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Measures needed to identify past pregnancy in transgender male blood donors
SAN DIEGO –
In study results presented at the annual meeting of the American Association of Blood Banks, 3% of transgender males who were identified as such reported a prior history of pregnancy. Importantly, this pregnancy history may not be divulged unless transgender males are asked “female” questions, said Kathleen M. Grima, MD, executive medical officer at the American Red Cross and medical director of the blood bank at the Brooklyn Hospital Center, New York.
Several studies have suggested that blood from ever-pregnant female donors can present increased risks to male recipients. Research also has suggested that antibodies or other immune system factors that women develop when pregnant could trigger transfusion-related acute lung injury (TRALI), a serious inflammatory reaction that can result in death, in male blood-transfusion recipients.
For this reason, it is important to have pregnancy histories from blood donors, and obtaining those histories from transgender males “presents a challenge for blood centers,” she said. “At our center, when a donor requests a gender change from female to male, an HLA test is requested for the next donation.” But as first-time donors are qualified based on their stated gender, transgender donors who have been pregnant will not be identified unless they volunteer the information or are asked about their pregnancy history.
The AABB recommends that a facility can perform HLA testing on all apheresis plasma donors and all whole blood donors whose units are intended for production into plasma components or, as an alternative, obtain a pregnancy history from all female donors and perform HLA typing only on women with a history of one or more full-term pregnancies.
Dr. Grima explained that, prior to the implementation of the Food and Drug Administration’s “final rule” on requirements for blood and blood components, blood centers asked donors to identify their birth gender to determine eligibility. If gender had changed, the donor was then asked to answer both the male and female questions. The FDA’s final rule now allows blood centers to accept the donor’s stated gender and eligibility can be determined based on that gender.
Dr. Grima and her colleagues conducted a review to determine the number of transgender males who were actively donating with a large blood center and to assess the risk of failing to ask a transgender male donor about pregnancy.
From 2013 to 2015, there were 121 female donors who had changed their gender to male and 60 male donors who had changed their gender to female. Of this group, seven (6%) transgender male donors (female at birth) stated at one of their donations that they had a pregnancy history; three were apheresis donors who had been tested for HLA antibodies (one was positive and two negative). The other four were whole blood donors and had not been tested.
After 2016, donors self-identified their gender, and 326 had requested a gender change from female to male. Of this group, 5 (1.5%) answered yes to pregnancy questions, 56 said no, and 265 did not respond.
“In our system, if a donor identifies as a male, then they only see male questions,” she pointed out. The center subsequently added in a test for HLA antibodies, and 101 donors were tested. Of this group, 13 (13%) tested positive; 2 had answered yes to pregnancy, 4 answered no, and 7 did not respond to the pregnancy question.
Combining the two cohorts, there were 447 transgender males who were identified; 12 (3%) responded yes to pregnancy, and 5 (1%) tested positive for HLA antibodies.
“We are continuing to add the HLA test,” said Dr. Grima. “I’m not sure this is the best [approach], but we will see over time.”
But if a donor comes in for the first time or identifies as a male or transgender male, they won’t be tested, and this is an opportunity that will be missed, she added. “Another option is to ask all donors if they have been pregnant or continue to ask donors their birth gender and then require that they answer both the male and female questions.”
Dr. Grima had no financial disclosures.
SAN DIEGO –
In study results presented at the annual meeting of the American Association of Blood Banks, 3% of transgender males who were identified as such reported a prior history of pregnancy. Importantly, this pregnancy history may not be divulged unless transgender males are asked “female” questions, said Kathleen M. Grima, MD, executive medical officer at the American Red Cross and medical director of the blood bank at the Brooklyn Hospital Center, New York.
Several studies have suggested that blood from ever-pregnant female donors can present increased risks to male recipients. Research also has suggested that antibodies or other immune system factors that women develop when pregnant could trigger transfusion-related acute lung injury (TRALI), a serious inflammatory reaction that can result in death, in male blood-transfusion recipients.
For this reason, it is important to have pregnancy histories from blood donors, and obtaining those histories from transgender males “presents a challenge for blood centers,” she said. “At our center, when a donor requests a gender change from female to male, an HLA test is requested for the next donation.” But as first-time donors are qualified based on their stated gender, transgender donors who have been pregnant will not be identified unless they volunteer the information or are asked about their pregnancy history.
The AABB recommends that a facility can perform HLA testing on all apheresis plasma donors and all whole blood donors whose units are intended for production into plasma components or, as an alternative, obtain a pregnancy history from all female donors and perform HLA typing only on women with a history of one or more full-term pregnancies.
Dr. Grima explained that, prior to the implementation of the Food and Drug Administration’s “final rule” on requirements for blood and blood components, blood centers asked donors to identify their birth gender to determine eligibility. If gender had changed, the donor was then asked to answer both the male and female questions. The FDA’s final rule now allows blood centers to accept the donor’s stated gender and eligibility can be determined based on that gender.
Dr. Grima and her colleagues conducted a review to determine the number of transgender males who were actively donating with a large blood center and to assess the risk of failing to ask a transgender male donor about pregnancy.
From 2013 to 2015, there were 121 female donors who had changed their gender to male and 60 male donors who had changed their gender to female. Of this group, seven (6%) transgender male donors (female at birth) stated at one of their donations that they had a pregnancy history; three were apheresis donors who had been tested for HLA antibodies (one was positive and two negative). The other four were whole blood donors and had not been tested.
After 2016, donors self-identified their gender, and 326 had requested a gender change from female to male. Of this group, 5 (1.5%) answered yes to pregnancy questions, 56 said no, and 265 did not respond.
“In our system, if a donor identifies as a male, then they only see male questions,” she pointed out. The center subsequently added in a test for HLA antibodies, and 101 donors were tested. Of this group, 13 (13%) tested positive; 2 had answered yes to pregnancy, 4 answered no, and 7 did not respond to the pregnancy question.
Combining the two cohorts, there were 447 transgender males who were identified; 12 (3%) responded yes to pregnancy, and 5 (1%) tested positive for HLA antibodies.
“We are continuing to add the HLA test,” said Dr. Grima. “I’m not sure this is the best [approach], but we will see over time.”
But if a donor comes in for the first time or identifies as a male or transgender male, they won’t be tested, and this is an opportunity that will be missed, she added. “Another option is to ask all donors if they have been pregnant or continue to ask donors their birth gender and then require that they answer both the male and female questions.”
Dr. Grima had no financial disclosures.
SAN DIEGO –
In study results presented at the annual meeting of the American Association of Blood Banks, 3% of transgender males who were identified as such reported a prior history of pregnancy. Importantly, this pregnancy history may not be divulged unless transgender males are asked “female” questions, said Kathleen M. Grima, MD, executive medical officer at the American Red Cross and medical director of the blood bank at the Brooklyn Hospital Center, New York.
Several studies have suggested that blood from ever-pregnant female donors can present increased risks to male recipients. Research also has suggested that antibodies or other immune system factors that women develop when pregnant could trigger transfusion-related acute lung injury (TRALI), a serious inflammatory reaction that can result in death, in male blood-transfusion recipients.
For this reason, it is important to have pregnancy histories from blood donors, and obtaining those histories from transgender males “presents a challenge for blood centers,” she said. “At our center, when a donor requests a gender change from female to male, an HLA test is requested for the next donation.” But as first-time donors are qualified based on their stated gender, transgender donors who have been pregnant will not be identified unless they volunteer the information or are asked about their pregnancy history.
The AABB recommends that a facility can perform HLA testing on all apheresis plasma donors and all whole blood donors whose units are intended for production into plasma components or, as an alternative, obtain a pregnancy history from all female donors and perform HLA typing only on women with a history of one or more full-term pregnancies.
Dr. Grima explained that, prior to the implementation of the Food and Drug Administration’s “final rule” on requirements for blood and blood components, blood centers asked donors to identify their birth gender to determine eligibility. If gender had changed, the donor was then asked to answer both the male and female questions. The FDA’s final rule now allows blood centers to accept the donor’s stated gender and eligibility can be determined based on that gender.
Dr. Grima and her colleagues conducted a review to determine the number of transgender males who were actively donating with a large blood center and to assess the risk of failing to ask a transgender male donor about pregnancy.
From 2013 to 2015, there were 121 female donors who had changed their gender to male and 60 male donors who had changed their gender to female. Of this group, seven (6%) transgender male donors (female at birth) stated at one of their donations that they had a pregnancy history; three were apheresis donors who had been tested for HLA antibodies (one was positive and two negative). The other four were whole blood donors and had not been tested.
After 2016, donors self-identified their gender, and 326 had requested a gender change from female to male. Of this group, 5 (1.5%) answered yes to pregnancy questions, 56 said no, and 265 did not respond.
“In our system, if a donor identifies as a male, then they only see male questions,” she pointed out. The center subsequently added in a test for HLA antibodies, and 101 donors were tested. Of this group, 13 (13%) tested positive; 2 had answered yes to pregnancy, 4 answered no, and 7 did not respond to the pregnancy question.
Combining the two cohorts, there were 447 transgender males who were identified; 12 (3%) responded yes to pregnancy, and 5 (1%) tested positive for HLA antibodies.
“We are continuing to add the HLA test,” said Dr. Grima. “I’m not sure this is the best [approach], but we will see over time.”
But if a donor comes in for the first time or identifies as a male or transgender male, they won’t be tested, and this is an opportunity that will be missed, she added. “Another option is to ask all donors if they have been pregnant or continue to ask donors their birth gender and then require that they answer both the male and female questions.”
Dr. Grima had no financial disclosures.
AT AABB17
Key clinical point: First-time transgender male donors with a history of pregnancy will not be identified, and HLA testing might not be performed unless these donors volunteer this information.
Major finding: Among 447 transgender males who were identified, 3% had been pregnant, and 1% tested positive for HLA antibodies.
Data source: A review of data from the blood bank at the Brooklyn Hospital Center, New York.
Disclosures: Dr. Grima had no financial disclosures.
Antibiotic exposure blunted metabolic improvement following vertical sleeve gastrectomy
SAN DIEGO – results from a mouse study demonstrated.
The finding raises the question of whether patients with suboptimal outcomes following vertical sleeve gastrectomy may benefit from microbial modulation.
According to Dr. Jahansouz of the University of Minnesota Microbiota Transplantation Program, mechanisms mediating metabolic improvement following bariatric surgery remain incompletely understood. “Outcomes are also somewhat variable: As many as 40%-75% of patients regain weight in the years following nadir of weight loss,” he said. “Human studies have shown an acute and sustained shift in the gut microbiota, and an altered bile acid profile. Bile acids increase following surgery.”
