2.7%. A patient’s score ranges from 0–7 and is based on the following six variables:

• brief (ictal) rhythmic discharges (B[I]RDS) (2 points)
• presence of lateralized periodic discharges, lateralized rhythmic delta activity, or bilateral independent periodic discharges (1 point)
• prior seizure (1 point)
• sporadic epileptiform discharges (1 point)
• frequency greater than 2.0 Hz for any periodic or rhythmic pattern (1 point)
• presence of “plus” features (ie, superimposed, rhythmic, sharp, or fast activity) (1 point).

The seizure risk associated with each score from 0–5 was 5%, 12%, 27%, 50%, 73%, and 88%, respectively. For a score of 6 or 7, the probable seizure risk was greater than 95%.

The large sample size and use of data from multiple centers are among the study’s strengths. Limitations of the study include that duration of EEG was not included in the database, and that no sessions of less than six hours were included in the study.

“The 2HELPS2B score is an easy-to-use tool to augment clinical judgment of the risk for seizures in individual patients,” Dr. Struck and colleagues said. “The simplicity of the system allows for easy integration into clinical workflow. With increasing familiarity, 2HELPS2B will improve communication between EEG interpreters and clinicians through the use of a quickly comprehensible single number to describe seizure risk for patients on continuous EEG.”

Questions Remain

The investigators designed “a simple scale with good accuracy, which can be easily used by clinicians to estimate seizure risk in their patients,” said Barry M. Czeisler, MD, Assistant Professor of Neurology and Neurosurgery at New York University School of Medicine, and Jan Claassen, MD, PhD, Associate Professor of Neurology at Columbia University College of Physicians and Surgeons in New York, in an accompanying editorial. Still, the score is unvalidated for prediction based on less than six hours of EEG recordings and should be validated in prospective studies, they said.

A seizure risk scale has the potential to inform clinical practice. “Certain patients may not need to stay on continuous EEG for a long time if their seizure risk is low,” but an acceptable level of risk remains unclear, said Drs. Czeisler and Claassen. In addition, the score potentially could guide which patterns of features warrant more aggressive treatment, such as with additional antiepileptic medication. “Appropriate risk stratification using 2HELPS2B may allow us to answer these questions adequately in the near future,” they said. “The development of adequate measurement tools is often necessary to appropriately study a condition, which in turn may allow for future optimization of treatment algorithms.”

—Jake Remaly

Suggested Reading

Czeisler BM, Claassen J. A novel clinical score to assess seizure risk. JAMA Neurology. 2017 Oct 9 [Epub ahead of print].

Struck AF, Ustun B, Rodriguez Ruiz A, et al. Association of an electroencephalography-based risk score with seizure probability in hospitalized patients. JAMA Neurology. 2017 Oct 9 [Epub ahead of print].

A risk score based on EEG variables and seizure history may quickly and accurately aid clinical judgment of seizure risk in patients who are critically ill, according to research published online ahead of print October 9 in JAMA Neurology.

Studies have detected a high incidence of subclinical seizures in patients with sepsis, traumatic brain injury, and other conditions, but no simple, validated method exists to assess a patient’s seizure risk using a combination of factors. Aaron F. Struck, MD, Assistant Professor of Neurology at the University of Wisconsin in Madison, and colleagues sought to create a simple scoring system associated with the probability of seizures in patients with acute illness.

Data From Three Centers

The investigators created the scoring system using data from a multicenter prospective database. The database included clinical and electrographic variables from patients who had more than six hours of uninterrupted EEG recordings for clinical indications other than epilepsy monitoring unit admissions. The continuous EEG sessions were recorded at Emory University Hospital in Atlanta, Brigham and Women’s Hospital in Boston, and Yale New Haven Hospital in Connecticut. In all, 5,427 continuous EEGs were performed on 4,772 patients (49.9% men; median age, 61).

To build their scoring model, the investigators used a machine-learning method, Risk-Calibrated Supersparse Linear Integer Model (RiskSLIM), that considered 24 candidate variables. The researchers used cross-validation to validate the model’s accuracy and risk calibration.

The final model, which the researchers called 2HELPS2B, had an area under the curve of 0.819 and an average calibration error of 2.7%. A patient’s score ranges from 0–7 and is based on the following six variables:

• brief (ictal) rhythmic discharges (B[I]RDS) (2 points)
• presence of lateralized periodic discharges, lateralized rhythmic delta activity, or bilateral independent periodic discharges (1 point)
• prior seizure (1 point)
• sporadic epileptiform discharges (1 point)
• frequency greater than 2.0 Hz for any periodic or rhythmic pattern (1 point)
• presence of “plus” features (ie, superimposed, rhythmic, sharp, or fast activity) (1 point).

