User login
Mindful kids, part 2: Integration into practice
In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1
An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).2 While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.
Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.
A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.
Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:
- Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
- Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
- As you breathe out, feel your belly drop as you let air out.
- Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.
In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”
This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.
For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:
- The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
- As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
- Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
- Let your hands rest in your lap. Then, move to counting silently in your head.
Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.
In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”
After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.
Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.
Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
Online resources:
- A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
- Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
- Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
- Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).
2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1
An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).2 While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.
Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.
A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.
Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:
- Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
- Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
- As you breathe out, feel your belly drop as you let air out.
- Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.
In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”
This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.
For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:
- The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
- As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
- Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
- Let your hands rest in your lap. Then, move to counting silently in your head.
Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.
In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”
After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.
Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.
Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
Online resources:
- A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
- Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
- Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
- Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).
2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1
An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).2 While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.
Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.
A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.
Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:
- Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
- Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
- As you breathe out, feel your belly drop as you let air out.
- Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.
In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”
This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.
For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:
- The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
- As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
- Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
- Let your hands rest in your lap. Then, move to counting silently in your head.
Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.
In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”
After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.
Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.
Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
Online resources:
- A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
- Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
- Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
- Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).
2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
FDA approves sarilumab for DMARD-intolerant RA patients
The Food and Drug Administration has approved sarilumab (Kevzara), a human monoclonal antibody against the interleukin-6 receptor, for the treatment of adult patients with rheumatoid arthritis (RA), the manufacturer Regeneron Pharmaceuticals announced May 22.
Interleukin-6 is an important factor in RA, as excess amounts of IL-6 build up in the body and contribute to RA-associated inflammation. Sarilumab has been shown to bind to and reduce IL-6R signaling, and is intended for people who have shown inadequate response to or are intolerant to conventional synthetic disease-modifying antirheumatic drugs (DMARDs).
“Not all currently available treatments work in all patients, and some patients may spend years cycling through different treatments without achieving their treatment goals. Sarilumab works differently from the most commonly used biologics, such as those in the anti-TNF [tumor necrosis factor] class, and is a welcome new option for patients and their physicians,” Alan Kivitz, MD, an investigator in sarilumab clinical trials and a rheumatologist in group practice in Duncansville, Pa., said in Regeneron’s announcement.
The recommended dosage of sarilumab is 200 mg once every 2 weeks given as a subcutaneous injection, which can be self-administered. The dosage can be reduced from 200 mg to 150 mg once every 2 weeks, as needed, to help manage certain laboratory abnormalities (neutropenia, thrombocytopenia, and liver enzyme elevations). Significant adverse events associated with sarilumab include weakening of the immune system, changes in certain laboratory tests, perforation in the stomach or intestines, increased risk of cancer, and serious allergic reaction.
The Food and Drug Administration has approved sarilumab (Kevzara), a human monoclonal antibody against the interleukin-6 receptor, for the treatment of adult patients with rheumatoid arthritis (RA), the manufacturer Regeneron Pharmaceuticals announced May 22.
Interleukin-6 is an important factor in RA, as excess amounts of IL-6 build up in the body and contribute to RA-associated inflammation. Sarilumab has been shown to bind to and reduce IL-6R signaling, and is intended for people who have shown inadequate response to or are intolerant to conventional synthetic disease-modifying antirheumatic drugs (DMARDs).
“Not all currently available treatments work in all patients, and some patients may spend years cycling through different treatments without achieving their treatment goals. Sarilumab works differently from the most commonly used biologics, such as those in the anti-TNF [tumor necrosis factor] class, and is a welcome new option for patients and their physicians,” Alan Kivitz, MD, an investigator in sarilumab clinical trials and a rheumatologist in group practice in Duncansville, Pa., said in Regeneron’s announcement.
The recommended dosage of sarilumab is 200 mg once every 2 weeks given as a subcutaneous injection, which can be self-administered. The dosage can be reduced from 200 mg to 150 mg once every 2 weeks, as needed, to help manage certain laboratory abnormalities (neutropenia, thrombocytopenia, and liver enzyme elevations). Significant adverse events associated with sarilumab include weakening of the immune system, changes in certain laboratory tests, perforation in the stomach or intestines, increased risk of cancer, and serious allergic reaction.
The Food and Drug Administration has approved sarilumab (Kevzara), a human monoclonal antibody against the interleukin-6 receptor, for the treatment of adult patients with rheumatoid arthritis (RA), the manufacturer Regeneron Pharmaceuticals announced May 22.
Interleukin-6 is an important factor in RA, as excess amounts of IL-6 build up in the body and contribute to RA-associated inflammation. Sarilumab has been shown to bind to and reduce IL-6R signaling, and is intended for people who have shown inadequate response to or are intolerant to conventional synthetic disease-modifying antirheumatic drugs (DMARDs).
“Not all currently available treatments work in all patients, and some patients may spend years cycling through different treatments without achieving their treatment goals. Sarilumab works differently from the most commonly used biologics, such as those in the anti-TNF [tumor necrosis factor] class, and is a welcome new option for patients and their physicians,” Alan Kivitz, MD, an investigator in sarilumab clinical trials and a rheumatologist in group practice in Duncansville, Pa., said in Regeneron’s announcement.
The recommended dosage of sarilumab is 200 mg once every 2 weeks given as a subcutaneous injection, which can be self-administered. The dosage can be reduced from 200 mg to 150 mg once every 2 weeks, as needed, to help manage certain laboratory abnormalities (neutropenia, thrombocytopenia, and liver enzyme elevations). Significant adverse events associated with sarilumab include weakening of the immune system, changes in certain laboratory tests, perforation in the stomach or intestines, increased risk of cancer, and serious allergic reaction.
Physician-created APMs: Early recommendations offer insight
Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.
Proposals are routed through the Physician-focused Payment Model Technical Advisory Committee (PTAC), comprising physicians and experts in value-based health care systems. Commissioners are appointed by the Comptroller General of the United States.
Each proposals was assigned to three commissioners, including at least one physician, for review against 10 criteria:
- Scope of proposed PFPM (high priority)
- Quality and cost (high priority)
- Payment methodology (high priority)
- Value over volume
- Flexibility
- Ability to be evaluated
- Integration and care coordination
- Patient choice
- Patient safety
- Health information technology
While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”
The two models that got the limited recommendation were
- Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
- APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model.
“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.
Proposals are routed through the Physician-focused Payment Model Technical Advisory Committee (PTAC), comprising physicians and experts in value-based health care systems. Commissioners are appointed by the Comptroller General of the United States.
Each proposals was assigned to three commissioners, including at least one physician, for review against 10 criteria:
- Scope of proposed PFPM (high priority)
- Quality and cost (high priority)
- Payment methodology (high priority)
- Value over volume
- Flexibility
- Ability to be evaluated
- Integration and care coordination
- Patient choice
- Patient safety
- Health information technology
While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”
The two models that got the limited recommendation were
- Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
- APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model.
“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.
Proposals are routed through the Physician-focused Payment Model Technical Advisory Committee (PTAC), comprising physicians and experts in value-based health care systems. Commissioners are appointed by the Comptroller General of the United States.
Each proposals was assigned to three commissioners, including at least one physician, for review against 10 criteria:
- Scope of proposed PFPM (high priority)
- Quality and cost (high priority)
- Payment methodology (high priority)
- Value over volume
- Flexibility
- Ability to be evaluated
- Integration and care coordination
- Patient choice
- Patient safety
- Health information technology
While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”
The two models that got the limited recommendation were
- Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
- APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model.
“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Oral HPV infections sharply lower for vaccinated youth
Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.
“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.
Results of the study showed that only about a sixth of the young adults surveyed between 2011 and 2014 had received at least one dose of an HPV vaccine. But relative to peers who had not received any doses, these young adults had an 88% lower prevalence of oral infection with HPV types 16, 18, 6, and 11, which are covered by vaccines; in particular, prevalence was 100% lower, with complete absence of these infections, in vaccinated young men, compared with unvaccinated young men, Dr. Gillison said in a presscast leading up to the annual meeting of the American Society of Clinical Oncology.
Analyses further suggested that based on levels of vaccine uptake seen in 2014 in the population, the vaccine was preventing only about 17% of the total of approximately 927,000 preventable oral infections with these virus types in that year.
“Our data indicate that HPV vaccines have tremendous potential to prevent oral infection,” said Dr. Gillison, noting that they are already strongly recommended by numerous health and medical organizations. Unfortunately, at the time of the study, “low vaccine uptake limited the population impact of the vaccine.”
However, there is now “considerable optimism,” she said, because recent data have shown that 60% of girls and 40% of boys younger than 18 have received at least one dose of HPV vaccine, marking a major increase in uptake.
“We can’t say that this is cause effect, the impact of these vaccines on infection, because this isn’t a prospective clinical trial,” she acknowledged. “Nevertheless, we can conclude that HPV vaccination may have additional benefits beyond prevention of anogenital cancers.”