Meanwhile, mice deficient in Farnesoid X-receptor (FXR) and Takeda G protein–coupled Receptor 5 (TGR5) do not experience metabolic improvement following bariatric surgery; the composition of the microbiome can significantly impact the composition of bile acids.
“By altering the postsurgical composition of mice following bariatric surgery, we eliminate the metabolic benefits of surgery, possibly by altering bile acid profiles,” Dr. Jahansouz said.
For the trial, diet-induced obese mice were randomized to vertical sleeve gastrectomy (VSG) or sham surgery, with or without exposure to antibiotics that selectively suppress mainly gram-positive (fidaxomicin, streptomycin) or gram-negative (ceftriaxone) bacteria on postoperative days 1-4. The researchers characterized fecal microbiota before surgery and on postoperative days 7 and 28. Mice were metabolically characterized on postoperative days 30-32 and euthanized on postoperative day 35.
Mice in the VSG group experienced weight loss and shifts in the intestinal microbiota composition, compared with those in the sham surgery group.
“Antibiotic exposure resulted in sustained reductions in alpha (within sample) diversity of microbiota and shifts in its composition,” the researchers wrote in their abstract. “Different antimicrobial specificity of antibiotics led to functionally distinct physiologic effects. Specifically, fidaxomicin and streptomycin markedly altered hepatic bile acid signaling and lipid metabolism, while ceftriaxone resulted in greater reduction in the expression of key antimicrobial peptides.
“However, VSG mice exposed to antibiotics, regardless of their specificity, had significantly increased subcutaneous adiposity and impaired glucose homeostasis without changes in food intake, relative to control mice,” the investigators noted.
Dr. Jahansouz said that he was surprised by the fact that all three antibiotics tested, no matter their specificity in gut bacteria eliminated, resulted in significantly diminished weight loss and metabolic improvement following vertical sleeve gastrectomy in the mouse model. He acknowledged that translating the findings from mice to humans is a key limitation of the analysis.
“There are fundamental physiologic differences between mice and humans that need consideration in all murine models of metabolic disorders,” he said. “Therefore, it is critical that insights gained from these models are followed up in human studies.”
The study was funded by the American Diabetes Association and a Minnesota Discovery, Research and InnoVation Economy grant from the University of Minnesota. Dr. Jahansouz reported having no financial disclosures.
SAN DIEGO – results from a mouse study demonstrated.
The finding raises the question of whether patients with suboptimal outcomes following vertical sleeve gastrectomy may benefit from microbial modulation.
According to Dr. Jahansouz of the University of Minnesota Microbiota Transplantation Program, mechanisms mediating metabolic improvement following bariatric surgery remain incompletely understood. “Outcomes are also somewhat variable: As many as 40%-75% of patients regain weight in the years following nadir of weight loss,” he said. “Human studies have shown an acute and sustained shift in the gut microbiota, and an altered bile acid profile. Bile acids increase following surgery.”
Meanwhile, mice deficient in Farnesoid X-receptor (FXR) and Takeda G protein–coupled Receptor 5 (TGR5) do not experience metabolic improvement following bariatric surgery; the composition of the microbiome can significantly impact the composition of bile acids.
“By altering the postsurgical composition of mice following bariatric surgery, we eliminate the metabolic benefits of surgery, possibly by altering bile acid profiles,” Dr. Jahansouz said.
For the trial, diet-induced obese mice were randomized to vertical sleeve gastrectomy (VSG) or sham surgery, with or without exposure to antibiotics that selectively suppress mainly gram-positive (fidaxomicin, streptomycin) or gram-negative (ceftriaxone) bacteria on postoperative days 1-4. The researchers characterized fecal microbiota before surgery and on postoperative days 7 and 28. Mice were metabolically characterized on postoperative days 30-32 and euthanized on postoperative day 35.
Mice in the VSG group experienced weight loss and shifts in the intestinal microbiota composition, compared with those in the sham surgery group.
“Antibiotic exposure resulted in sustained reductions in alpha (within sample) diversity of microbiota and shifts in its composition,” the researchers wrote in their abstract. “Different antimicrobial specificity of antibiotics led to functionally distinct physiologic effects. Specifically, fidaxomicin and streptomycin markedly altered hepatic bile acid signaling and lipid metabolism, while ceftriaxone resulted in greater reduction in the expression of key antimicrobial peptides.
“However, VSG mice exposed to antibiotics, regardless of their specificity, had significantly increased subcutaneous adiposity and impaired glucose homeostasis without changes in food intake, relative to control mice,” the investigators noted.
Dr. Jahansouz said that he was surprised by the fact that all three antibiotics tested, no matter their specificity in gut bacteria eliminated, resulted in significantly diminished weight loss and metabolic improvement following vertical sleeve gastrectomy in the mouse model. He acknowledged that translating the findings from mice to humans is a key limitation of the analysis.
“There are fundamental physiologic differences between mice and humans that need consideration in all murine models of metabolic disorders,” he said. “Therefore, it is critical that insights gained from these models are followed up in human studies.”
The study was funded by the American Diabetes Association and a Minnesota Discovery, Research and InnoVation Economy grant from the University of Minnesota. Dr. Jahansouz reported having no financial disclosures.
SAN DIEGO – results from a mouse study demonstrated.
The finding raises the question of whether patients with suboptimal outcomes following vertical sleeve gastrectomy may benefit from microbial modulation.
According to Dr. Jahansouz of the University of Minnesota Microbiota Transplantation Program, mechanisms mediating metabolic improvement following bariatric surgery remain incompletely understood. “Outcomes are also somewhat variable: As many as 40%-75% of patients regain weight in the years following nadir of weight loss,” he said. “Human studies have shown an acute and sustained shift in the gut microbiota, and an altered bile acid profile. Bile acids increase following surgery.”
Meanwhile, mice deficient in Farnesoid X-receptor (FXR) and Takeda G protein–coupled Receptor 5 (TGR5) do not experience metabolic improvement following bariatric surgery; the composition of the microbiome can significantly impact the composition of bile acids.
“By altering the postsurgical composition of mice following bariatric surgery, we eliminate the metabolic benefits of surgery, possibly by altering bile acid profiles,” Dr. Jahansouz said.
For the trial, diet-induced obese mice were randomized to vertical sleeve gastrectomy (VSG) or sham surgery, with or without exposure to antibiotics that selectively suppress mainly gram-positive (fidaxomicin, streptomycin) or gram-negative (ceftriaxone) bacteria on postoperative days 1-4. The researchers characterized fecal microbiota before surgery and on postoperative days 7 and 28. Mice were metabolically characterized on postoperative days 30-32 and euthanized on postoperative day 35.
Mice in the VSG group experienced weight loss and shifts in the intestinal microbiota composition, compared with those in the sham surgery group.
“Antibiotic exposure resulted in sustained reductions in alpha (within sample) diversity of microbiota and shifts in its composition,” the researchers wrote in their abstract. “Different antimicrobial specificity of antibiotics led to functionally distinct physiologic effects. Specifically, fidaxomicin and streptomycin markedly altered hepatic bile acid signaling and lipid metabolism, while ceftriaxone resulted in greater reduction in the expression of key antimicrobial peptides.
“However, VSG mice exposed to antibiotics, regardless of their specificity, had significantly increased subcutaneous adiposity and impaired glucose homeostasis without changes in food intake, relative to control mice,” the investigators noted.
Dr. Jahansouz said that he was surprised by the fact that all three antibiotics tested, no matter their specificity in gut bacteria eliminated, resulted in significantly diminished weight loss and metabolic improvement following vertical sleeve gastrectomy in the mouse model. He acknowledged that translating the findings from mice to humans is a key limitation of the analysis.
“There are fundamental physiologic differences between mice and humans that need consideration in all murine models of metabolic disorders,” he said. “Therefore, it is critical that insights gained from these models are followed up in human studies.”
The study was funded by the American Diabetes Association and a Minnesota Discovery, Research and InnoVation Economy grant from the University of Minnesota. Dr. Jahansouz reported having no financial disclosures.
AT THE ACS CLINICAL CONGRESS
Key clinical point: Postsurgical disruption of intestinal microbiota composition attenuates the metabolic efficacy of vertical sleeve gastrectomy.
Major finding: VSG mice exposed to antibiotics had significantly increased subcutaneous adiposity and impaired glucose homeostasis without changes in food intake, compared with control mice.
Study details: A study of diet-induced obese mice that were randomized to VSG or sham surgery, with or without exposure to antibiotics.
Disclosures: The study was funded by the American Diabetes Association and a Minnesota Discovery, Research and InnoVation Economy grant from the University of Minnesota. Dr. Jahansouz reported having no financial disclosures.
Emphasizing an entrepreneurial spirit: Raman Palabindala, MD
Venkatraraman “Raman” Palabindala, MD, FACP, SFHM, was destined to be a doctor since his first breath. Born in India, his father decided Dr. Palabindala would take the mantle as the doctor of the family, while his siblings took to other professions like engineering.
Eager to be in the thick of things, Dr. Palabindala has voraciously pursued leadership positions, leading to his current role as chief of the Division of Hospital Medicine at the University of Mississippi Medical Center, Jackson.
Dr. Palabindala is enthusiastic about his role as one of the eight new members of The Hospitalist editorial advisory board, and took time to tell us more about himself in a recent interview.
Q: How did you get into medicine?
A: It’s all because of my dad’s motivation. My father believed in education, so when I was born, he said, “He’s going to be a doctor,” and as I grew up, I just worked towards being a physician and nothing else. I didn’t even have an option of choosing anything else. My dad said that I would be a doctor, and I am a doctor. I feel like that was the best thing that happened to me, though; it worked out well.
Q: How and when did you decide to go into hospital medicine?
A: After I came to the U.S., I joined residency in internal medicine at GBMC – that’s Greater Baltimore Medical Center – it’s affiliated with Johns Hopkins. I always wanted to be an internist, but my experiences in the clinic world were not so great. But I really enjoyed inpatient medicine, so in my 3rd year, when I was doing my chief residency year, I did get opportunities to join a fellowship, but I decided just to be a hospitalist at that time.
Q: What do you find to be rewarding about hospital medicine?
Q: What is one of the biggest challenges in hospital medicine?
A: I think talking about the business aspect of medicine, because it is like a taboo. We don’t really want to talk about whether the patient is covered or not covered by insurance, how much we are billing, and why we must discuss business issues while we are trying to focus on patient care, but these things are going to indirectly affect patient care, too. If you didn’t note the patient status accurately, they are going to get an inappropriate bill.
Q: What’s the best advice you have received that you try to pass on to your students?