The seizure risk associated with each score from 0–5 was 5%, 12%, 27%, 50%, 73%, and 88%, respectively. For a score of 6 or 7, the probable seizure risk was greater than 95%.

The large sample size and use of data from multiple centers are among the study’s strengths. Limitations of the study include that duration of EEG was not included in the database, and that no sessions of less than six hours were included in the study.

“The 2HELPS2B score is an easy-to-use tool to augment clinical judgment of the risk for seizures in individual patients,” Dr. Struck and colleagues said. “The simplicity of the system allows for easy integration into clinical workflow. With increasing familiarity, 2HELPS2B will improve communication between EEG interpreters and clinicians through the use of a quickly comprehensible single number to describe seizure risk for patients on continuous EEG.”

Questions Remain

The investigators designed “a simple scale with good accuracy, which can be easily used by clinicians to estimate seizure risk in their patients,” said Barry M. Czeisler, MD, Assistant Professor of Neurology and Neurosurgery at New York University School of Medicine, and Jan Claassen, MD, PhD, Associate Professor of Neurology at Columbia University College of Physicians and Surgeons in New York, in an accompanying editorial. Still, the score is unvalidated for prediction based on less than six hours of EEG recordings and should be validated in prospective studies, they said.

A seizure risk scale has the potential to inform clinical practice. “Certain patients may not need to stay on continuous EEG for a long time if their seizure risk is low,” but an acceptable level of risk remains unclear, said Drs. Czeisler and Claassen. In addition, the score potentially could guide which patterns of features warrant more aggressive treatment, such as with additional antiepileptic medication. “Appropriate risk stratification using 2HELPS2B may allow us to answer these questions adequately in the near future,” they said. “The development of adequate measurement tools is often necessary to appropriately study a condition, which in turn may allow for future optimization of treatment algorithms.”

—Jake Remaly

Suggested Reading

Czeisler BM, Claassen J. A novel clinical score to assess seizure risk. JAMA Neurology. 2017 Oct 9 [Epub ahead of print].

Struck AF, Ustun B, Rodriguez Ruiz A, et al. Association of an electroencephalography-based risk score with seizure probability in hospitalized patients. JAMA Neurology. 2017 Oct 9 [Epub ahead of print].

ORLANDO – Nearly half of U.S. gastroenterologists who responded to a recent survey had symptoms of burnout that seemed largely driven by work-life balance issues.

Burnout appeared to disproportionately affect younger gastroenterologists, those who spend more time on chores at home including caring for young children, physicians who were neutral toward or dissatisfied with a spouse or partner, and clinicians planning to soon leave their practice, Carol A. Burke, MD, said at the World Congress of Gastroenterology at ACG 2017.

Factors not linked with burnout included their type of practice, whether the gastroenterologists worked full or part time, their location, and their compensation, said Dr. Burke, director of the Center for Colon Polyp and Cancer Prevention at the Cleveland Clinic.

The life issues that appeared most strongly linked to burnout “speak to a problem for physicians to balance” their professional and personal lives, Dr. Burke said in a video interview. Several interventions exist that can potentially mitigate burnout, and the American College of Gastroenterology, which ran the survey, is taking steps to make information on these interventions available to members, noted Dr. Burke, the organization’s president.

Dr. Burke and her associates sent a 60-item survey to all 11,080 College members during 2014 and 2015 and received 1,021 replies including 754 fully completed responses. Their prespecified definition of burnout was a high score for emotional exhaustion or for depersonalization, or both, on the Maslach Burnout Inventory. The results showed that 45% of respondents had a high score for emotional exhaustion, 21% scored high on depersonalization, and overall 49% met the burnout criteria set by the investigators. The Inventory answers also showed that 18% had a low sense of personal accomplishment.

A multivariate analysis showed that significant links with burnout were younger age, more time spent on domestic chores, having a neutral or dissatisfying relationship with a spouse or partner, and plans for imminent retirement from gastroenterology practice, Dr. Burke reported.

The main reasons for planning imminent retirement were reimbursement, cited by 32% of this subgroup, regulations, cited by 21%, recertification, cited by 16%, and electronic medical records, cited by 10% as the main reason for leaving practice.

Strategies and resources aimed at better dealing with burnout were requested by 60% of all survey respondents, and the College is in the process of making these tools available, Dr. Burke said.