The findings are encouraging in that they suggest it will be possible to avert infection-induced oropharyngeal cancer, according to ASCO President-Elect Bruce E. Johnson, MD, who is also chief clinical research officer at the Dana-Farber Cancer Institute and professor of medicine at Harvard Medical School, both in Boston.
“This certainly shows that in the target population to get vaccination, you can indeed prevent the infection, which is one of the first steps that would eventually potentially lead to cancer,” he said.
In the study, Dr. Gillison and her colleagues analyzed data from 2,627 men and women aged 18-33 years who participated in the National Health and Nutrition Examination Survey in the years 2011-2014. Oral rinses were collected as part of the survey to assess HPV infection.
The results showed that 18% of the young adults overall reported having received at least one dose of HPV vaccine, although receipt was much higher among young women than among young men (29% vs. 7%).
The prevalence of oral infection with HPV types 16/18/6/11 was sharply lower for these vaccinated young adults, compared with unvaccinated peers in the cohort as a whole (0.11% vs. 1.6%; P = .008). In a sex-stratified analysis, the reduction was especially striking among men (0% vs. 2%, P = .007), reported Dr. Gillison, who is now professor of thoracic/head and neck medical oncology at the University of Texas MD Anderson Cancer Center, Houston.
The vaccinated and unvaccinated groups did not differ significantly with respect to the combined prevalence of oral infection with 33 types of HPV that are not covered by vaccines.
When HPV vaccine uptake in the population in 2014 was considered, estimates suggested that vaccination was preventing only 17% of all vaccine-preventable oral HPV 16/18/6/11 infections in that year (25% in women and 7% in men).
Research on anogenital HPV infection, especially cervical HPV infection, suggests that most individuals will clear the infection on their own naturally, without any intervention, Dr. Gillison said. However, research has failed to identify good predictors of clearance or persistence.
“That’s why there is the current recommendation for universal vaccination of young boys and girls, because we don’t know how to distinguish someone who, like the overwhelming majority of individuals, is going to clear their infection with their own immune system, versus those who don’t have that capability and could progress to cancer,” she said.
Dr. Gillison disclosed that she has a consulting or advisory role with GlaxoSmithKline, Lilly, Bristol-Myers Squibb, AstraZeneca, Merck, and Celgene, and that she receives research funding (institutional) from Bristol-Myers Squibb, Kyowa Hakko Kirin, AstraZeneca, and Merck.
Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.
“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.
Results of the study showed that only about a sixth of the young adults surveyed between 2011 and 2014 had received at least one dose of an HPV vaccine. But relative to peers who had not received any doses, these young adults had an 88% lower prevalence of oral infection with HPV types 16, 18, 6, and 11, which are covered by vaccines; in particular, prevalence was 100% lower, with complete absence of these infections, in vaccinated young men, compared with unvaccinated young men, Dr. Gillison said in a presscast leading up to the annual meeting of the American Society of Clinical Oncology.
Analyses further suggested that based on levels of vaccine uptake seen in 2014 in the population, the vaccine was preventing only about 17% of the total of approximately 927,000 preventable oral infections with these virus types in that year.
“Our data indicate that HPV vaccines have tremendous potential to prevent oral infection,” said Dr. Gillison, noting that they are already strongly recommended by numerous health and medical organizations. Unfortunately, at the time of the study, “low vaccine uptake limited the population impact of the vaccine.”
However, there is now “considerable optimism,” she said, because recent data have shown that 60% of girls and 40% of boys younger than 18 have received at least one dose of HPV vaccine, marking a major increase in uptake.
“We can’t say that this is cause effect, the impact of these vaccines on infection, because this isn’t a prospective clinical trial,” she acknowledged. “Nevertheless, we can conclude that HPV vaccination may have additional benefits beyond prevention of anogenital cancers.”
The findings are encouraging in that they suggest it will be possible to avert infection-induced oropharyngeal cancer, according to ASCO President-Elect Bruce E. Johnson, MD, who is also chief clinical research officer at the Dana-Farber Cancer Institute and professor of medicine at Harvard Medical School, both in Boston.
“This certainly shows that in the target population to get vaccination, you can indeed prevent the infection, which is one of the first steps that would eventually potentially lead to cancer,” he said.
In the study, Dr. Gillison and her colleagues analyzed data from 2,627 men and women aged 18-33 years who participated in the National Health and Nutrition Examination Survey in the years 2011-2014. Oral rinses were collected as part of the survey to assess HPV infection.
The results showed that 18% of the young adults overall reported having received at least one dose of HPV vaccine, although receipt was much higher among young women than among young men (29% vs. 7%).
The prevalence of oral infection with HPV types 16/18/6/11 was sharply lower for these vaccinated young adults, compared with unvaccinated peers in the cohort as a whole (0.11% vs. 1.6%; P = .008). In a sex-stratified analysis, the reduction was especially striking among men (0% vs. 2%, P = .007), reported Dr. Gillison, who is now professor of thoracic/head and neck medical oncology at the University of Texas MD Anderson Cancer Center, Houston.
The vaccinated and unvaccinated groups did not differ significantly with respect to the combined prevalence of oral infection with 33 types of HPV that are not covered by vaccines.
When HPV vaccine uptake in the population in 2014 was considered, estimates suggested that vaccination was preventing only 17% of all vaccine-preventable oral HPV 16/18/6/11 infections in that year (25% in women and 7% in men).
Research on anogenital HPV infection, especially cervical HPV infection, suggests that most individuals will clear the infection on their own naturally, without any intervention, Dr. Gillison said. However, research has failed to identify good predictors of clearance or persistence.
“That’s why there is the current recommendation for universal vaccination of young boys and girls, because we don’t know how to distinguish someone who, like the overwhelming majority of individuals, is going to clear their infection with their own immune system, versus those who don’t have that capability and could progress to cancer,” she said.
Dr. Gillison disclosed that she has a consulting or advisory role with GlaxoSmithKline, Lilly, Bristol-Myers Squibb, AstraZeneca, Merck, and Celgene, and that she receives research funding (institutional) from Bristol-Myers Squibb, Kyowa Hakko Kirin, AstraZeneca, and Merck.
Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.
“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.
Results of the study showed that only about a sixth of the young adults surveyed between 2011 and 2014 had received at least one dose of an HPV vaccine. But relative to peers who had not received any doses, these young adults had an 88% lower prevalence of oral infection with HPV types 16, 18, 6, and 11, which are covered by vaccines; in particular, prevalence was 100% lower, with complete absence of these infections, in vaccinated young men, compared with unvaccinated young men, Dr. Gillison said in a presscast leading up to the annual meeting of the American Society of Clinical Oncology.
Analyses further suggested that based on levels of vaccine uptake seen in 2014 in the population, the vaccine was preventing only about 17% of the total of approximately 927,000 preventable oral infections with these virus types in that year.
“Our data indicate that HPV vaccines have tremendous potential to prevent oral infection,” said Dr. Gillison, noting that they are already strongly recommended by numerous health and medical organizations. Unfortunately, at the time of the study, “low vaccine uptake limited the population impact of the vaccine.”
However, there is now “considerable optimism,” she said, because recent data have shown that 60% of girls and 40% of boys younger than 18 have received at least one dose of HPV vaccine, marking a major increase in uptake.
“We can’t say that this is cause effect, the impact of these vaccines on infection, because this isn’t a prospective clinical trial,” she acknowledged. “Nevertheless, we can conclude that HPV vaccination may have additional benefits beyond prevention of anogenital cancers.”
The findings are encouraging in that they suggest it will be possible to avert infection-induced oropharyngeal cancer, according to ASCO President-Elect Bruce E. Johnson, MD, who is also chief clinical research officer at the Dana-Farber Cancer Institute and professor of medicine at Harvard Medical School, both in Boston.
“This certainly shows that in the target population to get vaccination, you can indeed prevent the infection, which is one of the first steps that would eventually potentially lead to cancer,” he said.
In the study, Dr. Gillison and her colleagues analyzed data from 2,627 men and women aged 18-33 years who participated in the National Health and Nutrition Examination Survey in the years 2011-2014. Oral rinses were collected as part of the survey to assess HPV infection.
The results showed that 18% of the young adults overall reported having received at least one dose of HPV vaccine, although receipt was much higher among young women than among young men (29% vs. 7%).
The prevalence of oral infection with HPV types 16/18/6/11 was sharply lower for these vaccinated young adults, compared with unvaccinated peers in the cohort as a whole (0.11% vs. 1.6%; P = .008). In a sex-stratified analysis, the reduction was especially striking among men (0% vs. 2%, P = .007), reported Dr. Gillison, who is now professor of thoracic/head and neck medical oncology at the University of Texas MD Anderson Cancer Center, Houston.
The vaccinated and unvaccinated groups did not differ significantly with respect to the combined prevalence of oral infection with 33 types of HPV that are not covered by vaccines.