A: Do the rounds at the bedside. We have the tendency of doing everything outside and then going in the room and just telling the patient what we are going to do. Instead, I encourage everyone to be at the bedside. Even without students, I go and sit at the bedside and then review the data in terms the patient can understand, and then explain the care plan, so they actually feel like we are at the bedside for a longer time. We are with the patient for at least 10 to 15 minutes, but at the same time, we are getting things done. I encourage my students and residents to do this.
Q: What is the worst advice you’ve received?
A: I don’t know if this is the “worst” advice, but in my second year, I was trying to take some leadership positions and was told I should wait, that leadership skills come with experience. I do think that’s a bad piece of advice. It’s all about learning how hard you work and then how fast you learn, and then how fast you implement. People who work, learn, and implement quickly can make a difference.
Q: Outside of patient care, what other career interests do you have?
A: I’m interested in smart clinics, and I actually have a patent for smart clinic chains. I’m a big fan of primary care, because, like hospitalists revolutionized inpatient care, I think we can revolutionize the outpatient care experience as well. I don’t think we are being very efficient with outpatient care.
But if I was not practicing medicine, I probably would be a chef. I like to cook, and I would open up my own restaurant if I was not doing this.
Q: Where do you see yourself in 10 years?
A: I want to be a consultant, evaluating hospitalist programs and guiding programs to grow and be more efficient. That, I think, would be the primary job that I would like to be doing, along with giving lectures and teaching about patient safety and quality, and educating younger physicians about the business of medicine.
Q: What experience with SHM has made the most lasting impact on you?
A: I would say the best impression was from the Academic Hospitalist Academy meeting I attended in Denver. I think that was helpful, because it was like a boot camp where you have only a limited number of attendees with a dedicated mentor. That was amazing, and I learned a lot. It helped me in redesigning my approach to where I would like to be both short- and long-term. I implemented at least 50 percent of what I learned at that meeting.
Q: What’s the best book that you’ve read recently and why was it the best?
A: Being Mortal by Atul Gawande. It’s a really beautiful book.
[email protected]
On Twitter @eaztweets
Venkatraraman “Raman” Palabindala, MD, FACP, SFHM, was destined to be a doctor since his first breath. Born in India, his father decided Dr. Palabindala would take the mantle as the doctor of the family, while his siblings took to other professions like engineering.
Eager to be in the thick of things, Dr. Palabindala has voraciously pursued leadership positions, leading to his current role as chief of the Division of Hospital Medicine at the University of Mississippi Medical Center, Jackson.
Dr. Palabindala is enthusiastic about his role as one of the eight new members of The Hospitalist editorial advisory board, and took time to tell us more about himself in a recent interview.
Q: How did you get into medicine?
A: It’s all because of my dad’s motivation. My father believed in education, so when I was born, he said, “He’s going to be a doctor,” and as I grew up, I just worked towards being a physician and nothing else. I didn’t even have an option of choosing anything else. My dad said that I would be a doctor, and I am a doctor. I feel like that was the best thing that happened to me, though; it worked out well.
Q: How and when did you decide to go into hospital medicine?
A: After I came to the U.S., I joined residency in internal medicine at GBMC – that’s Greater Baltimore Medical Center – it’s affiliated with Johns Hopkins. I always wanted to be an internist, but my experiences in the clinic world were not so great. But I really enjoyed inpatient medicine, so in my 3rd year, when I was doing my chief residency year, I did get opportunities to join a fellowship, but I decided just to be a hospitalist at that time.
Q: What do you find to be rewarding about hospital medicine?
Q: What is one of the biggest challenges in hospital medicine?
A: I think talking about the business aspect of medicine, because it is like a taboo. We don’t really want to talk about whether the patient is covered or not covered by insurance, how much we are billing, and why we must discuss business issues while we are trying to focus on patient care, but these things are going to indirectly affect patient care, too. If you didn’t note the patient status accurately, they are going to get an inappropriate bill.
Q: What’s the best advice you have received that you try to pass on to your students?
A: Do the rounds at the bedside. We have the tendency of doing everything outside and then going in the room and just telling the patient what we are going to do. Instead, I encourage everyone to be at the bedside. Even without students, I go and sit at the bedside and then review the data in terms the patient can understand, and then explain the care plan, so they actually feel like we are at the bedside for a longer time. We are with the patient for at least 10 to 15 minutes, but at the same time, we are getting things done. I encourage my students and residents to do this.
Q: What is the worst advice you’ve received?
A: I don’t know if this is the “worst” advice, but in my second year, I was trying to take some leadership positions and was told I should wait, that leadership skills come with experience. I do think that’s a bad piece of advice. It’s all about learning how hard you work and then how fast you learn, and then how fast you implement. People who work, learn, and implement quickly can make a difference.
Q: Outside of patient care, what other career interests do you have?
A: I’m interested in smart clinics, and I actually have a patent for smart clinic chains. I’m a big fan of primary care, because, like hospitalists revolutionized inpatient care, I think we can revolutionize the outpatient care experience as well. I don’t think we are being very efficient with outpatient care.
But if I was not practicing medicine, I probably would be a chef. I like to cook, and I would open up my own restaurant if I was not doing this.
Q: Where do you see yourself in 10 years?
A: I want to be a consultant, evaluating hospitalist programs and guiding programs to grow and be more efficient. That, I think, would be the primary job that I would like to be doing, along with giving lectures and teaching about patient safety and quality, and educating younger physicians about the business of medicine.
Q: What experience with SHM has made the most lasting impact on you?
A: I would say the best impression was from the Academic Hospitalist Academy meeting I attended in Denver. I think that was helpful, because it was like a boot camp where you have only a limited number of attendees with a dedicated mentor. That was amazing, and I learned a lot. It helped me in redesigning my approach to where I would like to be both short- and long-term. I implemented at least 50 percent of what I learned at that meeting.
Q: What’s the best book that you’ve read recently and why was it the best?
A: Being Mortal by Atul Gawande. It’s a really beautiful book.
[email protected]
On Twitter @eaztweets
Venkatraraman “Raman” Palabindala, MD, FACP, SFHM, was destined to be a doctor since his first breath. Born in India, his father decided Dr. Palabindala would take the mantle as the doctor of the family, while his siblings took to other professions like engineering.
Eager to be in the thick of things, Dr. Palabindala has voraciously pursued leadership positions, leading to his current role as chief of the Division of Hospital Medicine at the University of Mississippi Medical Center, Jackson.
Dr. Palabindala is enthusiastic about his role as one of the eight new members of The Hospitalist editorial advisory board, and took time to tell us more about himself in a recent interview.
Q: How did you get into medicine?
A: It’s all because of my dad’s motivation. My father believed in education, so when I was born, he said, “He’s going to be a doctor,” and as I grew up, I just worked towards being a physician and nothing else. I didn’t even have an option of choosing anything else. My dad said that I would be a doctor, and I am a doctor. I feel like that was the best thing that happened to me, though; it worked out well.
Q: How and when did you decide to go into hospital medicine?
A: After I came to the U.S., I joined residency in internal medicine at GBMC – that’s Greater Baltimore Medical Center – it’s affiliated with Johns Hopkins. I always wanted to be an internist, but my experiences in the clinic world were not so great. But I really enjoyed inpatient medicine, so in my 3rd year, when I was doing my chief residency year, I did get opportunities to join a fellowship, but I decided just to be a hospitalist at that time.
Q: What do you find to be rewarding about hospital medicine?
Q: What is one of the biggest challenges in hospital medicine?
A: I think talking about the business aspect of medicine, because it is like a taboo. We don’t really want to talk about whether the patient is covered or not covered by insurance, how much we are billing, and why we must discuss business issues while we are trying to focus on patient care, but these things are going to indirectly affect patient care, too. If you didn’t note the patient status accurately, they are going to get an inappropriate bill.
Q: What’s the best advice you have received that you try to pass on to your students?
A: Do the rounds at the bedside. We have the tendency of doing everything outside and then going in the room and just telling the patient what we are going to do. Instead, I encourage everyone to be at the bedside. Even without students, I go and sit at the bedside and then review the data in terms the patient can understand, and then explain the care plan, so they actually feel like we are at the bedside for a longer time. We are with the patient for at least 10 to 15 minutes, but at the same time, we are getting things done. I encourage my students and residents to do this.
Q: What is the worst advice you’ve received?
A: I don’t know if this is the “worst” advice, but in my second year, I was trying to take some leadership positions and was told I should wait, that leadership skills come with experience. I do think that’s a bad piece of advice. It’s all about learning how hard you work and then how fast you learn, and then how fast you implement. People who work, learn, and implement quickly can make a difference.
Q: Outside of patient care, what other career interests do you have?
A: I’m interested in smart clinics, and I actually have a patent for smart clinic chains. I’m a big fan of primary care, because, like hospitalists revolutionized inpatient care, I think we can revolutionize the outpatient care experience as well. I don’t think we are being very efficient with outpatient care.
But if I was not practicing medicine, I probably would be a chef. I like to cook, and I would open up my own restaurant if I was not doing this.
Q: Where do you see yourself in 10 years?
A: I want to be a consultant, evaluating hospitalist programs and guiding programs to grow and be more efficient. That, I think, would be the primary job that I would like to be doing, along with giving lectures and teaching about patient safety and quality, and educating younger physicians about the business of medicine.
Q: What experience with SHM has made the most lasting impact on you?
A: I would say the best impression was from the Academic Hospitalist Academy meeting I attended in Denver. I think that was helpful, because it was like a boot camp where you have only a limited number of attendees with a dedicated mentor. That was amazing, and I learned a lot. It helped me in redesigning my approach to where I would like to be both short- and long-term. I implemented at least 50 percent of what I learned at that meeting.
Q: What’s the best book that you’ve read recently and why was it the best?
A: Being Mortal by Atul Gawande. It’s a really beautiful book.
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On Twitter @eaztweets
You can help with behavior of children with autism spectrum disorder
There are lots of reasons you may be eager to refer children with autism spectrum disorder (ASD) to specialty agencies. You want the fastest possible entry for the child into intervention and the families into a support system. , as well as the general health care, of their children.
“Wait!” you say, “I do not have the special knowledge to help with behavior of children with autism! There is much you can and should do, however, as the specialist(s) may not provide such guidance, entry into behavioral services may take months, and behavior issues may feel urgent to families.
So pick an example of a behavior that is concerning to the family. One problem might be lack of cooperation with activities of daily living such as eating. In this case, the A is being asked to stop playing and sit at the table; the B may be refusing to eat what is served or even to sit very long, ending in a tantrum that disrupts the family meal; and the C could be the child being sent from the table to play on their iPad. But what is the G?
