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See you at DDW and the AGA Postgraduate course
AGA looks forward to seeing our members at Digestive Disease Week® (DDW) 2017, May 6-9 in Chicago. If you’re not yet registered for the meeting, visit www.ddw.org to reserve your spot.
Please also join us for the 2017 AGA Postgraduate Course. The 2017 course is set for May 6 and 7, 2017, in conjunction with DDW. This 1.5-day course is designed to help you step beyond basic learning and get the full scope of GI advances. You will measure, learn, and apply the newest advances that will help you make confident decisions for your patients.
The course will feature six general sessions:
- • Hot Topics (abdominal pain and opioid therapy, microbiome and obesity, viral hepatitis, and fecal microbiota transplantation)
- • IBD: It’s a Beautiful Day (IBD) to discuss Inflammatory Bowel Disease (IBD)
- • The Biliary Tree and Pancreas
- • Love the Liver
- • All Guts and Glory: Esophagus, Stomach and Small Intestine
- • Bringing Up the Rear: Disorders of the Colon and Rectum
The course will also include 29 breakout sessions. These focused, small-group sessions allow you to delve deeper into specific clinical topics and provide direct access to internationally renowned faculty.
To learn more about the AGA Postgraduate course, visit pgcourse.gastro.org.
AGA looks forward to seeing our members at Digestive Disease Week® (DDW) 2017, May 6-9 in Chicago. If you’re not yet registered for the meeting, visit www.ddw.org to reserve your spot.
Please also join us for the 2017 AGA Postgraduate Course. The 2017 course is set for May 6 and 7, 2017, in conjunction with DDW. This 1.5-day course is designed to help you step beyond basic learning and get the full scope of GI advances. You will measure, learn, and apply the newest advances that will help you make confident decisions for your patients.
The course will feature six general sessions:
- • Hot Topics (abdominal pain and opioid therapy, microbiome and obesity, viral hepatitis, and fecal microbiota transplantation)
- • IBD: It’s a Beautiful Day (IBD) to discuss Inflammatory Bowel Disease (IBD)
- • The Biliary Tree and Pancreas
- • Love the Liver
- • All Guts and Glory: Esophagus, Stomach and Small Intestine
- • Bringing Up the Rear: Disorders of the Colon and Rectum
The course will also include 29 breakout sessions. These focused, small-group sessions allow you to delve deeper into specific clinical topics and provide direct access to internationally renowned faculty.
To learn more about the AGA Postgraduate course, visit pgcourse.gastro.org.
AGA looks forward to seeing our members at Digestive Disease Week® (DDW) 2017, May 6-9 in Chicago. If you’re not yet registered for the meeting, visit www.ddw.org to reserve your spot.
Please also join us for the 2017 AGA Postgraduate Course. The 2017 course is set for May 6 and 7, 2017, in conjunction with DDW. This 1.5-day course is designed to help you step beyond basic learning and get the full scope of GI advances. You will measure, learn, and apply the newest advances that will help you make confident decisions for your patients.
The course will feature six general sessions:
- • Hot Topics (abdominal pain and opioid therapy, microbiome and obesity, viral hepatitis, and fecal microbiota transplantation)
- • IBD: It’s a Beautiful Day (IBD) to discuss Inflammatory Bowel Disease (IBD)
- • The Biliary Tree and Pancreas
- • Love the Liver
- • All Guts and Glory: Esophagus, Stomach and Small Intestine
- • Bringing Up the Rear: Disorders of the Colon and Rectum
The course will also include 29 breakout sessions. These focused, small-group sessions allow you to delve deeper into specific clinical topics and provide direct access to internationally renowned faculty.
To learn more about the AGA Postgraduate course, visit pgcourse.gastro.org.
AGA announces appointment of new Governing Board members
AGA is pleased to announce new AGA Institute Governing Board designate-elects for 2017-2018.
Hashem B. El-Serag, MD, MPH, AGAF, is the vice president-elect designate. Dr. El-Serag is professor and chair of medicine, Baylor College of Medicine, Houston, TX. He is the editor of Clinical Gastroenterology and Hepatology until July 2017, and serves on the AGA Institute Leadership and Publications Committee.
Lawrence S. Kim, MD, AGAF, is the secretary/treasurer-elect designate. Dr. Kim is a partner at South Denver Gastroenterology, P.C., Littleton, CO. He currently serves on the AGA Institute Clinical Practice Updates, Audit, and Finance and Operations Committees. Dr. Kim has previously served as an AGA Institute Private Practice Councillor.
Dr. El-Serag and Dr. Kim begin their terms immediately following Digestive Disease Week® (DDW) 2017.
AGA is pleased to announce new AGA Institute Governing Board designate-elects for 2017-2018.