When HPV vaccine uptake in the population in 2014 was considered, estimates suggested that vaccination was preventing only 17% of all vaccine-preventable oral HPV 16/18/6/11 infections in that year (25% in women and 7% in men).
Research on anogenital HPV infection, especially cervical HPV infection, suggests that most individuals will clear the infection on their own naturally, without any intervention, Dr. Gillison said. However, research has failed to identify good predictors of clearance or persistence.
“That’s why there is the current recommendation for universal vaccination of young boys and girls, because we don’t know how to distinguish someone who, like the overwhelming majority of individuals, is going to clear their infection with their own immune system, versus those who don’t have that capability and could progress to cancer,” she said.
Dr. Gillison disclosed that she has a consulting or advisory role with GlaxoSmithKline, Lilly, Bristol-Myers Squibb, AstraZeneca, Merck, and Celgene, and that she receives research funding (institutional) from Bristol-Myers Squibb, Kyowa Hakko Kirin, AstraZeneca, and Merck.
FROM THE 2017 ASCO ANNUAL MEETING
Key clinical point:
Major finding: Compared with unvaccinated peers, young adults who had received at least one dose of HPV vaccine had an 88% lower prevalence of oral infection with HPV types 16/18/6/11.
Data source: A cross-sectional cohort study of 2,627 men and women aged 18-33 years who participated in the National Health and Nutrition Examination Survey during 2011-2014.
Disclosures: Dr. Gillison disclosed that she has a consulting or advisory role with GlaxoSmithKline, Lilly, Bristol-Myers Squibb, AstraZeneca, Merck, and Celgene, and that she receives research funding (institutional) from Bristol-Myers Squibb, Kyowa Hakko Kirin, AstraZeneca, and Merck.
VIDEO: Use oil-based contrast for HSG fertility boost
VANCOUVER – Ongoing pregnancies and live births were substantially higher when oil-based contrast, instead of water-based contrast, was used for hysterosalpingography (HSG) in a randomized trial at 27 hospitals in the Netherlands.
It’s long been known that HSG, commonly used to assess reproductive tract patency, also improves fertility, perhaps by immunologic effects or simply by flushing debris and mucus out of the fallopian tubes. Until now, however, it’s been unclear if oil or water contrast boosts fertility the most.
To find out, investigators randomized 554 infertile women scheduled for HSG to poppy seed oil contrast (Lipiodol Ultra-Fluid, Guerbet) and 554 others to water contrast (Telebrix Hystero, Guerbet).
A total of 220 women in the oil group (39.7%), but 161 in the water group (29.1%), achieved ongoing pregnancies (rate ratio in favor of oil, 1.37; 95% CI, 1.16-1.61; P less than 0.001). Of 552 women in each of the groups, 214 in the oil group (38.8%) and 155 in the water group (28.1%) had live births (RR, 1.38; 95% CI, 1.17-1.64; P less than 0.001). Rates of adverse events were low and similar in the two groups. About three-quarters of the pregnancies were naturally conceived, and most of the rest resulted from intrauterine insemination. Only a few women in each group used in vitro fertilization (N Engl J Med. 2017 May 18. doi: 10.1056/NEJMoa1612337).
Three women in the oil group, but none in the water group, delivered a child with a congenital anomaly. “This finding is probably due to chance. The frequency of congenital anomalies with oil contrast was not greater than rates reported in the general population, and we are unaware of other data suggesting an increased risk of congenital anomalies with oil contrast,” the researchers said.
In an interview at the World Congress on Endometriosis, senior investigator Ben Mol, MD, PhD, a professor of obstetrics and gynecology at the University of Adelaide (Australia), shared his thoughts on how the new findings should be used in routine practice when women with endometriosis and other conditions experience difficulty conceiving.
There was no industry funding for the work. Dr. Mol reported personal fees from Guerbet unrelated to the study.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
VANCOUVER – Ongoing pregnancies and live births were substantially higher when oil-based contrast, instead of water-based contrast, was used for hysterosalpingography (HSG) in a randomized trial at 27 hospitals in the Netherlands.
It’s long been known that HSG, commonly used to assess reproductive tract patency, also improves fertility, perhaps by immunologic effects or simply by flushing debris and mucus out of the fallopian tubes. Until now, however, it’s been unclear if oil or water contrast boosts fertility the most.
To find out, investigators randomized 554 infertile women scheduled for HSG to poppy seed oil contrast (Lipiodol Ultra-Fluid, Guerbet) and 554 others to water contrast (Telebrix Hystero, Guerbet).
A total of 220 women in the oil group (39.7%), but 161 in the water group (29.1%), achieved ongoing pregnancies (rate ratio in favor of oil, 1.37; 95% CI, 1.16-1.61; P less than 0.001). Of 552 women in each of the groups, 214 in the oil group (38.8%) and 155 in the water group (28.1%) had live births (RR, 1.38; 95% CI, 1.17-1.64; P less than 0.001). Rates of adverse events were low and similar in the two groups. About three-quarters of the pregnancies were naturally conceived, and most of the rest resulted from intrauterine insemination. Only a few women in each group used in vitro fertilization (N Engl J Med. 2017 May 18. doi: 10.1056/NEJMoa1612337).
Three women in the oil group, but none in the water group, delivered a child with a congenital anomaly. “This finding is probably due to chance. The frequency of congenital anomalies with oil contrast was not greater than rates reported in the general population, and we are unaware of other data suggesting an increased risk of congenital anomalies with oil contrast,” the researchers said.
In an interview at the World Congress on Endometriosis, senior investigator Ben Mol, MD, PhD, a professor of obstetrics and gynecology at the University of Adelaide (Australia), shared his thoughts on how the new findings should be used in routine practice when women with endometriosis and other conditions experience difficulty conceiving.
There was no industry funding for the work. Dr. Mol reported personal fees from Guerbet unrelated to the study.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
VANCOUVER – Ongoing pregnancies and live births were substantially higher when oil-based contrast, instead of water-based contrast, was used for hysterosalpingography (HSG) in a randomized trial at 27 hospitals in the Netherlands.
It’s long been known that HSG, commonly used to assess reproductive tract patency, also improves fertility, perhaps by immunologic effects or simply by flushing debris and mucus out of the fallopian tubes. Until now, however, it’s been unclear if oil or water contrast boosts fertility the most.
To find out, investigators randomized 554 infertile women scheduled for HSG to poppy seed oil contrast (Lipiodol Ultra-Fluid, Guerbet) and 554 others to water contrast (Telebrix Hystero, Guerbet).
A total of 220 women in the oil group (39.7%), but 161 in the water group (29.1%), achieved ongoing pregnancies (rate ratio in favor of oil, 1.37; 95% CI, 1.16-1.61; P less than 0.001). Of 552 women in each of the groups, 214 in the oil group (38.8%) and 155 in the water group (28.1%) had live births (RR, 1.38; 95% CI, 1.17-1.64; P less than 0.001). Rates of adverse events were low and similar in the two groups. About three-quarters of the pregnancies were naturally conceived, and most of the rest resulted from intrauterine insemination. Only a few women in each group used in vitro fertilization (N Engl J Med. 2017 May 18. doi: 10.1056/NEJMoa1612337).
Three women in the oil group, but none in the water group, delivered a child with a congenital anomaly. “This finding is probably due to chance. The frequency of congenital anomalies with oil contrast was not greater than rates reported in the general population, and we are unaware of other data suggesting an increased risk of congenital anomalies with oil contrast,” the researchers said.
In an interview at the World Congress on Endometriosis, senior investigator Ben Mol, MD, PhD, a professor of obstetrics and gynecology at the University of Adelaide (Australia), shared his thoughts on how the new findings should be used in routine practice when women with endometriosis and other conditions experience difficulty conceiving.
There was no industry funding for the work. Dr. Mol reported personal fees from Guerbet unrelated to the study.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT WEC 2017
VIDEO: Chronic cough drug shows phase II efficacy, tolerability
WASHINGTON – A new oral drug that blocks a nerve ion channel was generally tolerable and effective at reducing chronic, refractory cough in a placebo-controlled, dose-ranging, phase II study with 252 patients.
A 50 mg b.i.d dosage of MK-7264 cut cough frequency by at least 30% in 80% of patients, compared with 44% of patients on placebo, Jaclyn A. Smith, MD, said at an international conference of the American Thoracic Society.
At that dosage, 48% of patients reported some change in their taste sensations, an expected drug effect, with about 40% characterizing it as very bothersome or extremely bothersome. An additional 9% reported a complete loss of taste. However, only 6 patients out of 63 randomized to this dosage stopped taking their medication, suggesting that the drug was tolerable for most patients. The results also suggested that lower dosages with less potent taste adverse effects produced significant cough reductions in some patients.
“Patients with chronic, refractory cough are often “willing to accept some taste change to reduce their cough count. Patients are willing to put up with the taste side effects,” Dr. Smith said in a video interview.