Lack of social communication skills, restrictive interests, hypersensitivity, lack of coordination, and ADHD all may be playing a role. Lack of communication skills makes the social aspect of meals uninteresting. Giving verbal reasons for joining the family may not be effective. Hypersensitivity often is associated with extremes of food selectivity. Lack of fine motor coordination makes eating soup a challenge. And ADHD makes sitting for a long time difficult!
But what about that tantrum? Tantrums that are reinforced by allowing the child to leave and play on the iPad easily can turn into a chronic escape mechanism. Instead, parents need to watch for increasing restlessness, and allow the child to signal “all done” and be “excused” before any tantrum begins. Use of the iPad (a reward) should not be allowed until the family meal is over for everyone. Such accommodations are best decided on by all caregivers in advance, ideally also involving the higher-functioning child. A caregiver who persists in thinking that the child “should” be able to behave may be in denial or grief, and deserves counseling on ASD.
But he is so rigid, the parents say! The tendency of children with ASD to like sameness can be an asset to easing behavior. The key is to design and stick to routines as much as possible, 7 days per week. If the meal is at the same time each day, in the same seat, with the same plate, with no iPad, and the child is allowed to leave only after requesting to, the entire sequence is likely to be smoother. While flexibility does not come easily, it is acquired from the natural variability in family life, but only gradually and over time.
Creating and rehearsing “social stories” is an evidence-based way to help children with ASD have acceptable behaviors. Books, storyboards, and visual schedulers can be purchased to help. But even taking photos or a video of the components of a task and posting this online (private YouTube channel) or on the refrigerator, to review before, during, and/or after the activity, builds an internal image for the child. Children with ASD often watch the same YouTube videos over and over again, and even memorize and use chunks of the speech or songs at other times. Families can capitalize on this kind of repetition by using routines and songs to improve skills.
What to do when she only cares about her iPad? It is sometimes difficult to identify reinforcers to use to strengthen desired behaviors in a child with ASD. A smile or a hug or even candy may not be valued. Help parents think about an object, song, or touch the child tends to like. Media are a strong reinforcer, but need to be used sparingly, in specific situations, and kept under parental control, or else removing them can become a major source of upsets.
When a child with ASD gets upset or even violent, the behavior may be interpreted as defiance; it may scare or upset the whole family, and is not conducive to problem solving. Siblings may start screaming or begging for the parents to stop the behavior. While this creates a crisis, you can advise parents to first ensure that everyone is safe, take deep breaths, and then think about which gap is being stressed. A subtle change from what the child expected – new furniture, a guest at the table, a day off from school, or being interrupted mid video – can cause panic, especially for anxious children. Children with ASD also may act up when uncomfortable from a headache, tooth pain, constipation, hunger, or lack of sleep, but often are unable to vocalize the reason, even if they are verbal. Having parents make a few notes about the As, Bs, Cs, and Gs of each event (the essence of a functional behavioral assessment) to review with the child, each other, the teacher, or you is key to understanding the child with ASD and successfully shifting his behavior.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
There are lots of reasons you may be eager to refer children with autism spectrum disorder (ASD) to specialty agencies. You want the fastest possible entry for the child into intervention and the families into a support system. , as well as the general health care, of their children.
“Wait!” you say, “I do not have the special knowledge to help with behavior of children with autism! There is much you can and should do, however, as the specialist(s) may not provide such guidance, entry into behavioral services may take months, and behavior issues may feel urgent to families.
So pick an example of a behavior that is concerning to the family. One problem might be lack of cooperation with activities of daily living such as eating. In this case, the A is being asked to stop playing and sit at the table; the B may be refusing to eat what is served or even to sit very long, ending in a tantrum that disrupts the family meal; and the C could be the child being sent from the table to play on their iPad. But what is the G?
Lack of social communication skills, restrictive interests, hypersensitivity, lack of coordination, and ADHD all may be playing a role. Lack of communication skills makes the social aspect of meals uninteresting. Giving verbal reasons for joining the family may not be effective. Hypersensitivity often is associated with extremes of food selectivity. Lack of fine motor coordination makes eating soup a challenge. And ADHD makes sitting for a long time difficult!
But what about that tantrum? Tantrums that are reinforced by allowing the child to leave and play on the iPad easily can turn into a chronic escape mechanism. Instead, parents need to watch for increasing restlessness, and allow the child to signal “all done” and be “excused” before any tantrum begins. Use of the iPad (a reward) should not be allowed until the family meal is over for everyone. Such accommodations are best decided on by all caregivers in advance, ideally also involving the higher-functioning child. A caregiver who persists in thinking that the child “should” be able to behave may be in denial or grief, and deserves counseling on ASD.
But he is so rigid, the parents say! The tendency of children with ASD to like sameness can be an asset to easing behavior. The key is to design and stick to routines as much as possible, 7 days per week. If the meal is at the same time each day, in the same seat, with the same plate, with no iPad, and the child is allowed to leave only after requesting to, the entire sequence is likely to be smoother. While flexibility does not come easily, it is acquired from the natural variability in family life, but only gradually and over time.
Creating and rehearsing “social stories” is an evidence-based way to help children with ASD have acceptable behaviors. Books, storyboards, and visual schedulers can be purchased to help. But even taking photos or a video of the components of a task and posting this online (private YouTube channel) or on the refrigerator, to review before, during, and/or after the activity, builds an internal image for the child. Children with ASD often watch the same YouTube videos over and over again, and even memorize and use chunks of the speech or songs at other times. Families can capitalize on this kind of repetition by using routines and songs to improve skills.
What to do when she only cares about her iPad? It is sometimes difficult to identify reinforcers to use to strengthen desired behaviors in a child with ASD. A smile or a hug or even candy may not be valued. Help parents think about an object, song, or touch the child tends to like. Media are a strong reinforcer, but need to be used sparingly, in specific situations, and kept under parental control, or else removing them can become a major source of upsets.
When a child with ASD gets upset or even violent, the behavior may be interpreted as defiance; it may scare or upset the whole family, and is not conducive to problem solving. Siblings may start screaming or begging for the parents to stop the behavior. While this creates a crisis, you can advise parents to first ensure that everyone is safe, take deep breaths, and then think about which gap is being stressed. A subtle change from what the child expected – new furniture, a guest at the table, a day off from school, or being interrupted mid video – can cause panic, especially for anxious children. Children with ASD also may act up when uncomfortable from a headache, tooth pain, constipation, hunger, or lack of sleep, but often are unable to vocalize the reason, even if they are verbal. Having parents make a few notes about the As, Bs, Cs, and Gs of each event (the essence of a functional behavioral assessment) to review with the child, each other, the teacher, or you is key to understanding the child with ASD and successfully shifting his behavior.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
There are lots of reasons you may be eager to refer children with autism spectrum disorder (ASD) to specialty agencies. You want the fastest possible entry for the child into intervention and the families into a support system. , as well as the general health care, of their children.
“Wait!” you say, “I do not have the special knowledge to help with behavior of children with autism! There is much you can and should do, however, as the specialist(s) may not provide such guidance, entry into behavioral services may take months, and behavior issues may feel urgent to families.
So pick an example of a behavior that is concerning to the family. One problem might be lack of cooperation with activities of daily living such as eating. In this case, the A is being asked to stop playing and sit at the table; the B may be refusing to eat what is served or even to sit very long, ending in a tantrum that disrupts the family meal; and the C could be the child being sent from the table to play on their iPad. But what is the G?
Lack of social communication skills, restrictive interests, hypersensitivity, lack of coordination, and ADHD all may be playing a role. Lack of communication skills makes the social aspect of meals uninteresting. Giving verbal reasons for joining the family may not be effective. Hypersensitivity often is associated with extremes of food selectivity. Lack of fine motor coordination makes eating soup a challenge. And ADHD makes sitting for a long time difficult!
But what about that tantrum? Tantrums that are reinforced by allowing the child to leave and play on the iPad easily can turn into a chronic escape mechanism. Instead, parents need to watch for increasing restlessness, and allow the child to signal “all done” and be “excused” before any tantrum begins. Use of the iPad (a reward) should not be allowed until the family meal is over for everyone. Such accommodations are best decided on by all caregivers in advance, ideally also involving the higher-functioning child. A caregiver who persists in thinking that the child “should” be able to behave may be in denial or grief, and deserves counseling on ASD.
But he is so rigid, the parents say! The tendency of children with ASD to like sameness can be an asset to easing behavior. The key is to design and stick to routines as much as possible, 7 days per week. If the meal is at the same time each day, in the same seat, with the same plate, with no iPad, and the child is allowed to leave only after requesting to, the entire sequence is likely to be smoother. While flexibility does not come easily, it is acquired from the natural variability in family life, but only gradually and over time.
Creating and rehearsing “social stories” is an evidence-based way to help children with ASD have acceptable behaviors. Books, storyboards, and visual schedulers can be purchased to help. But even taking photos or a video of the components of a task and posting this online (private YouTube channel) or on the refrigerator, to review before, during, and/or after the activity, builds an internal image for the child. Children with ASD often watch the same YouTube videos over and over again, and even memorize and use chunks of the speech or songs at other times. Families can capitalize on this kind of repetition by using routines and songs to improve skills.
What to do when she only cares about her iPad? It is sometimes difficult to identify reinforcers to use to strengthen desired behaviors in a child with ASD. A smile or a hug or even candy may not be valued. Help parents think about an object, song, or touch the child tends to like. Media are a strong reinforcer, but need to be used sparingly, in specific situations, and kept under parental control, or else removing them can become a major source of upsets.
When a child with ASD gets upset or even violent, the behavior may be interpreted as defiance; it may scare or upset the whole family, and is not conducive to problem solving. Siblings may start screaming or begging for the parents to stop the behavior. While this creates a crisis, you can advise parents to first ensure that everyone is safe, take deep breaths, and then think about which gap is being stressed. A subtle change from what the child expected – new furniture, a guest at the table, a day off from school, or being interrupted mid video – can cause panic, especially for anxious children. Children with ASD also may act up when uncomfortable from a headache, tooth pain, constipation, hunger, or lack of sleep, but often are unable to vocalize the reason, even if they are verbal. Having parents make a few notes about the As, Bs, Cs, and Gs of each event (the essence of a functional behavioral assessment) to review with the child, each other, the teacher, or you is key to understanding the child with ASD and successfully shifting his behavior.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Caprini score is not a good predictor of PE in patients with DVT
The Caprini score, commonly used to risk stratify patients for the development of venous thromboembolism and to determine the optimal dose of prophylaxis, failed to predict the development of pulmonary embolism and hemodynamically significant PE in patients presenting with deep vein thrombosis (DVT), according to the results of a large, retrospective single-center study.
Recent surgery was not associated with the development of hemodynamically significant PE, but the presence of proximal DVT was, according to a report published online in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (2017. doi: 10.1016/j.jvsv.2017.08.015).