Hashem B. El-Serag, MD, MPH, AGAF, is the vice president-elect designate. Dr. El-Serag is professor and chair of medicine, Baylor College of Medicine, Houston, TX. He is the editor of Clinical Gastroenterology and Hepatology until July 2017, and serves on the AGA Institute Leadership and Publications Committee.
Lawrence S. Kim, MD, AGAF, is the secretary/treasurer-elect designate. Dr. Kim is a partner at South Denver Gastroenterology, P.C., Littleton, CO. He currently serves on the AGA Institute Clinical Practice Updates, Audit, and Finance and Operations Committees. Dr. Kim has previously served as an AGA Institute Private Practice Councillor.
Dr. El-Serag and Dr. Kim begin their terms immediately following Digestive Disease Week® (DDW) 2017.
AGA is pleased to announce new AGA Institute Governing Board designate-elects for 2017-2018.
Hashem B. El-Serag, MD, MPH, AGAF, is the vice president-elect designate. Dr. El-Serag is professor and chair of medicine, Baylor College of Medicine, Houston, TX. He is the editor of Clinical Gastroenterology and Hepatology until July 2017, and serves on the AGA Institute Leadership and Publications Committee.
Lawrence S. Kim, MD, AGAF, is the secretary/treasurer-elect designate. Dr. Kim is a partner at South Denver Gastroenterology, P.C., Littleton, CO. He currently serves on the AGA Institute Clinical Practice Updates, Audit, and Finance and Operations Committees. Dr. Kim has previously served as an AGA Institute Private Practice Councillor.
Dr. El-Serag and Dr. Kim begin their terms immediately following Digestive Disease Week® (DDW) 2017.
Announcing new Crohn’s & colitis congress
AGA and the Crohn’s & Colitis Foundation are partnering to cosponsor a new annual conference for health care professionals and researchers. By joining the nation’s leading IBD patient organization with the premier GI professional organization, this will be the must-attend IBD conference, bringing state-of-the-art comprehensive care together with the latest research to advance prevention, treatment, and cures for IBD patients.
Save the date – Jan. 18-20, 2018, in Las Vegas. Get ready to expand your knowledge, network with other leaders, and be inspired! Stay tuned for our website launch and more details coming this spring.
AGA and the Crohn’s & Colitis Foundation are partnering to cosponsor a new annual conference for health care professionals and researchers. By joining the nation’s leading IBD patient organization with the premier GI professional organization, this will be the must-attend IBD conference, bringing state-of-the-art comprehensive care together with the latest research to advance prevention, treatment, and cures for IBD patients.
Save the date – Jan. 18-20, 2018, in Las Vegas. Get ready to expand your knowledge, network with other leaders, and be inspired! Stay tuned for our website launch and more details coming this spring.
AGA and the Crohn’s & Colitis Foundation are partnering to cosponsor a new annual conference for health care professionals and researchers. By joining the nation’s leading IBD patient organization with the premier GI professional organization, this will be the must-attend IBD conference, bringing state-of-the-art comprehensive care together with the latest research to advance prevention, treatment, and cures for IBD patients.
Save the date – Jan. 18-20, 2018, in Las Vegas. Get ready to expand your knowledge, network with other leaders, and be inspired! Stay tuned for our website launch and more details coming this spring.
Gradual increase of nonoperative management of selected abdominal gunshot wounds
Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now, at least at Level I and Level II trauma centers across New England, according to a report published online in the Journal of the American College of Surgeons.
“Mandatory laparotomy used to be the only acceptable standard of care” for this patient population, but many surgeons now realize that a hole in the abdomen doesn’t necessitate immediate laparotomy. “Patients with a reliable clinical exam, who are hemodynamically stable and without signs of peritonitis, can be observed under structured protocols of close monitoring, frequent clinical exams, and appropriate imaging,” said Thomas Peponis, MD, of Massachusetts General Hospital, Boston, and his associates.
Two findings belie the main arguments that opponents of SNOM have made in favor of routine laparotomy: delaying surgery leads to devastating consequences and “unnecessary” laparotomies are virtually harmless.
The first finding was that the 18 patients in the SNOM group (1.9% of the entire study population) who eventually required a delayed laparotomy had few postoperative complications, and none of the complications appeared to be directly related to the delay in surgery. Those SNOM patients who eventually had surgery did not differ in terms of age, sex, location of the gunshot wound, vitals on ED presentation, Glasgow Coma Scale on ED presentation, presence of hemodynamic instability, or presence of diffuse abdominal tenderness on clinical exam.