The study enrolled patients with chronic, refractory cough at U.S. and UK centers and randomized 63 to each of three active treatment arms receiving 7.5 mg, 20 mg, or 50 mg b.i.d. of MK-7264 or to placebo for 12 weeks. The patients averaged 60 years of age and about three-quarters were women. On average, they had their cough for more than 10 years, and these patients coughed roughly 30 times an hour when awake.
The study’s primary endpoint was reduction in awake cough frequency, and, after 12 weeks on treatment with 50 mg b.i.d., this had fallen an average of 37%, compared with placebo, said Dr. Smith, a professor of respiratory medicine at the University of Manchester, England.
The 7.5-mg and 20-mg b.i.d. dosages each led to cough frequency reductions of about 22% over placebo that were not statistically significant. This was likely a result of the unexpectedly strong placebo effect in the study, Dr. Smith said. Most of the cough effect was evident after the first 4 weeks on treatment.
Dr. Smith noted that she and her associates “most definitely” plan to progress to a phase III trial. “We really lack effective treatments for cough,” she said.
The study was sponsored by Merck, the company developing MK-7264. Dr. Smith is a consultant to Merck and has a licensing agreement with Vitalograph.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
WASHINGTON – A new oral drug that blocks a nerve ion channel was generally tolerable and effective at reducing chronic, refractory cough in a placebo-controlled, dose-ranging, phase II study with 252 patients.
A 50 mg b.i.d dosage of MK-7264 cut cough frequency by at least 30% in 80% of patients, compared with 44% of patients on placebo, Jaclyn A. Smith, MD, said at an international conference of the American Thoracic Society.
At that dosage, 48% of patients reported some change in their taste sensations, an expected drug effect, with about 40% characterizing it as very bothersome or extremely bothersome. An additional 9% reported a complete loss of taste. However, only 6 patients out of 63 randomized to this dosage stopped taking their medication, suggesting that the drug was tolerable for most patients. The results also suggested that lower dosages with less potent taste adverse effects produced significant cough reductions in some patients.
“Patients with chronic, refractory cough are often “willing to accept some taste change to reduce their cough count. Patients are willing to put up with the taste side effects,” Dr. Smith said in a video interview.
The study enrolled patients with chronic, refractory cough at U.S. and UK centers and randomized 63 to each of three active treatment arms receiving 7.5 mg, 20 mg, or 50 mg b.i.d. of MK-7264 or to placebo for 12 weeks. The patients averaged 60 years of age and about three-quarters were women. On average, they had their cough for more than 10 years, and these patients coughed roughly 30 times an hour when awake.
The study’s primary endpoint was reduction in awake cough frequency, and, after 12 weeks on treatment with 50 mg b.i.d., this had fallen an average of 37%, compared with placebo, said Dr. Smith, a professor of respiratory medicine at the University of Manchester, England.
The 7.5-mg and 20-mg b.i.d. dosages each led to cough frequency reductions of about 22% over placebo that were not statistically significant. This was likely a result of the unexpectedly strong placebo effect in the study, Dr. Smith said. Most of the cough effect was evident after the first 4 weeks on treatment.
Dr. Smith noted that she and her associates “most definitely” plan to progress to a phase III trial. “We really lack effective treatments for cough,” she said.
The study was sponsored by Merck, the company developing MK-7264. Dr. Smith is a consultant to Merck and has a licensing agreement with Vitalograph.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
WASHINGTON – A new oral drug that blocks a nerve ion channel was generally tolerable and effective at reducing chronic, refractory cough in a placebo-controlled, dose-ranging, phase II study with 252 patients.
A 50 mg b.i.d dosage of MK-7264 cut cough frequency by at least 30% in 80% of patients, compared with 44% of patients on placebo, Jaclyn A. Smith, MD, said at an international conference of the American Thoracic Society.
At that dosage, 48% of patients reported some change in their taste sensations, an expected drug effect, with about 40% characterizing it as very bothersome or extremely bothersome. An additional 9% reported a complete loss of taste. However, only 6 patients out of 63 randomized to this dosage stopped taking their medication, suggesting that the drug was tolerable for most patients. The results also suggested that lower dosages with less potent taste adverse effects produced significant cough reductions in some patients.
“Patients with chronic, refractory cough are often “willing to accept some taste change to reduce their cough count. Patients are willing to put up with the taste side effects,” Dr. Smith said in a video interview.
The study enrolled patients with chronic, refractory cough at U.S. and UK centers and randomized 63 to each of three active treatment arms receiving 7.5 mg, 20 mg, or 50 mg b.i.d. of MK-7264 or to placebo for 12 weeks. The patients averaged 60 years of age and about three-quarters were women. On average, they had their cough for more than 10 years, and these patients coughed roughly 30 times an hour when awake.
The study’s primary endpoint was reduction in awake cough frequency, and, after 12 weeks on treatment with 50 mg b.i.d., this had fallen an average of 37%, compared with placebo, said Dr. Smith, a professor of respiratory medicine at the University of Manchester, England.
The 7.5-mg and 20-mg b.i.d. dosages each led to cough frequency reductions of about 22% over placebo that were not statistically significant. This was likely a result of the unexpectedly strong placebo effect in the study, Dr. Smith said. Most of the cough effect was evident after the first 4 weeks on treatment.
Dr. Smith noted that she and her associates “most definitely” plan to progress to a phase III trial. “We really lack effective treatments for cough,” she said.
The study was sponsored by Merck, the company developing MK-7264. Dr. Smith is a consultant to Merck and has a licensing agreement with Vitalograph.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
AT ATS 2017
Key clinical point:
Major finding: A 50 mg b.i.d. dosage of MK-7264 reduced awake cough frequency by an average of 37%, compared with placebo.
Data source: A multicenter, randomized, placebo-controlled, dose-ranging study with 252 patients.
Disclosures: The study was sponsored by Merck, the company developing MK-7264. Dr. Smith is a consultant to Merck and has a licensing agreement with Vitalograph.
Biologic may reduce glucocorticoid use
WASHINGTON – The biologic benralizumab cut glucocorticoid dosage by nearly 75% among patients with severe, uncontrolled asthma, compared with a 25% reduction in dosage among patients using a placebo, according to a study.
In this three-armed, double-blind study of 220 patients, those administered benralizumab every 4 and 8 weeks were 4.09 (95% confidence interval, 2.22-7.57) and 4.12 (95% CI, 2.22-7.57) times as likely to see a reduction in glucocorticoid dose, compared with those in the placebo group, according to investigators (NEJM. 2017 May 21. doi: 10.1056/NEJMoa1703501).The study was presented at an international conference of the American Thoracic Society and published simultaneously in the New England Journal of Medicine.
“Frequent or long-term use of systemic corticosteroids can lead to potentially life-threatening complications, including osteoporosis, diabetes, cardiovascular disease, and adrenal suppression,” Parameswaran Nair, MD, PhD, professor at McMaster University, Hamilton, Ont., said in a press release. “We need new, safe therapies that would replace the need for systemic corticosteroids for patients with severe asthma.”
To test benralizumab’s effectiveness, investigators measured a baseline level of glucocorticoid dosage of 220 patients with severe, uncontrolled asthma. Patients were then given one of three treatment options: one dose of benralizumab every 4 weeks, one dose of benralizumab every 8 weeks, or a placebo. All three treatments were decreased each time until minimal dosage was found while still maintaining asthma control. The average age of patients was around 50 years, with the majority of patients in both treatment groups and the placebo group having been female.
The researchers also analyzed patients’ accounts of any worsening asthma symptoms, which were recorded in an electronic asthma daily diary.
Along with the median 75% decrease in glucocorticoid dosage seen in both groups of patients receiving benralizumab, 24 patients (33%) in the 4-week group and 27 patients in the 8-week group (37%) showed a 90% reduction from their baseline glucocorticoid dosage. In contrast, only nine patients (12%) in the placebo group experienced a 90% drop in glucocorticoid use.
The researchers observed an additional finding suggesting benralizumab’s usefulness in a subgroup of patients with a baseline prednisone dose of less than 12.5 mg. These patients were more likely to stop taking their glucocorticoid dose if they were taking benralizumab instead of the placebo. Specifically, patients who took benralizumab every 4 weeks were 5.23 times more likely and those who took the biologic every 8 weeks were 4.19 times more likely to cease using glucocorticoids.
Similar to the current biologics used to treat severe eosinophilic asthma, mepolizumab and reslizumab, benralizumab is a form of a monoclonal antibody. Instead of targeting interleukin-5, benralizumab works against a subunit of the iterleukin-5 receptor. They investigators said this aspect of benralizumab may explain why it was successful in this study.
“Targeting of the alpha-subunit of the iterleukin-5 receptor with benralizumab has potential advantages over existing anti–interleukin-5 therapies,” according to Dr. Nier and fellow investigators. “By targeting the interleukin receptor rather than the cytokine, luminal depletion of eosinophils can occur, which may be related to greater clinical efficiency.”