Their results showed that patients who had undergone recent surgery were less likely to develop hemodynamically significant PE (13.3% vs. 27.2%; P = .01). In contrast, patients with proximal DVT were at higher risk for development of hemodynamically significant PE (80.7% vs. 64.2%; P = .007). They found no association between Caprini score and PE severity (P = .17) or the Caprini score and proximal DVT (P = .89).
“This study shows that the Caprini score does not correlate with the occurrence of PE or the severity of PE. On the other hand, a proximal location of DVT seems to have a high association with hemodynamically significant PE. Such patients may benefit from more aggressive anticoagulant therapy and work-up for PE,” the researchers concluded.
The authors reported that they had no conflicts of interest.
The Caprini score, commonly used to risk stratify patients for the development of venous thromboembolism and to determine the optimal dose of prophylaxis, failed to predict the development of pulmonary embolism and hemodynamically significant PE in patients presenting with deep vein thrombosis (DVT), according to the results of a large, retrospective single-center study.
Recent surgery was not associated with the development of hemodynamically significant PE, but the presence of proximal DVT was, according to a report published online in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (2017. doi: 10.1016/j.jvsv.2017.08.015).
Their results showed that patients who had undergone recent surgery were less likely to develop hemodynamically significant PE (13.3% vs. 27.2%; P = .01). In contrast, patients with proximal DVT were at higher risk for development of hemodynamically significant PE (80.7% vs. 64.2%; P = .007). They found no association between Caprini score and PE severity (P = .17) or the Caprini score and proximal DVT (P = .89).
“This study shows that the Caprini score does not correlate with the occurrence of PE or the severity of PE. On the other hand, a proximal location of DVT seems to have a high association with hemodynamically significant PE. Such patients may benefit from more aggressive anticoagulant therapy and work-up for PE,” the researchers concluded.
The authors reported that they had no conflicts of interest.
The Caprini score, commonly used to risk stratify patients for the development of venous thromboembolism and to determine the optimal dose of prophylaxis, failed to predict the development of pulmonary embolism and hemodynamically significant PE in patients presenting with deep vein thrombosis (DVT), according to the results of a large, retrospective single-center study.
Recent surgery was not associated with the development of hemodynamically significant PE, but the presence of proximal DVT was, according to a report published online in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (2017. doi: 10.1016/j.jvsv.2017.08.015).
Their results showed that patients who had undergone recent surgery were less likely to develop hemodynamically significant PE (13.3% vs. 27.2%; P = .01). In contrast, patients with proximal DVT were at higher risk for development of hemodynamically significant PE (80.7% vs. 64.2%; P = .007). They found no association between Caprini score and PE severity (P = .17) or the Caprini score and proximal DVT (P = .89).
“This study shows that the Caprini score does not correlate with the occurrence of PE or the severity of PE. On the other hand, a proximal location of DVT seems to have a high association with hemodynamically significant PE. Such patients may benefit from more aggressive anticoagulant therapy and work-up for PE,” the researchers concluded.
The authors reported that they had no conflicts of interest.
FROM THE JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
Key clinical point:
Major finding: Among 838 patients presenting with DVT, nearly 26% had concomitant PE, more than half of which was hemodynamically significant.
Data source: A single-center, retrospective review of 838 patients diagnosed with DVT.
Disclosures: The authors reported that they had no conflicts of interest.
News from SVS: Post-thrombotic venous obstructions and stenting
Endovascular treatment of iliocaval and infrainguinal post-thrombotic venous obstruction results do not appear to be adversely affected by extension of the iliac vein stents into the femoral venous system, according to a report in the November edition of the Journal of Vascular Surgery: Venous and Lymphatic Diseases (J Vasc Surg: Venous and Lym Dis 2017;5:789-99).
Deep venous thrombosis remains a significant problem with well over 500,000 people affected in the United States. Over a quarter of these patients will experience post-thrombotic syndrome (PTS), despite appropriate anti-coagulation. Patients with iliocaval thrombosis face a three-fold risk of PTS. Treatment of the complications of PTS, including leg swelling, venous claudication, skin changes and ulceration, results in healthcare costs estimated at $7 to $10 billion per year.
Popularized by Drs. Seshadri Raju and Peter Neglen, venous stenting for symptomatic patients has increased significantly in this setting. Several large series since then have demonstrated safety, efficacy and good durability of this technique in iliocaval obstruction. Questions, however, remain as to the outcomes with regards to etiology (i.e., thrombotic versus non-thrombotic occlusion) and extent of stenting (i.e., extension below the inguinal ligament). Concern for the latter is raised as the mobility of the common femoral vein may result in stent fracture and thrombosis.
Researchers from UCLA, led by vascular surgeon Dr. Brian DeRubertis, retrospectively evaluated their single-center experience with percutaneous treatment of post-thrombotic iliocaval obstruction. In this series, 31 patients (42 limbs) presented with pain/swelling (100%) including venous claudication (81%) and active ulceration (10%). Percutaneous interventions, including iliocaval angioplasty/stent in 81% with extension into the femoral system (38%), resulted in 100% technical success. Of those with IVC filters, 46% were able to be removed.
At an average of 15 months follow-up (range 2-49 months), the following results were achieved:
- Improvement in pain/swelling 84%
- Resolved pain/swelling 42%
- Decreased CEAP classification 65%
- 1 year primary stent patency 66%
- 1 year secondary stent patency 75%
Those requiring infrainguinal extension of the stent realized no significant difference in primary stent patency at one year compared to those who did not (68% versus 65%). However, in those whose IVC filter could not be removed, resolution of symptoms was achieved in only 17%.
“Our aim was to better understand risk factors for poor clinical outcomes in patients undergoing percutaneous intervention for symptomatic chronic venous obstruction secondary to post-thrombotic lesions,” comments first author Dr. Johnathon Rollo. “Our results suggest that stenting below the inguinal ligament does not result in inferior outcomes, at least in the short-term, and may be necessary in a higher percentage of patients than previously reported. Additionally, the failure to remove an IVC filter in this setting appears to result in inferior outcome and an attempt to safely remove the filter should be made in this high-risk population.”
This data suggests a role for early filter removal after, or not even placing them at all, during ileocaval lytic therapy.
The authors emphasize stenting from normal vein above to normal vein below the occlusive disease, if technically possible. Based on these results, going below the inguinal ligament to achieve adequate inflow makes sense.
To download the complete article (link available free through 12/31/2017), click here.
Endovascular treatment of iliocaval and infrainguinal post-thrombotic venous obstruction results do not appear to be adversely affected by extension of the iliac vein stents into the femoral venous system, according to a report in the November edition of the Journal of Vascular Surgery: Venous and Lymphatic Diseases (J Vasc Surg: Venous and Lym Dis 2017;5:789-99).
Deep venous thrombosis remains a significant problem with well over 500,000 people affected in the United States. Over a quarter of these patients will experience post-thrombotic syndrome (PTS), despite appropriate anti-coagulation. Patients with iliocaval thrombosis face a three-fold risk of PTS. Treatment of the complications of PTS, including leg swelling, venous claudication, skin changes and ulceration, results in healthcare costs estimated at $7 to $10 billion per year.
Popularized by Drs. Seshadri Raju and Peter Neglen, venous stenting for symptomatic patients has increased significantly in this setting. Several large series since then have demonstrated safety, efficacy and good durability of this technique in iliocaval obstruction. Questions, however, remain as to the outcomes with regards to etiology (i.e., thrombotic versus non-thrombotic occlusion) and extent of stenting (i.e., extension below the inguinal ligament). Concern for the latter is raised as the mobility of the common femoral vein may result in stent fracture and thrombosis.
Researchers from UCLA, led by vascular surgeon Dr. Brian DeRubertis, retrospectively evaluated their single-center experience with percutaneous treatment of post-thrombotic iliocaval obstruction. In this series, 31 patients (42 limbs) presented with pain/swelling (100%) including venous claudication (81%) and active ulceration (10%). Percutaneous interventions, including iliocaval angioplasty/stent in 81% with extension into the femoral system (38%), resulted in 100% technical success. Of those with IVC filters, 46% were able to be removed.
At an average of 15 months follow-up (range 2-49 months), the following results were achieved:
- Improvement in pain/swelling 84%
- Resolved pain/swelling 42%
- Decreased CEAP classification 65%
- 1 year primary stent patency 66%
- 1 year secondary stent patency 75%
Those requiring infrainguinal extension of the stent realized no significant difference in primary stent patency at one year compared to those who did not (68% versus 65%). However, in those whose IVC filter could not be removed, resolution of symptoms was achieved in only 17%.
“Our aim was to better understand risk factors for poor clinical outcomes in patients undergoing percutaneous intervention for symptomatic chronic venous obstruction secondary to post-thrombotic lesions,” comments first author Dr. Johnathon Rollo. “Our results suggest that stenting below the inguinal ligament does not result in inferior outcomes, at least in the short-term, and may be necessary in a higher percentage of patients than previously reported. Additionally, the failure to remove an IVC filter in this setting appears to result in inferior outcome and an attempt to safely remove the filter should be made in this high-risk population.”
This data suggests a role for early filter removal after, or not even placing them at all, during ileocaval lytic therapy.
The authors emphasize stenting from normal vein above to normal vein below the occlusive disease, if technically possible. Based on these results, going below the inguinal ligament to achieve adequate inflow makes sense.
To download the complete article (link available free through 12/31/2017), click here.
Endovascular treatment of iliocaval and infrainguinal post-thrombotic venous obstruction results do not appear to be adversely affected by extension of the iliac vein stents into the femoral venous system, according to a report in the November edition of the Journal of Vascular Surgery: Venous and Lymphatic Diseases (J Vasc Surg: Venous and Lym Dis 2017;5:789-99).
Deep venous thrombosis remains a significant problem with well over 500,000 people affected in the United States. Over a quarter of these patients will experience post-thrombotic syndrome (PTS), despite appropriate anti-coagulation. Patients with iliocaval thrombosis face a three-fold risk of PTS. Treatment of the complications of PTS, including leg swelling, venous claudication, skin changes and ulceration, results in healthcare costs estimated at $7 to $10 billion per year.
Popularized by Drs. Seshadri Raju and Peter Neglen, venous stenting for symptomatic patients has increased significantly in this setting. Several large series since then have demonstrated safety, efficacy and good durability of this technique in iliocaval obstruction. Questions, however, remain as to the outcomes with regards to etiology (i.e., thrombotic versus non-thrombotic occlusion) and extent of stenting (i.e., extension below the inguinal ligament). Concern for the latter is raised as the mobility of the common femoral vein may result in stent fracture and thrombosis.