The second finding concerned the 104 patients who underwent immediate exploratory laparotomy. Dr. Peponis and his associates deemed the immediacy to be nontherapeutic (unnecessary) because “the mere presence of a hole to the abdomen was the only indication” for the surgery. Nearly one in six patients operated on for an abdominal gunshot wound underwent a nontherapeutic laparotomy. Of those, 18 (17.3%) developed postoperative complications, including wound infections, ileus, pneumonia, pleural effusion requiring a chest tube, intra-abdominal abscess, acute kidney injury, sepsis, venous embolus, and a fistula related to a retained bullet.
The rate of abdominal gunshot wounds treated nonoperatively in the centers studied has grown from around 18% before 2010 to 27% in the following years. The increasing use of CT scans has bolstered the trend, but the clinical exam remains the critical element in deciding whether to operate immediately. The investigators recommended immediate surgery for all abdominal gunshot wound patients who are hemodynamically unstable or who exhibit diffuse abdominal tenderness. “There is no other place for a patient with an abdominal gunshot wound and definitively worsening clinical symptoms than the OR. The remaining patients are appropriate for SNOM under close observation, repeat clinical evaluations, and immediate OR availability in case the clinical picture changes.”
The limitations of the study are the following: First, it represents only Level I and II centers with experienced trauma teams. Second, there is no commonly established protocol across trauma centers for SNOM, giving rise to a variability in decision making and care. Third, the definition of immediate and delayed surgery was within a 2-hour window, a somewhat arbitrary time period.
The investigation was sponsored by the Research Consortium of New England Centers for Trauma (ReCoNECT). The authors had no disclosures.
Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now, at least at Level I and Level II trauma centers across New England, according to a report published online in the Journal of the American College of Surgeons.
“Mandatory laparotomy used to be the only acceptable standard of care” for this patient population, but many surgeons now realize that a hole in the abdomen doesn’t necessitate immediate laparotomy. “Patients with a reliable clinical exam, who are hemodynamically stable and without signs of peritonitis, can be observed under structured protocols of close monitoring, frequent clinical exams, and appropriate imaging,” said Thomas Peponis, MD, of Massachusetts General Hospital, Boston, and his associates.
Two findings belie the main arguments that opponents of SNOM have made in favor of routine laparotomy: delaying surgery leads to devastating consequences and “unnecessary” laparotomies are virtually harmless.
The first finding was that the 18 patients in the SNOM group (1.9% of the entire study population) who eventually required a delayed laparotomy had few postoperative complications, and none of the complications appeared to be directly related to the delay in surgery. Those SNOM patients who eventually had surgery did not differ in terms of age, sex, location of the gunshot wound, vitals on ED presentation, Glasgow Coma Scale on ED presentation, presence of hemodynamic instability, or presence of diffuse abdominal tenderness on clinical exam.
The second finding concerned the 104 patients who underwent immediate exploratory laparotomy. Dr. Peponis and his associates deemed the immediacy to be nontherapeutic (unnecessary) because “the mere presence of a hole to the abdomen was the only indication” for the surgery. Nearly one in six patients operated on for an abdominal gunshot wound underwent a nontherapeutic laparotomy. Of those, 18 (17.3%) developed postoperative complications, including wound infections, ileus, pneumonia, pleural effusion requiring a chest tube, intra-abdominal abscess, acute kidney injury, sepsis, venous embolus, and a fistula related to a retained bullet.
The rate of abdominal gunshot wounds treated nonoperatively in the centers studied has grown from around 18% before 2010 to 27% in the following years. The increasing use of CT scans has bolstered the trend, but the clinical exam remains the critical element in deciding whether to operate immediately. The investigators recommended immediate surgery for all abdominal gunshot wound patients who are hemodynamically unstable or who exhibit diffuse abdominal tenderness. “There is no other place for a patient with an abdominal gunshot wound and definitively worsening clinical symptoms than the OR. The remaining patients are appropriate for SNOM under close observation, repeat clinical evaluations, and immediate OR availability in case the clinical picture changes.”
The limitations of the study are the following: First, it represents only Level I and II centers with experienced trauma teams. Second, there is no commonly established protocol across trauma centers for SNOM, giving rise to a variability in decision making and care. Third, the definition of immediate and delayed surgery was within a 2-hour window, a somewhat arbitrary time period.
The investigation was sponsored by the Research Consortium of New England Centers for Trauma (ReCoNECT). The authors had no disclosures.
Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now, at least at Level I and Level II trauma centers across New England, according to a report published online in the Journal of the American College of Surgeons.
“Mandatory laparotomy used to be the only acceptable standard of care” for this patient population, but many surgeons now realize that a hole in the abdomen doesn’t necessitate immediate laparotomy. “Patients with a reliable clinical exam, who are hemodynamically stable and without signs of peritonitis, can be observed under structured protocols of close monitoring, frequent clinical exams, and appropriate imaging,” said Thomas Peponis, MD, of Massachusetts General Hospital, Boston, and his associates.