A recent study conducted by the AGA Institute Education and Training Committee and reported in AGA Perspectives supports these findings. Read more here and join the discussion on the AGA Community.

[email protected]

On Twitter @mitchelzoler

ORLANDO – Nearly half of U.S. gastroenterologists who responded to a recent survey had symptoms of burnout that seemed largely driven by work-life balance issues.

Burnout appeared to disproportionately affect younger gastroenterologists, those who spend more time on chores at home including caring for young children, physicians who were neutral toward or dissatisfied with a spouse or partner, and clinicians planning to soon leave their practice, Carol A. Burke, MD, said at the World Congress of Gastroenterology at ACG 2017.

Factors not linked with burnout included their type of practice, whether the gastroenterologists worked full or part time, their location, and their compensation, said Dr. Burke, director of the Center for Colon Polyp and Cancer Prevention at the Cleveland Clinic.

The life issues that appeared most strongly linked to burnout “speak to a problem for physicians to balance” their professional and personal lives, Dr. Burke said in a video interview. Several interventions exist that can potentially mitigate burnout, and the American College of Gastroenterology, which ran the survey, is taking steps to make information on these interventions available to members, noted Dr. Burke, the organization’s president.

Dr. Burke and her associates sent a 60-item survey to all 11,080 College members during 2014 and 2015 and received 1,021 replies including 754 fully completed responses. Their prespecified definition of burnout was a high score for emotional exhaustion or for depersonalization, or both, on the Maslach Burnout Inventory. The results showed that 45% of respondents had a high score for emotional exhaustion, 21% scored high on depersonalization, and overall 49% met the burnout criteria set by the investigators. The Inventory answers also showed that 18% had a low sense of personal accomplishment.

A multivariate analysis showed that significant links with burnout were younger age, more time spent on domestic chores, having a neutral or dissatisfying relationship with a spouse or partner, and plans for imminent retirement from gastroenterology practice, Dr. Burke reported.

The main reasons for planning imminent retirement were reimbursement, cited by 32% of this subgroup, regulations, cited by 21%, recertification, cited by 16%, and electronic medical records, cited by 10% as the main reason for leaving practice.

Strategies and resources aimed at better dealing with burnout were requested by 60% of all survey respondents, and the College is in the process of making these tools available, Dr. Burke said.

A recent study conducted by the AGA Institute Education and Training Committee and reported in AGA Perspectives supports these findings. Read more here and join the discussion on the AGA Community.

[email protected]

On Twitter @mitchelzoler

ORLANDO – Nearly half of U.S. gastroenterologists who responded to a recent survey had symptoms of burnout that seemed largely driven by work-life balance issues.

Burnout appeared to disproportionately affect younger gastroenterologists, those who spend more time on chores at home including caring for young children, physicians who were neutral toward or dissatisfied with a spouse or partner, and clinicians planning to soon leave their practice, Carol A. Burke, MD, said at the World Congress of Gastroenterology at ACG 2017.

Factors not linked with burnout included their type of practice, whether the gastroenterologists worked full or part time, their location, and their compensation, said Dr. Burke, director of the Center for Colon Polyp and Cancer Prevention at the Cleveland Clinic.

The life issues that appeared most strongly linked to burnout “speak to a problem for physicians to balance” their professional and personal lives, Dr. Burke said in a video interview. Several interventions exist that can potentially mitigate burnout, and the American College of Gastroenterology, which ran the survey, is taking steps to make information on these interventions available to members, noted Dr. Burke, the organization’s president.

Dr. Burke and her associates sent a 60-item survey to all 11,080 College members during 2014 and 2015 and received 1,021 replies including 754 fully completed responses. Their prespecified definition of burnout was a high score for emotional exhaustion or for depersonalization, or both, on the Maslach Burnout Inventory. The results showed that 45% of respondents had a high score for emotional exhaustion, 21% scored high on depersonalization, and overall 49% met the burnout criteria set by the investigators. The Inventory answers also showed that 18% had a low sense of personal accomplishment.

A multivariate analysis showed that significant links with burnout were younger age, more time spent on domestic chores, having a neutral or dissatisfying relationship with a spouse or partner, and plans for imminent retirement from gastroenterology practice, Dr. Burke reported.

The main reasons for planning imminent retirement were reimbursement, cited by 32% of this subgroup, regulations, cited by 21%, recertification, cited by 16%, and electronic medical records, cited by 10% as the main reason for leaving practice.