The investigators noted that FEV1 levels seemed relatively unaffected by benralizumab.
This study was limited by the length of the trials, which lasted 28 weeks. Investigators also note that 20% of the original patients were not used in the final population.
This study was sponsored by, and organized in partnership with, AstraZeneca. All of the investigators reported having a financial or other type of relationship with AstraZeneca.
[email protected]
On Twitter @eaztweets
WASHINGTON – The biologic benralizumab cut glucocorticoid dosage by nearly 75% among patients with severe, uncontrolled asthma, compared with a 25% reduction in dosage among patients using a placebo, according to a study.
In this three-armed, double-blind study of 220 patients, those administered benralizumab every 4 and 8 weeks were 4.09 (95% confidence interval, 2.22-7.57) and 4.12 (95% CI, 2.22-7.57) times as likely to see a reduction in glucocorticoid dose, compared with those in the placebo group, according to investigators (NEJM. 2017 May 21. doi: 10.1056/NEJMoa1703501).The study was presented at an international conference of the American Thoracic Society and published simultaneously in the New England Journal of Medicine.
“Frequent or long-term use of systemic corticosteroids can lead to potentially life-threatening complications, including osteoporosis, diabetes, cardiovascular disease, and adrenal suppression,” Parameswaran Nair, MD, PhD, professor at McMaster University, Hamilton, Ont., said in a press release. “We need new, safe therapies that would replace the need for systemic corticosteroids for patients with severe asthma.”
To test benralizumab’s effectiveness, investigators measured a baseline level of glucocorticoid dosage of 220 patients with severe, uncontrolled asthma. Patients were then given one of three treatment options: one dose of benralizumab every 4 weeks, one dose of benralizumab every 8 weeks, or a placebo. All three treatments were decreased each time until minimal dosage was found while still maintaining asthma control. The average age of patients was around 50 years, with the majority of patients in both treatment groups and the placebo group having been female.
The researchers also analyzed patients’ accounts of any worsening asthma symptoms, which were recorded in an electronic asthma daily diary.
Along with the median 75% decrease in glucocorticoid dosage seen in both groups of patients receiving benralizumab, 24 patients (33%) in the 4-week group and 27 patients in the 8-week group (37%) showed a 90% reduction from their baseline glucocorticoid dosage. In contrast, only nine patients (12%) in the placebo group experienced a 90% drop in glucocorticoid use.
The researchers observed an additional finding suggesting benralizumab’s usefulness in a subgroup of patients with a baseline prednisone dose of less than 12.5 mg. These patients were more likely to stop taking their glucocorticoid dose if they were taking benralizumab instead of the placebo. Specifically, patients who took benralizumab every 4 weeks were 5.23 times more likely and those who took the biologic every 8 weeks were 4.19 times more likely to cease using glucocorticoids.
Similar to the current biologics used to treat severe eosinophilic asthma, mepolizumab and reslizumab, benralizumab is a form of a monoclonal antibody. Instead of targeting interleukin-5, benralizumab works against a subunit of the iterleukin-5 receptor. They investigators said this aspect of benralizumab may explain why it was successful in this study.
“Targeting of the alpha-subunit of the iterleukin-5 receptor with benralizumab has potential advantages over existing anti–interleukin-5 therapies,” according to Dr. Nier and fellow investigators. “By targeting the interleukin receptor rather than the cytokine, luminal depletion of eosinophils can occur, which may be related to greater clinical efficiency.”
The investigators noted that FEV1 levels seemed relatively unaffected by benralizumab.
This study was limited by the length of the trials, which lasted 28 weeks. Investigators also note that 20% of the original patients were not used in the final population.
This study was sponsored by, and organized in partnership with, AstraZeneca. All of the investigators reported having a financial or other type of relationship with AstraZeneca.
[email protected]
On Twitter @eaztweets
WASHINGTON – The biologic benralizumab cut glucocorticoid dosage by nearly 75% among patients with severe, uncontrolled asthma, compared with a 25% reduction in dosage among patients using a placebo, according to a study.
In this three-armed, double-blind study of 220 patients, those administered benralizumab every 4 and 8 weeks were 4.09 (95% confidence interval, 2.22-7.57) and 4.12 (95% CI, 2.22-7.57) times as likely to see a reduction in glucocorticoid dose, compared with those in the placebo group, according to investigators (NEJM. 2017 May 21. doi: 10.1056/NEJMoa1703501).The study was presented at an international conference of the American Thoracic Society and published simultaneously in the New England Journal of Medicine.
“Frequent or long-term use of systemic corticosteroids can lead to potentially life-threatening complications, including osteoporosis, diabetes, cardiovascular disease, and adrenal suppression,” Parameswaran Nair, MD, PhD, professor at McMaster University, Hamilton, Ont., said in a press release. “We need new, safe therapies that would replace the need for systemic corticosteroids for patients with severe asthma.”
To test benralizumab’s effectiveness, investigators measured a baseline level of glucocorticoid dosage of 220 patients with severe, uncontrolled asthma. Patients were then given one of three treatment options: one dose of benralizumab every 4 weeks, one dose of benralizumab every 8 weeks, or a placebo. All three treatments were decreased each time until minimal dosage was found while still maintaining asthma control. The average age of patients was around 50 years, with the majority of patients in both treatment groups and the placebo group having been female.
The researchers also analyzed patients’ accounts of any worsening asthma symptoms, which were recorded in an electronic asthma daily diary.
Along with the median 75% decrease in glucocorticoid dosage seen in both groups of patients receiving benralizumab, 24 patients (33%) in the 4-week group and 27 patients in the 8-week group (37%) showed a 90% reduction from their baseline glucocorticoid dosage. In contrast, only nine patients (12%) in the placebo group experienced a 90% drop in glucocorticoid use.
The researchers observed an additional finding suggesting benralizumab’s usefulness in a subgroup of patients with a baseline prednisone dose of less than 12.5 mg. These patients were more likely to stop taking their glucocorticoid dose if they were taking benralizumab instead of the placebo. Specifically, patients who took benralizumab every 4 weeks were 5.23 times more likely and those who took the biologic every 8 weeks were 4.19 times more likely to cease using glucocorticoids.
Similar to the current biologics used to treat severe eosinophilic asthma, mepolizumab and reslizumab, benralizumab is a form of a monoclonal antibody. Instead of targeting interleukin-5, benralizumab works against a subunit of the iterleukin-5 receptor. They investigators said this aspect of benralizumab may explain why it was successful in this study.
“Targeting of the alpha-subunit of the iterleukin-5 receptor with benralizumab has potential advantages over existing anti–interleukin-5 therapies,” according to Dr. Nier and fellow investigators. “By targeting the interleukin receptor rather than the cytokine, luminal depletion of eosinophils can occur, which may be related to greater clinical efficiency.”
The investigators noted that FEV1 levels seemed relatively unaffected by benralizumab.
This study was limited by the length of the trials, which lasted 28 weeks. Investigators also note that 20% of the original patients were not used in the final population.
This study was sponsored by, and organized in partnership with, AstraZeneca. All of the investigators reported having a financial or other type of relationship with AstraZeneca.
[email protected]
On Twitter @eaztweets
FROM ATS 2017
Key clinical point:
Major finding: Patients administered benralizumab averaged a 75% reduction rate in final glucocorticoid dosage, compared with 25% in the control group (P less than .001).
Data source: Randomized, double blind, placebo-controlled study of 220 patients with severe asthma given benralizumab every 4 weeks or every 8 weeks or a placebo between April 2014 and November 2015.
Disclosures: The study was sponsored by and designed in collaboration with AstraZeneca. All of the investigators reported having a financial or other type of relationship with AstraZeneca.
Treatment challenges for lichen planopilaris
SYDNEY – Responses to treatments for lichen planopilaris varied widely, and decreased with second- and third-line therapies, in a retrospective study, Karolina Kerkemeyer, MD, said at the annual meeting of the Australasian College of Dermatologists.
An analysis of computerized medical records for 32 patients who had been treated for lichen planopilaris at a tertiary referral hair center in Australia was conducted from 2012 to 2016 by Dr. Kerkemeyer of the University of Notre Dame Australia, Werribee, and Jack Green, MD, of the Skin and Cancer Foundation and St. Vincent’s Hospital in Melbourne. The study excluded patients with a dual diagnosis, or those followed for less than 12 months.
The most common treatment was topical steroids, used to treat 31 patients, followed by tetracyclines – minocycline or doxycycline – used to treat 21 patients, and hydroxychloroquine, used to treat 18 patients. Some patients were also treated with steroid-sparing immunosuppressants, including methotrexate, mycophenolate, and cyclosporine. Fourteen patients were also treated with intralesional steroids, and seven were treated with topical tacrolimus.
The researchers used a graded four-point scale to assess patients’ response to treatment, which corresponded to remission, partial improvement, no change, and worsening of disease, based on patients’ clinical signs, symptoms, and extent of alopecia.