Researchers from UCLA, led by vascular surgeon Dr. Brian DeRubertis, retrospectively evaluated their single-center experience with percutaneous treatment of post-thrombotic iliocaval obstruction. In this series, 31 patients (42 limbs) presented with pain/swelling (100%) including venous claudication (81%) and active ulceration (10%). Percutaneous interventions, including iliocaval angioplasty/stent in 81% with extension into the femoral system (38%), resulted in 100% technical success. Of those with IVC filters, 46% were able to be removed.
At an average of 15 months follow-up (range 2-49 months), the following results were achieved:
- Improvement in pain/swelling 84%
- Resolved pain/swelling 42%
- Decreased CEAP classification 65%
- 1 year primary stent patency 66%
- 1 year secondary stent patency 75%
Those requiring infrainguinal extension of the stent realized no significant difference in primary stent patency at one year compared to those who did not (68% versus 65%). However, in those whose IVC filter could not be removed, resolution of symptoms was achieved in only 17%.
“Our aim was to better understand risk factors for poor clinical outcomes in patients undergoing percutaneous intervention for symptomatic chronic venous obstruction secondary to post-thrombotic lesions,” comments first author Dr. Johnathon Rollo. “Our results suggest that stenting below the inguinal ligament does not result in inferior outcomes, at least in the short-term, and may be necessary in a higher percentage of patients than previously reported. Additionally, the failure to remove an IVC filter in this setting appears to result in inferior outcome and an attempt to safely remove the filter should be made in this high-risk population.”
This data suggests a role for early filter removal after, or not even placing them at all, during ileocaval lytic therapy.
The authors emphasize stenting from normal vein above to normal vein below the occlusive disease, if technically possible. Based on these results, going below the inguinal ligament to achieve adequate inflow makes sense.
To download the complete article (link available free through 12/31/2017), click here.
Beware the risks associated with greater saphenous vein thrombosis
Isolated greater saphenous vein thrombosis is not as benign as generally thought, according to the results of a single institution retrospective study of 61 patients (67 limbs) with isolated GSVT.
Instead, patients had a significant risk of persistent symptoms, recurrence, deep vein thrombosis (DVT), and pulmonary embolism (PE), according to a report published in the Annals of Vascular Surgery by Elizabeth Kudlaty, MD, Ohio State University, Columbus, and her colleagues.
Location of the GSVT within 5 cm of the saphenous vein junction (SVJ; 32 patients) as compared with GSVT greater than 5 cm from the SVJ (29 patients) was significantly associated with malignancy (37.5% vs. 6.9%, respectively; P = .01), in-patient status (71.9% vs. 41.4%; P = .02), and diabetes (37.5% vs. 10.3%; P = .02). PE also was significantly greater in patients with GSVT within 5 cm of the SVJ (18.8% vs. 0.0%; P = .02). Patients with GSVT greater than 5 cm from the SVJ showed significantly more GSVT propagation/new saphenous vein thrombosis (0% vs. 31.3%, P = .048). There was a nonsignificant trend toward greater mortality for patients with GSVT within 5 cm of the SVJ (P = .052).
Dr. Kudlaty and her colleagues found that the different management options used, including anticoagulation, observation, and aspirin use, did not significantly affect outcomes (Ann Vasc Surg. 2017 Nov;45:154-9).
“Isolated GSVT can be viewed as a marker of more serious systemic diseases, notably diabetes and cancer, and leaves patients at high risk for thromboembolic events, recurrence, and persistent symptoms, despite a variety of managements,” the researchers concluded.
The authors reported that they had no conflicts of interest and that there were no outside funding sources.
Isolated greater saphenous vein thrombosis is not as benign as generally thought, according to the results of a single institution retrospective study of 61 patients (67 limbs) with isolated GSVT.
Instead, patients had a significant risk of persistent symptoms, recurrence, deep vein thrombosis (DVT), and pulmonary embolism (PE), according to a report published in the Annals of Vascular Surgery by Elizabeth Kudlaty, MD, Ohio State University, Columbus, and her colleagues.
Location of the GSVT within 5 cm of the saphenous vein junction (SVJ; 32 patients) as compared with GSVT greater than 5 cm from the SVJ (29 patients) was significantly associated with malignancy (37.5% vs. 6.9%, respectively; P = .01), in-patient status (71.9% vs. 41.4%; P = .02), and diabetes (37.5% vs. 10.3%; P = .02). PE also was significantly greater in patients with GSVT within 5 cm of the SVJ (18.8% vs. 0.0%; P = .02). Patients with GSVT greater than 5 cm from the SVJ showed significantly more GSVT propagation/new saphenous vein thrombosis (0% vs. 31.3%, P = .048). There was a nonsignificant trend toward greater mortality for patients with GSVT within 5 cm of the SVJ (P = .052).
Dr. Kudlaty and her colleagues found that the different management options used, including anticoagulation, observation, and aspirin use, did not significantly affect outcomes (Ann Vasc Surg. 2017 Nov;45:154-9).
“Isolated GSVT can be viewed as a marker of more serious systemic diseases, notably diabetes and cancer, and leaves patients at high risk for thromboembolic events, recurrence, and persistent symptoms, despite a variety of managements,” the researchers concluded.
The authors reported that they had no conflicts of interest and that there were no outside funding sources.
Isolated greater saphenous vein thrombosis is not as benign as generally thought, according to the results of a single institution retrospective study of 61 patients (67 limbs) with isolated GSVT.
Instead, patients had a significant risk of persistent symptoms, recurrence, deep vein thrombosis (DVT), and pulmonary embolism (PE), according to a report published in the Annals of Vascular Surgery by Elizabeth Kudlaty, MD, Ohio State University, Columbus, and her colleagues.
Location of the GSVT within 5 cm of the saphenous vein junction (SVJ; 32 patients) as compared with GSVT greater than 5 cm from the SVJ (29 patients) was significantly associated with malignancy (37.5% vs. 6.9%, respectively; P = .01), in-patient status (71.9% vs. 41.4%; P = .02), and diabetes (37.5% vs. 10.3%; P = .02). PE also was significantly greater in patients with GSVT within 5 cm of the SVJ (18.8% vs. 0.0%; P = .02). Patients with GSVT greater than 5 cm from the SVJ showed significantly more GSVT propagation/new saphenous vein thrombosis (0% vs. 31.3%, P = .048). There was a nonsignificant trend toward greater mortality for patients with GSVT within 5 cm of the SVJ (P = .052).
Dr. Kudlaty and her colleagues found that the different management options used, including anticoagulation, observation, and aspirin use, did not significantly affect outcomes (Ann Vasc Surg. 2017 Nov;45:154-9).
“Isolated GSVT can be viewed as a marker of more serious systemic diseases, notably diabetes and cancer, and leaves patients at high risk for thromboembolic events, recurrence, and persistent symptoms, despite a variety of managements,” the researchers concluded.
The authors reported that they had no conflicts of interest and that there were no outside funding sources.
FROM THE ANNALS OF VASCULAR SURGERY
Key clinical point:
Major finding: Patients with GSVT show a significant risk of persistent symptoms, recurrence, deep vein thrombosis, and pulmonary embolism.
Data source: A retrospective review of all 61 patients with isolated GSVT at a single institution between 2008 and 2014.
Disclosures: The authors reported that they had no conflicts of interest and that there were no outside funding sources.
The Diagnostic Value of 2010 McDonald Criteria Versus 2016 MAGNIMS Guidelines for Special MS Populations
PARIS—When faced with patients with clinically isolated syndrome (CIS) or primary progressive multiple sclerosis (PPMS), diagnosis can be challenging. The 2010 McDonald criteria and the 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) criteria offer sound guidance for relapsing-remitting multiple sclerosis (MS), but for special patient populations, these criteria may fall short. At the Seventh Joint ECTRIMS–ACTRIMS Meeting, two studies looked at the suitability of diagnostic criteria for special MS populations.
Clinically Isolated Syndrome
The recently proposed MAGNIMS dissemination in space criteria include lesions in the optic nerve, cortex, and symptomatic region, in addition to an increase in the required number of periventricular lesions from one to three. Raquel Lamas Pérez, MD, and colleagues aimed to compare the diagnostic performance of the 2010 McDonald and 2016 MAGNIMS MRI criteria for dissemination in space in predicting the conversion to clinically definite MS in patients with CIS. Dr. Lamas Pérez is affiliated with the Hospital Universitario Virgen del Rocío in Sevilla, Spain.
Study inclusion criteria included CIS suggestive of CNS demyelination (since 2008), clinical assessment and baseline brain MRI within six months of CIS onset, availability of spinal cord MRI if patients presented with spinal cord syndrome, and clinical follow-up of at least 24 months.
The researchers included 161 patients with CIS (113 women) with a mean age at onset of 34. After a mean follow-up of 58 months, 102 (63.4%) patients had a diagnosis of MS according to the 2010 McDonald criteria. The overall conversion rate to clinically definite MS was 48.4%. Forty-six (45%) patients initiated a disease-modifying treatment before the second clinical event. The 2010 McDonald dissemination in space criteria were met in 100 (62.1%) and the 2016 MAGNIMS dissemination in space criteria in 95 (59%) patients with CIS. Six patients with one periventricular lesion fulfilled the 2010 McDonald criteria but not the 2016 MAGNIMS criteria. In contrast, when symptomatic infratentorial or spinal cord lesions were included, two more patients met the 2016 dissemination in space criteria than met the 2010 McDonald criteria. The sensitivity, specificity, and positive and negative predictive values of 2010 McDonald criteria were 80.7%, 55.4%, 63%, and 75.4%, respectively, and those for the 2016 MAGNIMS criteria were 75.6%, 56.6%, 62.1%, and 71.2%, respectively. Both dissemination in space criteria identified a subset of patients with CIS who were at high early risk of developing clinically definite MS (hazard ratio: 2.17 for McDonald and 2.07 for MAGNIMS).
“In our CIS patient cohort, 2016 MAGNIMS MRI criteria for dissemination in space showed lower sensitivity with similar specificity than 2010 McDonald criteria in predicting conversion to clinically definite MS, probably related to the increase in the required number of periventricular lesions,” Dr. Lamas Pérez said. “Because disease-modifying therapy can delay or prevent the conversion to clinically definite MS, the high number of patients that initiated these therapies before the second relapse would explain the intermediate specificity values obtained with both MRI criteria.”
Primary Progressive MS
The 2010 McDonald criteria for PPMS have not been fully validated, while 2016 MAGNIMS MRI guidelines have not been studied in PPMS yet.
To assess the sensitivity and specificity of 2010 McDonald and 2016 MAGNIMS criteria for patients with PPMS, Alberto Gajofatto, MD, PhD, Assistant Professor in Neurology in the Department of Neurological and Movement Sciences at the University of Verona in Italy, and colleagues applied the criteria to two retrospective cohorts.