Strategies and resources aimed at better dealing with burnout were requested by 60% of all survey respondents, and the College is in the process of making these tools available, Dr. Burke said.

A recent study conducted by the AGA Institute Education and Training Committee and reported in AGA Perspectives supports these findings. Read more here and join the discussion on the AGA Community.

[email protected]

On Twitter @mitchelzoler

Detainee operations is a dark topic and one that often is avoided in the welcome home of veterans participating in detainee operations. Many veterans who have been involved have hidden these missions, fearing that they would be tarnished by past scandals. However, the burden of these detainee missions may contribute to depression, moral injury, and suicidal behaviors.

The recent conflicts in Afghanistan and Iraq have produced many opportunities for lessons on detainee operations. Unfortunately, often the lessons learned from one conflict have not been carried forward to the next. The scandals at the Abu Ghraib prison in Iraq and the continuing controversy over practices at Guantanamo Bay (GTMO) in Cuba illustrate these lapses. This column will not dwell on these issues but on what has been the psychological effects on U.S. service members of guarding and caring for detainees.

Background

Since 9/11, military service members have been involved in detainee operations in many roles, including at the point of capture (when the detainee is taken into custody), guarding the detainee; interrogating the detainee, and providing medical and psychological care.

Our service members have been woefully underprepared for these missions, and as a result may have faced adverse psychological consequences. The work is often dangerous and tedious. The following dangerous or frustrating examples are from my experiences:

• Correctional staff at GTMO had feces thrown at them;
• U.S. staff were targeted by rocket propelled grenades at Abu Ghraib and moved into jail cells for protection;
• Medical personnel at Camp Bucca in Iraq were attacked by the detainees who used hand sanitizer and latex gloves to make miniature fire balls;
• Insufficient medical equipment at Abu Ghraib and other facilities to care for detainees;
• An overall lack of perceived support from the medical and correctional chain of commands; and
• Numerous different chains of commands with different priorities, leading to a sense of chaos.

Corrections Overlap

There is overlap with traditional correctional medical care, including the care of prisoners in traditional jails and prisons. Likewise, there are similar issues with migrants from Central America and other regions who enter the country illegally and often are put into makeshift camps or overcrowded jails. However, there are key differences when treating detainees in facilities outside the U.S.

These differences include the cultural aspects in caring for detainees from the Middle East and elsewhere, large holding areas with 200 to 300 detainees, such as Camp Bucca and Abhu Ghraib, indefinite terms of confinement, such as at GTMO, and high-visibility political implications especially suicide attempts and interrogations.

There are many challenges to providing medical support in detainee operations that may have adverse psychological consequences. These include the following:

• Care for detainees when first captured;
• Fear of infectious diseases in detainees;
• Care for detainees in the correctional facilities in Abu Ghraib, GTMO, the Theater Internment Facility at Bagram Air Base Afghanistan; and other facilities;
• Involvement in force-feeding and during hunger strikes;
• Avoiding abuse of detainees by military staff;
• Providing psychological support to interrogation efforts often known as Behavioral Science Consultation Teams; and
• Challenges in treatment of complex medical and psychiatric conditions among detainees, which may include a limited formulary, lack of full medical equipment, and austere conditions.

Psychological Reactions

These challenges contribute to the development of negative psychological reactions, including posttramatic stress syndrome (PTSD) and moral injury, in medical and corrections staff. The negative view of the American public toward these correctional issues contributes to a sense of shame among those who have guarded or treated detainees.

One veteran who worked at GTMO and the jail in Bagram reported that 10 of his colleagues killed themselves. Although there is robust literature on suicides in army and other military personnel, I do not know of any studies that examine suicides specifically in detainee’s operational staff.^1,2 There have been analyses of the relationship between suicide and military occupational specialty (MOS).¹ However, personnel in detainee operations may come from many different disciplines, including medical, correctional, and others.

Again, data here are anecdotal, since there is no public information available. However, I was sent to Abu Ghraib and Camp Bucca in 2004 to evaluate these issues. I have been to GTMO 5 times. Thus, I have personal experience that in forms this column.

Although there are many books and manuals about treating PTSD and some literature about providing mental health care to detainees, there is little published about providing care to staff involved with detainee’s operations. I postulate that many staff will have shame, guilt, or moral injury, which leads to suicidal thoughts. Treatment thus needs to be supportive, whether with medications or psychotherapy.

Conclusion

All these issues should be considered by clinical staff who are caring for service members who have been involved in detainee operations. Veterans may not volunteer that they have been involved in these operations; it is important to ask.