Only a small proportion – about 15% – of patients achieved remission, which was seen with topical steroids, hydroxychloroquine, and doxycycline. About one-third of patients treated with doxycycline actually showed a worsening of symptoms.
The greatest proportion (75%) of patients with partial remission was among those treated with systemic acitretin, although the numbers were low (three of four patients who received this therapy).
In addition, one of the seven patients treated with minocycline achieved partial remission during this therapy, one showed a worsening of the condition, and the remaining five were unchanged. Among those treated with an immunosuppressant, the 3 patients treated with mycophenolate had no change in the condition; 4 of the 10 patients treated with methotrexate achieved partial remission, 4 were unchanged, and 2 experienced a worsening of the condition. One of the three patients treated with cyclosporine achieved partial remission while the other two remained unchanged. With topical tacrolimus, two patients achieved partial remission, two showed a worsening of the condition, and the remaining three were unchanged.
The response rates to treatment significantly decreased with subsequent therapies: 18 of the 32 patients responded to first-line treatments, compared with 7 of 19 who received second-line treatment and only 1 of 9 patients who received third-line treatment. “Many patients were not responsive to therapy, highlighting the difficulty of treating this scarring alopecia,” Dr. Kerkemeyer said.
In an interview, she said that topical or intralesional steroids seemed to be the best first-line option because they are associated with fewer side effects than other options. “They were easier to start off in patients first,” and for those who do not respond, switching to another treatment, such as topical tacrolimus, if they wanted a topical option, or an oral treatment, such as an immunosuppressant like methotrexate, she noted.
No conflicts of interest were declared.
SYDNEY – Responses to treatments for lichen planopilaris varied widely, and decreased with second- and third-line therapies, in a retrospective study, Karolina Kerkemeyer, MD, said at the annual meeting of the Australasian College of Dermatologists.
An analysis of computerized medical records for 32 patients who had been treated for lichen planopilaris at a tertiary referral hair center in Australia was conducted from 2012 to 2016 by Dr. Kerkemeyer of the University of Notre Dame Australia, Werribee, and Jack Green, MD, of the Skin and Cancer Foundation and St. Vincent’s Hospital in Melbourne. The study excluded patients with a dual diagnosis, or those followed for less than 12 months.
The most common treatment was topical steroids, used to treat 31 patients, followed by tetracyclines – minocycline or doxycycline – used to treat 21 patients, and hydroxychloroquine, used to treat 18 patients. Some patients were also treated with steroid-sparing immunosuppressants, including methotrexate, mycophenolate, and cyclosporine. Fourteen patients were also treated with intralesional steroids, and seven were treated with topical tacrolimus.
The researchers used a graded four-point scale to assess patients’ response to treatment, which corresponded to remission, partial improvement, no change, and worsening of disease, based on patients’ clinical signs, symptoms, and extent of alopecia.
Only a small proportion – about 15% – of patients achieved remission, which was seen with topical steroids, hydroxychloroquine, and doxycycline. About one-third of patients treated with doxycycline actually showed a worsening of symptoms.
The greatest proportion (75%) of patients with partial remission was among those treated with systemic acitretin, although the numbers were low (three of four patients who received this therapy).
In addition, one of the seven patients treated with minocycline achieved partial remission during this therapy, one showed a worsening of the condition, and the remaining five were unchanged. Among those treated with an immunosuppressant, the 3 patients treated with mycophenolate had no change in the condition; 4 of the 10 patients treated with methotrexate achieved partial remission, 4 were unchanged, and 2 experienced a worsening of the condition. One of the three patients treated with cyclosporine achieved partial remission while the other two remained unchanged. With topical tacrolimus, two patients achieved partial remission, two showed a worsening of the condition, and the remaining three were unchanged.
The response rates to treatment significantly decreased with subsequent therapies: 18 of the 32 patients responded to first-line treatments, compared with 7 of 19 who received second-line treatment and only 1 of 9 patients who received third-line treatment. “Many patients were not responsive to therapy, highlighting the difficulty of treating this scarring alopecia,” Dr. Kerkemeyer said.
In an interview, she said that topical or intralesional steroids seemed to be the best first-line option because they are associated with fewer side effects than other options. “They were easier to start off in patients first,” and for those who do not respond, switching to another treatment, such as topical tacrolimus, if they wanted a topical option, or an oral treatment, such as an immunosuppressant like methotrexate, she noted.
No conflicts of interest were declared.
SYDNEY – Responses to treatments for lichen planopilaris varied widely, and decreased with second- and third-line therapies, in a retrospective study, Karolina Kerkemeyer, MD, said at the annual meeting of the Australasian College of Dermatologists.
An analysis of computerized medical records for 32 patients who had been treated for lichen planopilaris at a tertiary referral hair center in Australia was conducted from 2012 to 2016 by Dr. Kerkemeyer of the University of Notre Dame Australia, Werribee, and Jack Green, MD, of the Skin and Cancer Foundation and St. Vincent’s Hospital in Melbourne. The study excluded patients with a dual diagnosis, or those followed for less than 12 months.
The most common treatment was topical steroids, used to treat 31 patients, followed by tetracyclines – minocycline or doxycycline – used to treat 21 patients, and hydroxychloroquine, used to treat 18 patients. Some patients were also treated with steroid-sparing immunosuppressants, including methotrexate, mycophenolate, and cyclosporine. Fourteen patients were also treated with intralesional steroids, and seven were treated with topical tacrolimus.
The researchers used a graded four-point scale to assess patients’ response to treatment, which corresponded to remission, partial improvement, no change, and worsening of disease, based on patients’ clinical signs, symptoms, and extent of alopecia.
Only a small proportion – about 15% – of patients achieved remission, which was seen with topical steroids, hydroxychloroquine, and doxycycline. About one-third of patients treated with doxycycline actually showed a worsening of symptoms.
The greatest proportion (75%) of patients with partial remission was among those treated with systemic acitretin, although the numbers were low (three of four patients who received this therapy).
In addition, one of the seven patients treated with minocycline achieved partial remission during this therapy, one showed a worsening of the condition, and the remaining five were unchanged. Among those treated with an immunosuppressant, the 3 patients treated with mycophenolate had no change in the condition; 4 of the 10 patients treated with methotrexate achieved partial remission, 4 were unchanged, and 2 experienced a worsening of the condition. One of the three patients treated with cyclosporine achieved partial remission while the other two remained unchanged. With topical tacrolimus, two patients achieved partial remission, two showed a worsening of the condition, and the remaining three were unchanged.
The response rates to treatment significantly decreased with subsequent therapies: 18 of the 32 patients responded to first-line treatments, compared with 7 of 19 who received second-line treatment and only 1 of 9 patients who received third-line treatment. “Many patients were not responsive to therapy, highlighting the difficulty of treating this scarring alopecia,” Dr. Kerkemeyer said.
In an interview, she said that topical or intralesional steroids seemed to be the best first-line option because they are associated with fewer side effects than other options. “They were easier to start off in patients first,” and for those who do not respond, switching to another treatment, such as topical tacrolimus, if they wanted a topical option, or an oral treatment, such as an immunosuppressant like methotrexate, she noted.
No conflicts of interest were declared.
Key clinical point: Lichen planopilaris is a scarring alopecia that is particularly difficult to treat, and a significant number of patients may have refractory disease.
Major finding:
Data source: A retrospective analysis of 32 patients with lichen planopilaris.
Disclosures: No conflicts of interest were declared.
Trump presidency prompts Goldwater Rule debate at APA
SAN DIEGO – Over the past year, the American Psychiatric Association has reasserted its commitment to the Goldwater Rule, yet many psychiatrists have questioned – some publicly – whether the rule needs to be revisited based on their concerns about Donald Trump’s mental fitness to be president.
[polldaddy:9767626]Both sides of the issue got a hearing during a pro and con discussion of the Goldwater Rule at the annual meeting of the American Psychiatric Association. A trio of leading psychiatrists called for the Goldwater Rule to be revised and APA past leadership defended the ethical standards of the existing rule. One past-president of the APA remarked that psychiatrists who object to the rule can choose to quit the APA, a comment that one audience member said harkened back to the Vietnam War–era rebuttal to protesters: “Love it or leave it.”
Several news stories in recent months have highlighted the Trump-spawned debate over the Goldwater Rule, which states that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
The APA created the rule in 1973 after a backlash over the hundreds of U.S. psychiatrists who responded to a magazine survey by diagnosing 1964 GOP presidential candidate Barry Goldwater. He later won a libel suit against the magazine.
Prior to last year’s presidential election, the APA stood by its rule. Then, in March 2017, the APA’s Ethics Committee affirmed that “the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.”
During the pro and con discussion at the annual meeting, Paul S. Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York, called the Goldwater incident “a major embarrassment for psychiatry.”