Patients who were seen at the University of California San Francisco and Verona University MS Centers for suspected PPMS were retrospectively identified from existing databases between November 2015 and October 2016. Data were obtained from review of patient charts with adequate documentation of clinical, MRI, and CSF status to determine the fulfillment of 2010 McDonald criteria for PPMS and 2016 MAGNIMS guidelines for dissemination in space at first visit at study centers. PPMS diagnosis was confirmed at last available visit using stringent criteria (ie, dissemination in space according to 2005 McDonald criteria, dissemination in time according to 2001 McDonald criteria, and exclusion of a better explanation).
Dr. Gajofatto and colleagues included 108 patients with a mean follow-up duration of 10.1 years. The 2010 McDonald criteria had a sensitivity for PPMS of 92.1% and a specificity of 57.9%. The highest combined values of sensitivity and specificity (91.8% and 72.2%) were achieved by combining 2016 MAGNIMS dissemination in space criteria and the presence of oligoclonal bands or increased IgG index in the CSF.
“Our findings suggest that 2010 McDonald criteria for PPMS diagnosis have high sensitivity, while specificity appears to be modest,” Dr. Gajofatto said. “The substitution of 2016 MAGNIMS criteria for dissemination in space plus the incorporation of CSF status increased specificity without compromising sensitivity.”
PARIS—When faced with patients with clinically isolated syndrome (CIS) or primary progressive multiple sclerosis (PPMS), diagnosis can be challenging. The 2010 McDonald criteria and the 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) criteria offer sound guidance for relapsing-remitting multiple sclerosis (MS), but for special patient populations, these criteria may fall short. At the Seventh Joint ECTRIMS–ACTRIMS Meeting, two studies looked at the suitability of diagnostic criteria for special MS populations.
Clinically Isolated Syndrome
The recently proposed MAGNIMS dissemination in space criteria include lesions in the optic nerve, cortex, and symptomatic region, in addition to an increase in the required number of periventricular lesions from one to three. Raquel Lamas Pérez, MD, and colleagues aimed to compare the diagnostic performance of the 2010 McDonald and 2016 MAGNIMS MRI criteria for dissemination in space in predicting the conversion to clinically definite MS in patients with CIS. Dr. Lamas Pérez is affiliated with the Hospital Universitario Virgen del Rocío in Sevilla, Spain.
Study inclusion criteria included CIS suggestive of CNS demyelination (since 2008), clinical assessment and baseline brain MRI within six months of CIS onset, availability of spinal cord MRI if patients presented with spinal cord syndrome, and clinical follow-up of at least 24 months.
The researchers included 161 patients with CIS (113 women) with a mean age at onset of 34. After a mean follow-up of 58 months, 102 (63.4%) patients had a diagnosis of MS according to the 2010 McDonald criteria. The overall conversion rate to clinically definite MS was 48.4%. Forty-six (45%) patients initiated a disease-modifying treatment before the second clinical event. The 2010 McDonald dissemination in space criteria were met in 100 (62.1%) and the 2016 MAGNIMS dissemination in space criteria in 95 (59%) patients with CIS. Six patients with one periventricular lesion fulfilled the 2010 McDonald criteria but not the 2016 MAGNIMS criteria. In contrast, when symptomatic infratentorial or spinal cord lesions were included, two more patients met the 2016 dissemination in space criteria than met the 2010 McDonald criteria. The sensitivity, specificity, and positive and negative predictive values of 2010 McDonald criteria were 80.7%, 55.4%, 63%, and 75.4%, respectively, and those for the 2016 MAGNIMS criteria were 75.6%, 56.6%, 62.1%, and 71.2%, respectively. Both dissemination in space criteria identified a subset of patients with CIS who were at high early risk of developing clinically definite MS (hazard ratio: 2.17 for McDonald and 2.07 for MAGNIMS).
“In our CIS patient cohort, 2016 MAGNIMS MRI criteria for dissemination in space showed lower sensitivity with similar specificity than 2010 McDonald criteria in predicting conversion to clinically definite MS, probably related to the increase in the required number of periventricular lesions,” Dr. Lamas Pérez said. “Because disease-modifying therapy can delay or prevent the conversion to clinically definite MS, the high number of patients that initiated these therapies before the second relapse would explain the intermediate specificity values obtained with both MRI criteria.”
Primary Progressive MS
The 2010 McDonald criteria for PPMS have not been fully validated, while 2016 MAGNIMS MRI guidelines have not been studied in PPMS yet.
To assess the sensitivity and specificity of 2010 McDonald and 2016 MAGNIMS criteria for patients with PPMS, Alberto Gajofatto, MD, PhD, Assistant Professor in Neurology in the Department of Neurological and Movement Sciences at the University of Verona in Italy, and colleagues applied the criteria to two retrospective cohorts.
Patients who were seen at the University of California San Francisco and Verona University MS Centers for suspected PPMS were retrospectively identified from existing databases between November 2015 and October 2016. Data were obtained from review of patient charts with adequate documentation of clinical, MRI, and CSF status to determine the fulfillment of 2010 McDonald criteria for PPMS and 2016 MAGNIMS guidelines for dissemination in space at first visit at study centers. PPMS diagnosis was confirmed at last available visit using stringent criteria (ie, dissemination in space according to 2005 McDonald criteria, dissemination in time according to 2001 McDonald criteria, and exclusion of a better explanation).
Dr. Gajofatto and colleagues included 108 patients with a mean follow-up duration of 10.1 years. The 2010 McDonald criteria had a sensitivity for PPMS of 92.1% and a specificity of 57.9%. The highest combined values of sensitivity and specificity (91.8% and 72.2%) were achieved by combining 2016 MAGNIMS dissemination in space criteria and the presence of oligoclonal bands or increased IgG index in the CSF.
“Our findings suggest that 2010 McDonald criteria for PPMS diagnosis have high sensitivity, while specificity appears to be modest,” Dr. Gajofatto said. “The substitution of 2016 MAGNIMS criteria for dissemination in space plus the incorporation of CSF status increased specificity without compromising sensitivity.”
PARIS—When faced with patients with clinically isolated syndrome (CIS) or primary progressive multiple sclerosis (PPMS), diagnosis can be challenging. The 2010 McDonald criteria and the 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) criteria offer sound guidance for relapsing-remitting multiple sclerosis (MS), but for special patient populations, these criteria may fall short. At the Seventh Joint ECTRIMS–ACTRIMS Meeting, two studies looked at the suitability of diagnostic criteria for special MS populations.
Clinically Isolated Syndrome
The recently proposed MAGNIMS dissemination in space criteria include lesions in the optic nerve, cortex, and symptomatic region, in addition to an increase in the required number of periventricular lesions from one to three. Raquel Lamas Pérez, MD, and colleagues aimed to compare the diagnostic performance of the 2010 McDonald and 2016 MAGNIMS MRI criteria for dissemination in space in predicting the conversion to clinically definite MS in patients with CIS. Dr. Lamas Pérez is affiliated with the Hospital Universitario Virgen del Rocío in Sevilla, Spain.
Study inclusion criteria included CIS suggestive of CNS demyelination (since 2008), clinical assessment and baseline brain MRI within six months of CIS onset, availability of spinal cord MRI if patients presented with spinal cord syndrome, and clinical follow-up of at least 24 months.
The researchers included 161 patients with CIS (113 women) with a mean age at onset of 34. After a mean follow-up of 58 months, 102 (63.4%) patients had a diagnosis of MS according to the 2010 McDonald criteria. The overall conversion rate to clinically definite MS was 48.4%. Forty-six (45%) patients initiated a disease-modifying treatment before the second clinical event. The 2010 McDonald dissemination in space criteria were met in 100 (62.1%) and the 2016 MAGNIMS dissemination in space criteria in 95 (59%) patients with CIS. Six patients with one periventricular lesion fulfilled the 2010 McDonald criteria but not the 2016 MAGNIMS criteria. In contrast, when symptomatic infratentorial or spinal cord lesions were included, two more patients met the 2016 dissemination in space criteria than met the 2010 McDonald criteria. The sensitivity, specificity, and positive and negative predictive values of 2010 McDonald criteria were 80.7%, 55.4%, 63%, and 75.4%, respectively, and those for the 2016 MAGNIMS criteria were 75.6%, 56.6%, 62.1%, and 71.2%, respectively. Both dissemination in space criteria identified a subset of patients with CIS who were at high early risk of developing clinically definite MS (hazard ratio: 2.17 for McDonald and 2.07 for MAGNIMS).
“In our CIS patient cohort, 2016 MAGNIMS MRI criteria for dissemination in space showed lower sensitivity with similar specificity than 2010 McDonald criteria in predicting conversion to clinically definite MS, probably related to the increase in the required number of periventricular lesions,” Dr. Lamas Pérez said. “Because disease-modifying therapy can delay or prevent the conversion to clinically definite MS, the high number of patients that initiated these therapies before the second relapse would explain the intermediate specificity values obtained with both MRI criteria.”
Primary Progressive MS
The 2010 McDonald criteria for PPMS have not been fully validated, while 2016 MAGNIMS MRI guidelines have not been studied in PPMS yet.
To assess the sensitivity and specificity of 2010 McDonald and 2016 MAGNIMS criteria for patients with PPMS, Alberto Gajofatto, MD, PhD, Assistant Professor in Neurology in the Department of Neurological and Movement Sciences at the University of Verona in Italy, and colleagues applied the criteria to two retrospective cohorts.
Patients who were seen at the University of California San Francisco and Verona University MS Centers for suspected PPMS were retrospectively identified from existing databases between November 2015 and October 2016. Data were obtained from review of patient charts with adequate documentation of clinical, MRI, and CSF status to determine the fulfillment of 2010 McDonald criteria for PPMS and 2016 MAGNIMS guidelines for dissemination in space at first visit at study centers. PPMS diagnosis was confirmed at last available visit using stringent criteria (ie, dissemination in space according to 2005 McDonald criteria, dissemination in time according to 2001 McDonald criteria, and exclusion of a better explanation).
Dr. Gajofatto and colleagues included 108 patients with a mean follow-up duration of 10.1 years. The 2010 McDonald criteria had a sensitivity for PPMS of 92.1% and a specificity of 57.9%. The highest combined values of sensitivity and specificity (91.8% and 72.2%) were achieved by combining 2016 MAGNIMS dissemination in space criteria and the presence of oligoclonal bands or increased IgG index in the CSF.