Two findings belie the main arguments that opponents of SNOM have made in favor of routine laparotomy: delaying surgery leads to devastating consequences and “unnecessary” laparotomies are virtually harmless.
The first finding was that the 18 patients in the SNOM group (1.9% of the entire study population) who eventually required a delayed laparotomy had few postoperative complications, and none of the complications appeared to be directly related to the delay in surgery. Those SNOM patients who eventually had surgery did not differ in terms of age, sex, location of the gunshot wound, vitals on ED presentation, Glasgow Coma Scale on ED presentation, presence of hemodynamic instability, or presence of diffuse abdominal tenderness on clinical exam.
The second finding concerned the 104 patients who underwent immediate exploratory laparotomy. Dr. Peponis and his associates deemed the immediacy to be nontherapeutic (unnecessary) because “the mere presence of a hole to the abdomen was the only indication” for the surgery. Nearly one in six patients operated on for an abdominal gunshot wound underwent a nontherapeutic laparotomy. Of those, 18 (17.3%) developed postoperative complications, including wound infections, ileus, pneumonia, pleural effusion requiring a chest tube, intra-abdominal abscess, acute kidney injury, sepsis, venous embolus, and a fistula related to a retained bullet.
The rate of abdominal gunshot wounds treated nonoperatively in the centers studied has grown from around 18% before 2010 to 27% in the following years. The increasing use of CT scans has bolstered the trend, but the clinical exam remains the critical element in deciding whether to operate immediately. The investigators recommended immediate surgery for all abdominal gunshot wound patients who are hemodynamically unstable or who exhibit diffuse abdominal tenderness. “There is no other place for a patient with an abdominal gunshot wound and definitively worsening clinical symptoms than the OR. The remaining patients are appropriate for SNOM under close observation, repeat clinical evaluations, and immediate OR availability in case the clinical picture changes.”
The limitations of the study are the following: First, it represents only Level I and II centers with experienced trauma teams. Second, there is no commonly established protocol across trauma centers for SNOM, giving rise to a variability in decision making and care. Third, the definition of immediate and delayed surgery was within a 2-hour window, a somewhat arbitrary time period.
The investigation was sponsored by the Research Consortium of New England Centers for Trauma (ReCoNECT). The authors had no disclosures.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now.
Major finding: 197 patients (91.6% of the nonoperative group and 21.4% of the entire study population) were successfully managed nonoperatively and were discharged without requiring any abdominal surgery.
Data source: A retrospective review of the medical records of 922 gunshot wound patients treated at 10 New England trauma centers during a 20-year period.
Disclosures: The investigation was a multicenter study of the Research Consortium of New England Centers for Trauma (ReCoNECT). Dr. Peponis and his associates reported having no relevant financial disclosures.
Empirical evidence lags behind rise in preadolescents presenting with gender dysphoria
SCOTTSDALE, ARIZ. – The treatment of preadolescents who present with gender questions is often complicated by the absence of evidence-based data on who is most likely to remain gender dysphoric into adulthood and who is not, an expert said at the annual meeting of the American College of Psychiatrists.
“There are some [clinicians] who believe they can predict who will persist and who will not. But they have not published, to my satisfaction, a way to show anyone else how to tell the difference,” said Jack Drescher, MD, a member of the World Health Organization’s (WHO’s) Working Group on the Classification of Sexual Disorders and Sexual Health and clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla.
The WHO working group was tasked with categorizing sex and gender diagnoses in the forthcoming International Classification of Diseases (ICD-11). Dr. Drescher said that he and his fellow WHO working group members have identified at least three discrete transgender populations.
“There are persisters, desisters, and those who first develop gender dysphoria in adolescence and adulthood,” he said. “It would be a clinical mistake to think that there is a seamless transition from childhood gender dysphoria into adolescent and adult gender dysphoria.”
Dr. Drescher said that he believes the Dutch model for treating younger children diagnosed with what is interchangeably referred to as gender dysphoria or gender variance demonstrates the greatest sensitivity to how fluid the situation can be for many of these children. The absence of biomarkers for dysphoria that will persist into adulthood and the finding that a minority of prepubescent gender dysphoria diagnoses persist into adolescence inform the Dutch approach.
This approach, which originated at the VU University Medical Center Amsterdam, is based on 2 decades of research and practice. It assumes that it is better not to actively transition a child socially but to remain neutral to the way in which the child expresses gender identity. If children persist into late adolescence in this model, they are assisted in transitioning. If not, they are supported socially as they adjust to their natal gender. Puberty may sometimes have to be suppressed until the time one of the two paths has been decided.
“In my opinion, it is the most conservative approach,” Dr. Drescher said of the Dutch model. “They are the most cognizant of how much we don’t know, and they do a lot of good research.”