Guilt and shame may be large components of the presenting psychological presentation. This may lead to moral injury. Careful exploration of depressive and suicidal thoughts with these patients is needed. An understanding of these challenges will help with clinical care.

Detainee operations is a dark topic and one that often is avoided in the welcome home of veterans participating in detainee operations. Many veterans who have been involved have hidden these missions, fearing that they would be tarnished by past scandals. However, the burden of these detainee missions may contribute to depression, moral injury, and suicidal behaviors.

The recent conflicts in Afghanistan and Iraq have produced many opportunities for lessons on detainee operations. Unfortunately, often the lessons learned from one conflict have not been carried forward to the next. The scandals at the Abu Ghraib prison in Iraq and the continuing controversy over practices at Guantanamo Bay (GTMO) in Cuba illustrate these lapses. This column will not dwell on these issues but on what has been the psychological effects on U.S. service members of guarding and caring for detainees.

Background

Since 9/11, military service members have been involved in detainee operations in many roles, including at the point of capture (when the detainee is taken into custody), guarding the detainee; interrogating the detainee, and providing medical and psychological care.

Our service members have been woefully underprepared for these missions, and as a result may have faced adverse psychological consequences. The work is often dangerous and tedious. The following dangerous or frustrating examples are from my experiences:

• Correctional staff at GTMO had feces thrown at them;
• U.S. staff were targeted by rocket propelled grenades at Abu Ghraib and moved into jail cells for protection;
• Medical personnel at Camp Bucca in Iraq were attacked by the detainees who used hand sanitizer and latex gloves to make miniature fire balls;
• Insufficient medical equipment at Abu Ghraib and other facilities to care for detainees;
• An overall lack of perceived support from the medical and correctional chain of commands; and
• Numerous different chains of commands with different priorities, leading to a sense of chaos.

Corrections Overlap

There is overlap with traditional correctional medical care, including the care of prisoners in traditional jails and prisons. Likewise, there are similar issues with migrants from Central America and other regions who enter the country illegally and often are put into makeshift camps or overcrowded jails. However, there are key differences when treating detainees in facilities outside the U.S.

These differences include the cultural aspects in caring for detainees from the Middle East and elsewhere, large holding areas with 200 to 300 detainees, such as Camp Bucca and Abhu Ghraib, indefinite terms of confinement, such as at GTMO, and high-visibility political implications especially suicide attempts and interrogations.

There are many challenges to providing medical support in detainee operations that may have adverse psychological consequences. These include the following:

• Care for detainees when first captured;
• Fear of infectious diseases in detainees;
• Care for detainees in the correctional facilities in Abu Ghraib, GTMO, the Theater Internment Facility at Bagram Air Base Afghanistan; and other facilities;
• Involvement in force-feeding and during hunger strikes;
• Avoiding abuse of detainees by military staff;
• Providing psychological support to interrogation efforts often known as Behavioral Science Consultation Teams; and
• Challenges in treatment of complex medical and psychiatric conditions among detainees, which may include a limited formulary, lack of full medical equipment, and austere conditions.

Psychological Reactions

These challenges contribute to the development of negative psychological reactions, including posttramatic stress syndrome (PTSD) and moral injury, in medical and corrections staff. The negative view of the American public toward these correctional issues contributes to a sense of shame among those who have guarded or treated detainees.

One veteran who worked at GTMO and the jail in Bagram reported that 10 of his colleagues killed themselves. Although there is robust literature on suicides in army and other military personnel, I do not know of any studies that examine suicides specifically in detainee’s operational staff.^1,2 There have been analyses of the relationship between suicide and military occupational specialty (MOS).¹ However, personnel in detainee operations may come from many different disciplines, including medical, correctional, and others.

Again, data here are anecdotal, since there is no public information available. However, I was sent to Abu Ghraib and Camp Bucca in 2004 to evaluate these issues. I have been to GTMO 5 times. Thus, I have personal experience that in forms this column.

Although there are many books and manuals about treating PTSD and some literature about providing mental health care to detainees, there is little published about providing care to staff involved with detainee’s operations. I postulate that many staff will have shame, guilt, or moral injury, which leads to suicidal thoughts. Treatment thus needs to be supportive, whether with medications or psychotherapy.

Conclusion

All these issues should be considered by clinical staff who are caring for service members who have been involved in detainee operations. Veterans may not volunteer that they have been involved in these operations; it is important to ask.