But, he added, “there are more important justifications than whether we’re embarrassed or not. Part of [the rule] is to protect persons who may be harmed by our blithe speculation to the media. We’re also interested in avoiding an impact on people who may be in need of psychiatric care but are discouraged by what they see and hear about psychiatry in the media,” he said.
“A diagnosis based on casual encounters with a person through the media is necessarily inadequate as a basis for a psychiatric diagnosis or formulation of any reliable sort,” he pointed out.
Claire Pouncey, MD, PhD, a psychiatrist who practices in Philadelphia, questioned why speaking publicly about a public figure is inherently harmful.
“How does it threaten my integrity or integrity of the profession for me to choose to speak publicly about a public figure? The APA seems to not trust its members or recognize us as moral agents who are the arbiters of our own integrity. I wish the APA would trust me,” Dr. Pouncey said.
Last year, she outlined her concerns in an article written with Jerome Kroll, MD, and published in the Journal of the American Academy of Psychiatry and the Law (June 2016;44[2]:226-35).
As for concerns about the adequacy of information, she added, “we never have complete information. And I know we don’t always have a full consent of the person being evaluated. Anyone who’s been in an emergency room knows that in their heart and soul.”
Nassir Ghaemi, MD, MPH, who chaired the session and is professor and director of the mood disorders program at Tufts University in Boston, said that strictly abiding by the Goldwater Rule is “sending out the message that the world’s psychiatrists think it’s bad to get diagnosed with a psychiatric illness. … You are not going to harm patients by talking about psychiatric illness. You help them. We know that.”
Further, Dr. Ghaemi, author of the book “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness” (Penguin Books, 2012), argued that the “very qualities that mark those with mood disorders also make for the best leaders in times of crisis.”
President Trump’s reported traits, such as lack of sleep and talkativeness, could be portrayed as mania, he said. However, those qualities also could boost his creativity and resilience.
Jerrold M. Post, MD, a pioneer in profiling for the Central Intelligence Agency and professor of psychiatry, political psychology, and international affairs at George Washington University in Washington, D.C., said that psychiatrists have a role to play as experts, especially now. “I’m increasingly uncomfortable in not having commented on a welter of psychiatric diagnoses by people without psychiatric training,” he said. “It seems unethical to not comment at this time.”
Paul Summergrad, MD, a former APA president and chair of the department of psychiatry at Tufts, dismissed the idea that psychiatrists could mold public debate. “The assumption that we’ll somehow change opinion if we all speak out about these matters is giving us much more credit than we deserve.”
“The reality,” he said, “is that we need to wear a certain yoke of limitation and responsibility rather than thinking this is simply an issue of freedom.”
Dr. Post, Dr. Summergrad, and Dr. Pouncey reported no relevant disclosures. Dr. Ghaemi reported support (consultant/advisory board, speakers bureau, honoraria) from Sunovion. Dr. Appelbaum disclosed stock/other financial relationship with COVR.
[polldaddy:9767626]
SAN DIEGO – Over the past year, the American Psychiatric Association has reasserted its commitment to the Goldwater Rule, yet many psychiatrists have questioned – some publicly – whether the rule needs to be revisited based on their concerns about Donald Trump’s mental fitness to be president.
[polldaddy:9767626]Both sides of the issue got a hearing during a pro and con discussion of the Goldwater Rule at the annual meeting of the American Psychiatric Association. A trio of leading psychiatrists called for the Goldwater Rule to be revised and APA past leadership defended the ethical standards of the existing rule. One past-president of the APA remarked that psychiatrists who object to the rule can choose to quit the APA, a comment that one audience member said harkened back to the Vietnam War–era rebuttal to protesters: “Love it or leave it.”
Several news stories in recent months have highlighted the Trump-spawned debate over the Goldwater Rule, which states that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
The APA created the rule in 1973 after a backlash over the hundreds of U.S. psychiatrists who responded to a magazine survey by diagnosing 1964 GOP presidential candidate Barry Goldwater. He later won a libel suit against the magazine.
Prior to last year’s presidential election, the APA stood by its rule. Then, in March 2017, the APA’s Ethics Committee affirmed that “the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.”
During the pro and con discussion at the annual meeting, Paul S. Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York, called the Goldwater incident “a major embarrassment for psychiatry.”
But, he added, “there are more important justifications than whether we’re embarrassed or not. Part of [the rule] is to protect persons who may be harmed by our blithe speculation to the media. We’re also interested in avoiding an impact on people who may be in need of psychiatric care but are discouraged by what they see and hear about psychiatry in the media,” he said.
“A diagnosis based on casual encounters with a person through the media is necessarily inadequate as a basis for a psychiatric diagnosis or formulation of any reliable sort,” he pointed out.
Claire Pouncey, MD, PhD, a psychiatrist who practices in Philadelphia, questioned why speaking publicly about a public figure is inherently harmful.
“How does it threaten my integrity or integrity of the profession for me to choose to speak publicly about a public figure? The APA seems to not trust its members or recognize us as moral agents who are the arbiters of our own integrity. I wish the APA would trust me,” Dr. Pouncey said.
Last year, she outlined her concerns in an article written with Jerome Kroll, MD, and published in the Journal of the American Academy of Psychiatry and the Law (June 2016;44[2]:226-35).
As for concerns about the adequacy of information, she added, “we never have complete information. And I know we don’t always have a full consent of the person being evaluated. Anyone who’s been in an emergency room knows that in their heart and soul.”
Nassir Ghaemi, MD, MPH, who chaired the session and is professor and director of the mood disorders program at Tufts University in Boston, said that strictly abiding by the Goldwater Rule is “sending out the message that the world’s psychiatrists think it’s bad to get diagnosed with a psychiatric illness. … You are not going to harm patients by talking about psychiatric illness. You help them. We know that.”
Further, Dr. Ghaemi, author of the book “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness” (Penguin Books, 2012), argued that the “very qualities that mark those with mood disorders also make for the best leaders in times of crisis.”
President Trump’s reported traits, such as lack of sleep and talkativeness, could be portrayed as mania, he said. However, those qualities also could boost his creativity and resilience.
Jerrold M. Post, MD, a pioneer in profiling for the Central Intelligence Agency and professor of psychiatry, political psychology, and international affairs at George Washington University in Washington, D.C., said that psychiatrists have a role to play as experts, especially now. “I’m increasingly uncomfortable in not having commented on a welter of psychiatric diagnoses by people without psychiatric training,” he said. “It seems unethical to not comment at this time.”
Paul Summergrad, MD, a former APA president and chair of the department of psychiatry at Tufts, dismissed the idea that psychiatrists could mold public debate. “The assumption that we’ll somehow change opinion if we all speak out about these matters is giving us much more credit than we deserve.”
“The reality,” he said, “is that we need to wear a certain yoke of limitation and responsibility rather than thinking this is simply an issue of freedom.”
Dr. Post, Dr. Summergrad, and Dr. Pouncey reported no relevant disclosures. Dr. Ghaemi reported support (consultant/advisory board, speakers bureau, honoraria) from Sunovion. Dr. Appelbaum disclosed stock/other financial relationship with COVR.
[polldaddy:9767626]
SAN DIEGO – Over the past year, the American Psychiatric Association has reasserted its commitment to the Goldwater Rule, yet many psychiatrists have questioned – some publicly – whether the rule needs to be revisited based on their concerns about Donald Trump’s mental fitness to be president.
[polldaddy:9767626]Both sides of the issue got a hearing during a pro and con discussion of the Goldwater Rule at the annual meeting of the American Psychiatric Association. A trio of leading psychiatrists called for the Goldwater Rule to be revised and APA past leadership defended the ethical standards of the existing rule. One past-president of the APA remarked that psychiatrists who object to the rule can choose to quit the APA, a comment that one audience member said harkened back to the Vietnam War–era rebuttal to protesters: “Love it or leave it.”
Several news stories in recent months have highlighted the Trump-spawned debate over the Goldwater Rule, which states that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
The APA created the rule in 1973 after a backlash over the hundreds of U.S. psychiatrists who responded to a magazine survey by diagnosing 1964 GOP presidential candidate Barry Goldwater. He later won a libel suit against the magazine.
Prior to last year’s presidential election, the APA stood by its rule. Then, in March 2017, the APA’s Ethics Committee affirmed that “the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.”
During the pro and con discussion at the annual meeting, Paul S. Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York, called the Goldwater incident “a major embarrassment for psychiatry.”
But, he added, “there are more important justifications than whether we’re embarrassed or not. Part of [the rule] is to protect persons who may be harmed by our blithe speculation to the media. We’re also interested in avoiding an impact on people who may be in need of psychiatric care but are discouraged by what they see and hear about psychiatry in the media,” he said.
“A diagnosis based on casual encounters with a person through the media is necessarily inadequate as a basis for a psychiatric diagnosis or formulation of any reliable sort,” he pointed out.
Claire Pouncey, MD, PhD, a psychiatrist who practices in Philadelphia, questioned why speaking publicly about a public figure is inherently harmful.