An approach originating at the Child and Adolescent Gender Center Clinic, which is affiliated with the University of California, San Francisco, supports a child socially into a cross-gendered role without medical or surgical intervention but also suppresses puberty. This method is based on the presumption of an adult transgender outcome, despite the absence of a way to predict results, said Dr. Drescher, who also cautions about the iatrogenic effects of such a presumption. “It takes a lot of work to socially transition a child in one direction. It would take a lot to transition back in the other direction, and there is no good empirical data as to whether this is entirely a benign process,” he said.
A third method originated in Toronto at the Centre for Addiction and Mental Health. This method actively discourages a child’s atypical gender interests and views transsexualism as an undesirable outcome that can be prevented, despite what Dr. Drescher said is a complete lack of evidence to either support or refute this claim. This method largely has been abandoned, in part since Ontario and five U.S. states and the District of Columbia have passed laws banning efforts to change a minor’s sexual orientation or gender identity. This method does have puberty suppression in children whose gender dysphoria appears to be persisting into adolescence in common with the other two.
Dr. Drescher said puberty suppression has helped decrease the levels of anxiety, depression, and suicidal ideation typically associated with this cohort. Postponing the development of secondary sexual characteristics gives those who ultimately will desist from their dysphoria more time to let it run its course. The Dutch first initiated this procedure 2 decades ago and have shown that any possible future side effects are outweighed by the psychosocial advantages it provides in the present.
The clinical view of gender dysphoria probably will get a jolt in 2018 upon publication of the ICD-11. In an interview, Dr. Drescher said that, if the condition is no longer categorized by the WHO as a mental disorder and is instead called “gender incongruence” in a chapter dedicated to gender and sexuality issues as currently planned, “it is likely the [American Psychiatric Association] will follow suit and remove gender dysphoria from the DSM. However, I don’t know how long that will take,” he said.
In his presentation, Dr. Drescher said that the causes for gender dysphoria remain unknown, as do the ways in which gender identity develops. It is also unclear how biological, psychosocial, and environmental factors affect gender dysphoria. What is clear, he said, is that “we have to rethink our developmental literature.”
Meanwhile, although gender dysphoria affects a relatively small percentage of the population – less than 1% of “nonreferred” children and adolescents, according to the DSM-5 – the number of prepubescent children presenting to gender clinics is on the rise. This increase might be driven more by social forces than by scientific ones. Dr. Drescher made an anecdotal observation during the presentation that more children are presenting to gender clinics already socially transitioned by their parents than there are children in the research literature on persisters and desisters.
Dr. Drescher recalled in the interview that, during the public comment period for the DSM-5, gender dysphoria elicited the third most responses, compared with other diagnoses, despite its rarity as a condition. “Interest in the subject far outweighs its prevalence.”
Gender-related glossary of terms
"There are so many moving parts to our understanding of gender," said Jack Drescher, MD, during a plenary session at the annual meeting of the American College of Psychiatrists. For that reason, "language is very important" when addressing children who might have questions about their gender identity, he said.
To help establish as much clarity as possible when discussing gender in the clinical setting, Dr. Drescher offered the following glossary of terms. These are not listed alphabetically but in a stepwise fashion aimed at leading to a clearer understanding of successive terms.
Sex: The biological attributes of being male or female. This includes sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.
Gender: The public - and typically the legal - recognition of one's lived role as a boy, girl, man, woman or of other biological factors in combination with psychosocial factors that are seen as contributing to identity development.
Sexual orientation: A person's erotic response tendency or sexual attractions, either directed toward individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual).
Gender identity: Often an independent variable from sexual orientation, this refers to how an individual identifies as either male, female, or, in some cases, some other category.
Gender assignment: The natal presentation as either male or female. The historical terms are "biological male" or "biological female"; also occasionally known as "birth assigned male" or "birth assigned female."
Gender atypical: The somatic features or behaviors not statistically typical in individuals with the same assigned gender in a given society or era.
Gender nonconforming: Typically used as an alternative descriptive term for "gender atypical".
Gender dysphoria: The conflict between a person's assigned gender and that person's gender identity and expression; replaced "gender identity disorder" in the DSM-5.
Gender variant: Often used by those who are concerned the term "gender dysphoria" will unnecessarily pathologize a child.
Gender expression: How an individual demonstrates gender to others, including by way of dress, behavior, and appearance. Increasingly, the term is used in antidiscrimination documents.
Desister: Prepubescent children who present with gender dysphoria but who do not become transgender adults.
Persister: This refers to children who present with gender dysphoria and progress to a transgender adulthood.
Gender reassignment: An official - and often legal - change of gender by way of cross-sex endocrine therapy and/or gender reassignment surgery.