“Our findings suggest that 2010 McDonald criteria for PPMS diagnosis have high sensitivity, while specificity appears to be modest,” Dr. Gajofatto said. “The substitution of 2016 MAGNIMS criteria for dissemination in space plus the incorporation of CSF status increased specificity without compromising sensitivity.”
Research projects aid clinical knowledge
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
One of my favorite aspects of research is how reading a paper or working on a project will inevitably augment my clinical knowledge as well.
In terms of my current project, I am pleased to say that I am on track to complete it within the dedicated ten week time period. I am now in writing mode, typing away furiously to complete an abstract to showcase my work, and eventually a manuscript to publish in an academic journal. I believe careful planning and prioritization has helped me stay on track with such a short deadline.
The one problem I have faced in the last couple of weeks has been figuring out how to display my data graphically. Unfortunately, the nature of the data lends itself to tables rather than figurers. Although a figure by itself won’t change the results, I personally enjoy reading papers with interesting figures more than those without them. However, I also don’t want to create meaningless figures just for the sake of having them, so it’s been a challenge figuring out how to display data in a way that will assist readers in interpreting the data.
Overall, this experience has encouraged me to participate in future research projects. I now know the importance of mentors in guiding a successful research project, and the impact preparation and planning can have on the outcome of the project. I am enthusiastic about incorporating clinical research into my medical career.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
One of my favorite aspects of research is how reading a paper or working on a project will inevitably augment my clinical knowledge as well.
In terms of my current project, I am pleased to say that I am on track to complete it within the dedicated ten week time period. I am now in writing mode, typing away furiously to complete an abstract to showcase my work, and eventually a manuscript to publish in an academic journal. I believe careful planning and prioritization has helped me stay on track with such a short deadline.
The one problem I have faced in the last couple of weeks has been figuring out how to display my data graphically. Unfortunately, the nature of the data lends itself to tables rather than figurers. Although a figure by itself won’t change the results, I personally enjoy reading papers with interesting figures more than those without them. However, I also don’t want to create meaningless figures just for the sake of having them, so it’s been a challenge figuring out how to display data in a way that will assist readers in interpreting the data.
Overall, this experience has encouraged me to participate in future research projects. I now know the importance of mentors in guiding a successful research project, and the impact preparation and planning can have on the outcome of the project. I am enthusiastic about incorporating clinical research into my medical career.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
One of my favorite aspects of research is how reading a paper or working on a project will inevitably augment my clinical knowledge as well.
In terms of my current project, I am pleased to say that I am on track to complete it within the dedicated ten week time period. I am now in writing mode, typing away furiously to complete an abstract to showcase my work, and eventually a manuscript to publish in an academic journal. I believe careful planning and prioritization has helped me stay on track with such a short deadline.
The one problem I have faced in the last couple of weeks has been figuring out how to display my data graphically. Unfortunately, the nature of the data lends itself to tables rather than figurers. Although a figure by itself won’t change the results, I personally enjoy reading papers with interesting figures more than those without them. However, I also don’t want to create meaningless figures just for the sake of having them, so it’s been a challenge figuring out how to display data in a way that will assist readers in interpreting the data.
Overall, this experience has encouraged me to participate in future research projects. I now know the importance of mentors in guiding a successful research project, and the impact preparation and planning can have on the outcome of the project. I am enthusiastic about incorporating clinical research into my medical career.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
The Maintenance of Certification wars come to your state
The struggle against mandatory maintenance of certification (MOC) is working its way across the country. Personally, I have always been opposed to mandatory MOC, and based on my experience with the Board of Directors of the American Academy of Dermatology, most of them also are opposed. . Practically, I have not wanted dermatologists to be the first specialty group to break ranks, refuse to participate and be branded as anti-quality and anti-improvement, although there is no good evidence MOC improves quality of care.
While several states have passed anti-MOC legislation, not all are as comprehensive as the proposal in Ohio. Notably, anti-MOC legislation failed in Florida, and is considered dead in Michigan and Mississippi. If you are planning to practice in those states in the near future, you had better stay on the MOC treadmill.
The following was excerpted from my testimony at the Ohio statehouse on Oct. 11 in favor of House Bill 273:
I have nothing personal to gain from passage of this legislation since I am old enough to be “grandfathered” in as lifetime board certified in internal medicine and dermatology. However, since I was serving as president of the American College of Mohs Surgeons and the American Academy of Dermatology, I did retake the certification exam and participate in MOC, just to walk the walk, so to speak ...
My personal experience with MOC has demonstrated how useless much of it is ... most of what I must study and retest on are diseases I will never see. The “quizzes” I pay for and self-score are silly, and the 10-year exam is terrifying since it has little relevance to my practice.
Please note that I am not saying that initial board certification is not of value ... I think the requirement for several years of certified residency training, and years of study do set a high quality bar for physicians, and believe it is a useful exercise for the physician and useful for public safety and quality assurance. I do not believe a practicing physician loses all of this [knowledge] every 10 years, in fact, they learn much more as they go. The MOC process assumes that we are all rusty scuba tanks that need to be pressure tested at 10-year intervals. I must also point out that Ohio physicians are required to complete 100 continuing medical education hours every 2 years for their medical licensure, which I have no complaint about. So even if there is some leakage, there is already some topping off.
I think one board certification gauntlet is enough. I note that physicians are the only professional group masochistic enough to self-flagellate with recertification in such a fashion. ... Lawyers pass their bar once. ...
Physician burnout has been identified as a major issue for Ohio physicians and relieving them of these onerous mandates can only help. These recertification requirements cost a lot of money, and take a lot of time. ... Ohio still has a shortage of physicians relative to other Midwestern states, and anything to make the environment more hospitable is welcome. Some physicians may argue that only physicians should regulate physicians, a position I agree with until it results in unreasonable tyranny by the few [physicians] who may materially profit from the rest [of us]. Then a legislative remedy such as this is called for.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
The struggle against mandatory maintenance of certification (MOC) is working its way across the country. Personally, I have always been opposed to mandatory MOC, and based on my experience with the Board of Directors of the American Academy of Dermatology, most of them also are opposed. . Practically, I have not wanted dermatologists to be the first specialty group to break ranks, refuse to participate and be branded as anti-quality and anti-improvement, although there is no good evidence MOC improves quality of care.
While several states have passed anti-MOC legislation, not all are as comprehensive as the proposal in Ohio. Notably, anti-MOC legislation failed in Florida, and is considered dead in Michigan and Mississippi. If you are planning to practice in those states in the near future, you had better stay on the MOC treadmill.
The following was excerpted from my testimony at the Ohio statehouse on Oct. 11 in favor of House Bill 273:
I have nothing personal to gain from passage of this legislation since I am old enough to be “grandfathered” in as lifetime board certified in internal medicine and dermatology. However, since I was serving as president of the American College of Mohs Surgeons and the American Academy of Dermatology, I did retake the certification exam and participate in MOC, just to walk the walk, so to speak ...
My personal experience with MOC has demonstrated how useless much of it is ... most of what I must study and retest on are diseases I will never see. The “quizzes” I pay for and self-score are silly, and the 10-year exam is terrifying since it has little relevance to my practice.
Please note that I am not saying that initial board certification is not of value ... I think the requirement for several years of certified residency training, and years of study do set a high quality bar for physicians, and believe it is a useful exercise for the physician and useful for public safety and quality assurance. I do not believe a practicing physician loses all of this [knowledge] every 10 years, in fact, they learn much more as they go. The MOC process assumes that we are all rusty scuba tanks that need to be pressure tested at 10-year intervals. I must also point out that Ohio physicians are required to complete 100 continuing medical education hours every 2 years for their medical licensure, which I have no complaint about. So even if there is some leakage, there is already some topping off.
I think one board certification gauntlet is enough. I note that physicians are the only professional group masochistic enough to self-flagellate with recertification in such a fashion. ... Lawyers pass their bar once. ...
Physician burnout has been identified as a major issue for Ohio physicians and relieving them of these onerous mandates can only help. These recertification requirements cost a lot of money, and take a lot of time. ... Ohio still has a shortage of physicians relative to other Midwestern states, and anything to make the environment more hospitable is welcome. Some physicians may argue that only physicians should regulate physicians, a position I agree with until it results in unreasonable tyranny by the few [physicians] who may materially profit from the rest [of us]. Then a legislative remedy such as this is called for.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
The struggle against mandatory maintenance of certification (MOC) is working its way across the country. Personally, I have always been opposed to mandatory MOC, and based on my experience with the Board of Directors of the American Academy of Dermatology, most of them also are opposed. . Practically, I have not wanted dermatologists to be the first specialty group to break ranks, refuse to participate and be branded as anti-quality and anti-improvement, although there is no good evidence MOC improves quality of care.
While several states have passed anti-MOC legislation, not all are as comprehensive as the proposal in Ohio. Notably, anti-MOC legislation failed in Florida, and is considered dead in Michigan and Mississippi. If you are planning to practice in those states in the near future, you had better stay on the MOC treadmill.
The following was excerpted from my testimony at the Ohio statehouse on Oct. 11 in favor of House Bill 273:
I have nothing personal to gain from passage of this legislation since I am old enough to be “grandfathered” in as lifetime board certified in internal medicine and dermatology. However, since I was serving as president of the American College of Mohs Surgeons and the American Academy of Dermatology, I did retake the certification exam and participate in MOC, just to walk the walk, so to speak ...
My personal experience with MOC has demonstrated how useless much of it is ... most of what I must study and retest on are diseases I will never see. The “quizzes” I pay for and self-score are silly, and the 10-year exam is terrifying since it has little relevance to my practice.
Please note that I am not saying that initial board certification is not of value ... I think the requirement for several years of certified residency training, and years of study do set a high quality bar for physicians, and believe it is a useful exercise for the physician and useful for public safety and quality assurance. I do not believe a practicing physician loses all of this [knowledge] every 10 years, in fact, they learn much more as they go. The MOC process assumes that we are all rusty scuba tanks that need to be pressure tested at 10-year intervals. I must also point out that Ohio physicians are required to complete 100 continuing medical education hours every 2 years for their medical licensure, which I have no complaint about. So even if there is some leakage, there is already some topping off.
I think one board certification gauntlet is enough. I note that physicians are the only professional group masochistic enough to self-flagellate with recertification in such a fashion. ... Lawyers pass their bar once. ...
Physician burnout has been identified as a major issue for Ohio physicians and relieving them of these onerous mandates can only help. These recertification requirements cost a lot of money, and take a lot of time. ... Ohio still has a shortage of physicians relative to other Midwestern states, and anything to make the environment more hospitable is welcome. Some physicians may argue that only physicians should regulate physicians, a position I agree with until it results in unreasonable tyranny by the few [physicians] who may materially profit from the rest [of us]. Then a legislative remedy such as this is called for.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].