“How does it threaten my integrity or integrity of the profession for me to choose to speak publicly about a public figure? The APA seems to not trust its members or recognize us as moral agents who are the arbiters of our own integrity. I wish the APA would trust me,” Dr. Pouncey said.
Last year, she outlined her concerns in an article written with Jerome Kroll, MD, and published in the Journal of the American Academy of Psychiatry and the Law (June 2016;44[2]:226-35).
As for concerns about the adequacy of information, she added, “we never have complete information. And I know we don’t always have a full consent of the person being evaluated. Anyone who’s been in an emergency room knows that in their heart and soul.”
Nassir Ghaemi, MD, MPH, who chaired the session and is professor and director of the mood disorders program at Tufts University in Boston, said that strictly abiding by the Goldwater Rule is “sending out the message that the world’s psychiatrists think it’s bad to get diagnosed with a psychiatric illness. … You are not going to harm patients by talking about psychiatric illness. You help them. We know that.”
Further, Dr. Ghaemi, author of the book “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness” (Penguin Books, 2012), argued that the “very qualities that mark those with mood disorders also make for the best leaders in times of crisis.”
President Trump’s reported traits, such as lack of sleep and talkativeness, could be portrayed as mania, he said. However, those qualities also could boost his creativity and resilience.
Jerrold M. Post, MD, a pioneer in profiling for the Central Intelligence Agency and professor of psychiatry, political psychology, and international affairs at George Washington University in Washington, D.C., said that psychiatrists have a role to play as experts, especially now. “I’m increasingly uncomfortable in not having commented on a welter of psychiatric diagnoses by people without psychiatric training,” he said. “It seems unethical to not comment at this time.”
Paul Summergrad, MD, a former APA president and chair of the department of psychiatry at Tufts, dismissed the idea that psychiatrists could mold public debate. “The assumption that we’ll somehow change opinion if we all speak out about these matters is giving us much more credit than we deserve.”
“The reality,” he said, “is that we need to wear a certain yoke of limitation and responsibility rather than thinking this is simply an issue of freedom.”
Dr. Post, Dr. Summergrad, and Dr. Pouncey reported no relevant disclosures. Dr. Ghaemi reported support (consultant/advisory board, speakers bureau, honoraria) from Sunovion. Dr. Appelbaum disclosed stock/other financial relationship with COVR.
[polldaddy:9767626]
EXPERT ANALYSIS FROM APA
HM17 session summary: The art of story in delivering memorable lectures
Presenter
Ethan Cumbler, MD, FACP, FHM
Session summary
This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.
Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.
This will help anchor your presentation and will hopefully assist in creating an organizational framework. Most people are familiar with lectures that have a “standard” format: “I’m going to talk about disease/problem X. This is the scope of the problem, epidemiology, pathology, etiology, diagnosis, treatment, complications, and prognosis.” While this is an organizational structure, it doesn’t draw the audience in. Instead, what was suggested was to think about a real patient case to keep the audience engaged. Since everything may not be known in real time, you can add drama and suspense as the audience and the speaker work through the case together.
One should have a “hook” as an analogy to engage with the audience while reinforcing the central “take-home” message. One can think of it as a kind of leitmotif. Another example would be the “call-back” in stand-up comedy where a concept or joke is introduced early in the routine, is not addressed for a period of time, and then reintroduced and becomes more funny the second time around.
Many people are used to seeing PowerPoint presentations with 5-7 lines per slide, 5-7 words per line, with greater than 24 point font. Dr. Cumbler recommends thinking of one’s slide from a design perspective. For example, in TED talks, one will often see large images that act as a reference but there is often very little text on the slide. In order to provide more content while not burdening slides with more text, one should reconsider handouts. Instead of sheets of paper with 6 slides which are repeats of the PowerPoint, use the handout to provide information that one cannot show during the presentation.
It is incredibly difficult to stay engaged in a lecture delivered at the same pace and in a monotone. Timing is important in music, comedy, and presentations. One should vary the volume and tempo during the talk and allow for pauses when appropriate. An example to illustrate the point was dubstep music; it is set at a tempo of 140 beats per minute, but the song is not 140 beats per minute the entire time. It will sometimes slow down, and there is always a point where the “beat drops.”
Again, a good talk is not only the information itself, but a presenter’s presence, so one should think of body language and positioning. One should use hand gestures to emphasize points in the lecture and draw the learners in. Dr. Cumbler recommended making eye contact with individuals periodically instead of a distant, vacant stare into the great expanse. One should feel free to move across the stage or walk through the audience, so ask for a wireless microphone to liberate oneself from the podium.
Key takeaways for HM
- Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
- Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
- If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.
Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.
Presenter
Ethan Cumbler, MD, FACP, FHM
Session summary
This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.
Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.
This will help anchor your presentation and will hopefully assist in creating an organizational framework. Most people are familiar with lectures that have a “standard” format: “I’m going to talk about disease/problem X. This is the scope of the problem, epidemiology, pathology, etiology, diagnosis, treatment, complications, and prognosis.” While this is an organizational structure, it doesn’t draw the audience in. Instead, what was suggested was to think about a real patient case to keep the audience engaged. Since everything may not be known in real time, you can add drama and suspense as the audience and the speaker work through the case together.
One should have a “hook” as an analogy to engage with the audience while reinforcing the central “take-home” message. One can think of it as a kind of leitmotif. Another example would be the “call-back” in stand-up comedy where a concept or joke is introduced early in the routine, is not addressed for a period of time, and then reintroduced and becomes more funny the second time around.
Many people are used to seeing PowerPoint presentations with 5-7 lines per slide, 5-7 words per line, with greater than 24 point font. Dr. Cumbler recommends thinking of one’s slide from a design perspective. For example, in TED talks, one will often see large images that act as a reference but there is often very little text on the slide. In order to provide more content while not burdening slides with more text, one should reconsider handouts. Instead of sheets of paper with 6 slides which are repeats of the PowerPoint, use the handout to provide information that one cannot show during the presentation.
It is incredibly difficult to stay engaged in a lecture delivered at the same pace and in a monotone. Timing is important in music, comedy, and presentations. One should vary the volume and tempo during the talk and allow for pauses when appropriate. An example to illustrate the point was dubstep music; it is set at a tempo of 140 beats per minute, but the song is not 140 beats per minute the entire time. It will sometimes slow down, and there is always a point where the “beat drops.”
Again, a good talk is not only the information itself, but a presenter’s presence, so one should think of body language and positioning. One should use hand gestures to emphasize points in the lecture and draw the learners in. Dr. Cumbler recommended making eye contact with individuals periodically instead of a distant, vacant stare into the great expanse. One should feel free to move across the stage or walk through the audience, so ask for a wireless microphone to liberate oneself from the podium.
Key takeaways for HM
- Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
- Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
- If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.
Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.
Presenter
Ethan Cumbler, MD, FACP, FHM
Session summary
This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.
Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.
This will help anchor your presentation and will hopefully assist in creating an organizational framework. Most people are familiar with lectures that have a “standard” format: “I’m going to talk about disease/problem X. This is the scope of the problem, epidemiology, pathology, etiology, diagnosis, treatment, complications, and prognosis.” While this is an organizational structure, it doesn’t draw the audience in. Instead, what was suggested was to think about a real patient case to keep the audience engaged. Since everything may not be known in real time, you can add drama and suspense as the audience and the speaker work through the case together.
One should have a “hook” as an analogy to engage with the audience while reinforcing the central “take-home” message. One can think of it as a kind of leitmotif. Another example would be the “call-back” in stand-up comedy where a concept or joke is introduced early in the routine, is not addressed for a period of time, and then reintroduced and becomes more funny the second time around.
Many people are used to seeing PowerPoint presentations with 5-7 lines per slide, 5-7 words per line, with greater than 24 point font. Dr. Cumbler recommends thinking of one’s slide from a design perspective. For example, in TED talks, one will often see large images that act as a reference but there is often very little text on the slide. In order to provide more content while not burdening slides with more text, one should reconsider handouts. Instead of sheets of paper with 6 slides which are repeats of the PowerPoint, use the handout to provide information that one cannot show during the presentation.
It is incredibly difficult to stay engaged in a lecture delivered at the same pace and in a monotone. Timing is important in music, comedy, and presentations. One should vary the volume and tempo during the talk and allow for pauses when appropriate. An example to illustrate the point was dubstep music; it is set at a tempo of 140 beats per minute, but the song is not 140 beats per minute the entire time. It will sometimes slow down, and there is always a point where the “beat drops.”
Again, a good talk is not only the information itself, but a presenter’s presence, so one should think of body language and positioning. One should use hand gestures to emphasize points in the lecture and draw the learners in. Dr. Cumbler recommended making eye contact with individuals periodically instead of a distant, vacant stare into the great expanse. One should feel free to move across the stage or walk through the audience, so ask for a wireless microphone to liberate oneself from the podium.
Key takeaways for HM
- Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
- Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
- If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.
Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.