Transsexual: An individual who modifies the body via endocrine and/or surgical means to conform with gender identity either partially or completely.
Transwoman: A person, such as Caitlyn Jenner, who transitions from a male sex assignment to become female.
Transman: A person who transitions from a female sex assignment to become male.
Transgender: The "T" in the acronym LGBT; the popular - not scientific - inclusive term for those whose gender identity, gender expression, or behavior does not conform to that which is typically associated with the natal sex assignment.
Cisgender: From the Latin for "on the same side"; used in the transgender community to describe those whose gender identities align with their natal assignment.
Gender beliefs: Used to refer to the implicit, typically binary, cultural views on the "essential" qualities of men and women.
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SCOTTSDALE, ARIZ. – The treatment of preadolescents who present with gender questions is often complicated by the absence of evidence-based data on who is most likely to remain gender dysphoric into adulthood and who is not, an expert said at the annual meeting of the American College of Psychiatrists.
“There are some [clinicians] who believe they can predict who will persist and who will not. But they have not published, to my satisfaction, a way to show anyone else how to tell the difference,” said Jack Drescher, MD, a member of the World Health Organization’s (WHO’s) Working Group on the Classification of Sexual Disorders and Sexual Health and clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla.
The WHO working group was tasked with categorizing sex and gender diagnoses in the forthcoming International Classification of Diseases (ICD-11). Dr. Drescher said that he and his fellow WHO working group members have identified at least three discrete transgender populations.
“There are persisters, desisters, and those who first develop gender dysphoria in adolescence and adulthood,” he said. “It would be a clinical mistake to think that there is a seamless transition from childhood gender dysphoria into adolescent and adult gender dysphoria.”
Dr. Drescher said that he believes the Dutch model for treating younger children diagnosed with what is interchangeably referred to as gender dysphoria or gender variance demonstrates the greatest sensitivity to how fluid the situation can be for many of these children. The absence of biomarkers for dysphoria that will persist into adulthood and the finding that a minority of prepubescent gender dysphoria diagnoses persist into adolescence inform the Dutch approach.
This approach, which originated at the VU University Medical Center Amsterdam, is based on 2 decades of research and practice. It assumes that it is better not to actively transition a child socially but to remain neutral to the way in which the child expresses gender identity. If children persist into late adolescence in this model, they are assisted in transitioning. If not, they are supported socially as they adjust to their natal gender. Puberty may sometimes have to be suppressed until the time one of the two paths has been decided.
“In my opinion, it is the most conservative approach,” Dr. Drescher said of the Dutch model. “They are the most cognizant of how much we don’t know, and they do a lot of good research.”
An approach originating at the Child and Adolescent Gender Center Clinic, which is affiliated with the University of California, San Francisco, supports a child socially into a cross-gendered role without medical or surgical intervention but also suppresses puberty. This method is based on the presumption of an adult transgender outcome, despite the absence of a way to predict results, said Dr. Drescher, who also cautions about the iatrogenic effects of such a presumption. “It takes a lot of work to socially transition a child in one direction. It would take a lot to transition back in the other direction, and there is no good empirical data as to whether this is entirely a benign process,” he said.
A third method originated in Toronto at the Centre for Addiction and Mental Health. This method actively discourages a child’s atypical gender interests and views transsexualism as an undesirable outcome that can be prevented, despite what Dr. Drescher said is a complete lack of evidence to either support or refute this claim. This method largely has been abandoned, in part since Ontario and five U.S. states and the District of Columbia have passed laws banning efforts to change a minor’s sexual orientation or gender identity. This method does have puberty suppression in children whose gender dysphoria appears to be persisting into adolescence in common with the other two.
Dr. Drescher said puberty suppression has helped decrease the levels of anxiety, depression, and suicidal ideation typically associated with this cohort. Postponing the development of secondary sexual characteristics gives those who ultimately will desist from their dysphoria more time to let it run its course. The Dutch first initiated this procedure 2 decades ago and have shown that any possible future side effects are outweighed by the psychosocial advantages it provides in the present.
The clinical view of gender dysphoria probably will get a jolt in 2018 upon publication of the ICD-11. In an interview, Dr. Drescher said that, if the condition is no longer categorized by the WHO as a mental disorder and is instead called “gender incongruence” in a chapter dedicated to gender and sexuality issues as currently planned, “it is likely the [American Psychiatric Association] will follow suit and remove gender dysphoria from the DSM. However, I don’t know how long that will take,” he said.
In his presentation, Dr. Drescher said that the causes for gender dysphoria remain unknown, as do the ways in which gender identity develops. It is also unclear how biological, psychosocial, and environmental factors affect gender dysphoria. What is clear, he said, is that “we have to rethink our developmental literature.”