Guilt and shame may be large components of the presenting psychological presentation. This may lead to moral injury. Careful exploration of depressive and suicidal thoughts with these patients is needed. An understanding of these challenges will help with clinical care.

Detainee operations is a dark topic and one that often is avoided in the welcome home of veterans participating in detainee operations. Many veterans who have been involved have hidden these missions, fearing that they would be tarnished by past scandals. However, the burden of these detainee missions may contribute to depression, moral injury, and suicidal behaviors.

The recent conflicts in Afghanistan and Iraq have produced many opportunities for lessons on detainee operations. Unfortunately, often the lessons learned from one conflict have not been carried forward to the next. The scandals at the Abu Ghraib prison in Iraq and the continuing controversy over practices at Guantanamo Bay (GTMO) in Cuba illustrate these lapses. This column will not dwell on these issues but on what has been the psychological effects on U.S. service members of guarding and caring for detainees.

Background

Since 9/11, military service members have been involved in detainee operations in many roles, including at the point of capture (when the detainee is taken into custody), guarding the detainee; interrogating the detainee, and providing medical and psychological care.

Our service members have been woefully underprepared for these missions, and as a result may have faced adverse psychological consequences. The work is often dangerous and tedious. The following dangerous or frustrating examples are from my experiences:

• Correctional staff at GTMO had feces thrown at them;
• U.S. staff were targeted by rocket propelled grenades at Abu Ghraib and moved into jail cells for protection;
• Medical personnel at Camp Bucca in Iraq were attacked by the detainees who used hand sanitizer and latex gloves to make miniature fire balls;
• Insufficient medical equipment at Abu Ghraib and other facilities to care for detainees;
• An overall lack of perceived support from the medical and correctional chain of commands; and
• Numerous different chains of commands with different priorities, leading to a sense of chaos.

Corrections Overlap

There is overlap with traditional correctional medical care, including the care of prisoners in traditional jails and prisons. Likewise, there are similar issues with migrants from Central America and other regions who enter the country illegally and often are put into makeshift camps or overcrowded jails. However, there are key differences when treating detainees in facilities outside the U.S.

These differences include the cultural aspects in caring for detainees from the Middle East and elsewhere, large holding areas with 200 to 300 detainees, such as Camp Bucca and Abhu Ghraib, indefinite terms of confinement, such as at GTMO, and high-visibility political implications especially suicide attempts and interrogations.

There are many challenges to providing medical support in detainee operations that may have adverse psychological consequences. These include the following:

• Care for detainees when first captured;
• Fear of infectious diseases in detainees;
• Care for detainees in the correctional facilities in Abu Ghraib, GTMO, the Theater Internment Facility at Bagram Air Base Afghanistan; and other facilities;
• Involvement in force-feeding and during hunger strikes;
• Avoiding abuse of detainees by military staff;
• Providing psychological support to interrogation efforts often known as Behavioral Science Consultation Teams; and
• Challenges in treatment of complex medical and psychiatric conditions among detainees, which may include a limited formulary, lack of full medical equipment, and austere conditions.

Psychological Reactions

These challenges contribute to the development of negative psychological reactions, including posttramatic stress syndrome (PTSD) and moral injury, in medical and corrections staff. The negative view of the American public toward these correctional issues contributes to a sense of shame among those who have guarded or treated detainees.

One veteran who worked at GTMO and the jail in Bagram reported that 10 of his colleagues killed themselves. Although there is robust literature on suicides in army and other military personnel, I do not know of any studies that examine suicides specifically in detainee’s operational staff.^1,2 There have been analyses of the relationship between suicide and military occupational specialty (MOS).¹ However, personnel in detainee operations may come from many different disciplines, including medical, correctional, and others.

Again, data here are anecdotal, since there is no public information available. However, I was sent to Abu Ghraib and Camp Bucca in 2004 to evaluate these issues. I have been to GTMO 5 times. Thus, I have personal experience that in forms this column.

Although there are many books and manuals about treating PTSD and some literature about providing mental health care to detainees, there is little published about providing care to staff involved with detainee’s operations. I postulate that many staff will have shame, guilt, or moral injury, which leads to suicidal thoughts. Treatment thus needs to be supportive, whether with medications or psychotherapy.

Conclusion

All these issues should be considered by clinical staff who are caring for service members who have been involved in detainee operations. Veterans may not volunteer that they have been involved in these operations; it is important to ask.

Guilt and shame may be large components of the presenting psychological presentation. This may lead to moral injury. Careful exploration of depressive and suicidal thoughts with these patients is needed. An understanding of these challenges will help with clinical care.