Meanwhile, although gender dysphoria affects a relatively small percentage of the population – less than 1% of “nonreferred” children and adolescents, according to the DSM-5 – the number of prepubescent children presenting to gender clinics is on the rise. This increase might be driven more by social forces than by scientific ones. Dr. Drescher made an anecdotal observation during the presentation that more children are presenting to gender clinics already socially transitioned by their parents than there are children in the research literature on persisters and desisters.
Dr. Drescher recalled in the interview that, during the public comment period for the DSM-5, gender dysphoria elicited the third most responses, compared with other diagnoses, despite its rarity as a condition. “Interest in the subject far outweighs its prevalence.”
Gender-related glossary of terms
"There are so many moving parts to our understanding of gender," said Jack Drescher, MD, during a plenary session at the annual meeting of the American College of Psychiatrists. For that reason, "language is very important" when addressing children who might have questions about their gender identity, he said.
To help establish as much clarity as possible when discussing gender in the clinical setting, Dr. Drescher offered the following glossary of terms. These are not listed alphabetically but in a stepwise fashion aimed at leading to a clearer understanding of successive terms.
Sex: The biological attributes of being male or female. This includes sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.
Gender: The public - and typically the legal - recognition of one's lived role as a boy, girl, man, woman or of other biological factors in combination with psychosocial factors that are seen as contributing to identity development.
Sexual orientation: A person's erotic response tendency or sexual attractions, either directed toward individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual).
Gender identity: Often an independent variable from sexual orientation, this refers to how an individual identifies as either male, female, or, in some cases, some other category.
Gender assignment: The natal presentation as either male or female. The historical terms are "biological male" or "biological female"; also occasionally known as "birth assigned male" or "birth assigned female."
Gender atypical: The somatic features or behaviors not statistically typical in individuals with the same assigned gender in a given society or era.
Gender nonconforming: Typically used as an alternative descriptive term for "gender atypical".
Gender dysphoria: The conflict between a person's assigned gender and that person's gender identity and expression; replaced "gender identity disorder" in the DSM-5.
Gender variant: Often used by those who are concerned the term "gender dysphoria" will unnecessarily pathologize a child.
Gender expression: How an individual demonstrates gender to others, including by way of dress, behavior, and appearance. Increasingly, the term is used in antidiscrimination documents.
Desister: Prepubescent children who present with gender dysphoria but who do not become transgender adults.
Persister: This refers to children who present with gender dysphoria and progress to a transgender adulthood.
Gender reassignment: An official - and often legal - change of gender by way of cross-sex endocrine therapy and/or gender reassignment surgery.
Transsexual: An individual who modifies the body via endocrine and/or surgical means to conform with gender identity either partially or completely.
Transwoman: A person, such as Caitlyn Jenner, who transitions from a male sex assignment to become female.
Transman: A person who transitions from a female sex assignment to become male.
Transgender: The "T" in the acronym LGBT; the popular - not scientific - inclusive term for those whose gender identity, gender expression, or behavior does not conform to that which is typically associated with the natal sex assignment.
Cisgender: From the Latin for "on the same side"; used in the transgender community to describe those whose gender identities align with their natal assignment.
Gender beliefs: Used to refer to the implicit, typically binary, cultural views on the "essential" qualities of men and women.
[email protected]
On Twitter @whitneymcknight
SCOTTSDALE, ARIZ. – The treatment of preadolescents who present with gender questions is often complicated by the absence of evidence-based data on who is most likely to remain gender dysphoric into adulthood and who is not, an expert said at the annual meeting of the American College of Psychiatrists.
“There are some [clinicians] who believe they can predict who will persist and who will not. But they have not published, to my satisfaction, a way to show anyone else how to tell the difference,” said Jack Drescher, MD, a member of the World Health Organization’s (WHO’s) Working Group on the Classification of Sexual Disorders and Sexual Health and clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla.
The WHO working group was tasked with categorizing sex and gender diagnoses in the forthcoming International Classification of Diseases (ICD-11). Dr. Drescher said that he and his fellow WHO working group members have identified at least three discrete transgender populations.
“There are persisters, desisters, and those who first develop gender dysphoria in adolescence and adulthood,” he said. “It would be a clinical mistake to think that there is a seamless transition from childhood gender dysphoria into adolescent and adult gender dysphoria.”
Dr. Drescher said that he believes the Dutch model for treating younger children diagnosed with what is interchangeably referred to as gender dysphoria or gender variance demonstrates the greatest sensitivity to how fluid the situation can be for many of these children. The absence of biomarkers for dysphoria that will persist into adulthood and the finding that a minority of prepubescent gender dysphoria diagnoses persist into adolescence inform the Dutch approach.
This approach, which originated at the VU University Medical Center Amsterdam, is based on 2 decades of research and practice. It assumes that it is better not to actively transition a child socially but to remain neutral to the way in which the child expresses gender identity. If children persist into late adolescence in this model, they are assisted in transitioning. If not, they are supported socially as they adjust to their natal gender. Puberty may sometimes have to be suppressed until the time one of the two paths has been decided.
“In my opinion, it is the most conservative approach,” Dr. Drescher said of the Dutch model. “They are the most cognizant of how much we don’t know, and they do a lot of good research.”
An approach originating at the Child and Adolescent Gender Center Clinic, which is affiliated with the University of California, San Francisco, supports a child socially into a cross-gendered role without medical or surgical intervention but also suppresses puberty. This method is based on the presumption of an adult transgender outcome, despite the absence of a way to predict results, said Dr. Drescher, who also cautions about the iatrogenic effects of such a presumption. “It takes a lot of work to socially transition a child in one direction. It would take a lot to transition back in the other direction, and there is no good empirical data as to whether this is entirely a benign process,” he said.
A third method originated in Toronto at the Centre for Addiction and Mental Health. This method actively discourages a child’s atypical gender interests and views transsexualism as an undesirable outcome that can be prevented, despite what Dr. Drescher said is a complete lack of evidence to either support or refute this claim. This method largely has been abandoned, in part since Ontario and five U.S. states and the District of Columbia have passed laws banning efforts to change a minor’s sexual orientation or gender identity. This method does have puberty suppression in children whose gender dysphoria appears to be persisting into adolescence in common with the other two.
Dr. Drescher said puberty suppression has helped decrease the levels of anxiety, depression, and suicidal ideation typically associated with this cohort. Postponing the development of secondary sexual characteristics gives those who ultimately will desist from their dysphoria more time to let it run its course. The Dutch first initiated this procedure 2 decades ago and have shown that any possible future side effects are outweighed by the psychosocial advantages it provides in the present.
The clinical view of gender dysphoria probably will get a jolt in 2018 upon publication of the ICD-11. In an interview, Dr. Drescher said that, if the condition is no longer categorized by the WHO as a mental disorder and is instead called “gender incongruence” in a chapter dedicated to gender and sexuality issues as currently planned, “it is likely the [American Psychiatric Association] will follow suit and remove gender dysphoria from the DSM. However, I don’t know how long that will take,” he said.
In his presentation, Dr. Drescher said that the causes for gender dysphoria remain unknown, as do the ways in which gender identity develops. It is also unclear how biological, psychosocial, and environmental factors affect gender dysphoria. What is clear, he said, is that “we have to rethink our developmental literature.”
Meanwhile, although gender dysphoria affects a relatively small percentage of the population – less than 1% of “nonreferred” children and adolescents, according to the DSM-5 – the number of prepubescent children presenting to gender clinics is on the rise. This increase might be driven more by social forces than by scientific ones. Dr. Drescher made an anecdotal observation during the presentation that more children are presenting to gender clinics already socially transitioned by their parents than there are children in the research literature on persisters and desisters.
Dr. Drescher recalled in the interview that, during the public comment period for the DSM-5, gender dysphoria elicited the third most responses, compared with other diagnoses, despite its rarity as a condition. “Interest in the subject far outweighs its prevalence.”
Gender-related glossary of terms
"There are so many moving parts to our understanding of gender," said Jack Drescher, MD, during a plenary session at the annual meeting of the American College of Psychiatrists. For that reason, "language is very important" when addressing children who might have questions about their gender identity, he said.
To help establish as much clarity as possible when discussing gender in the clinical setting, Dr. Drescher offered the following glossary of terms. These are not listed alphabetically but in a stepwise fashion aimed at leading to a clearer understanding of successive terms.
Sex: The biological attributes of being male or female. This includes sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.
Gender: The public - and typically the legal - recognition of one's lived role as a boy, girl, man, woman or of other biological factors in combination with psychosocial factors that are seen as contributing to identity development.
Sexual orientation: A person's erotic response tendency or sexual attractions, either directed toward individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual).
Gender identity: Often an independent variable from sexual orientation, this refers to how an individual identifies as either male, female, or, in some cases, some other category.
Gender assignment: The natal presentation as either male or female. The historical terms are "biological male" or "biological female"; also occasionally known as "birth assigned male" or "birth assigned female."
Gender atypical: The somatic features or behaviors not statistically typical in individuals with the same assigned gender in a given society or era.
Gender nonconforming: Typically used as an alternative descriptive term for "gender atypical".
Gender dysphoria: The conflict between a person's assigned gender and that person's gender identity and expression; replaced "gender identity disorder" in the DSM-5.
Gender variant: Often used by those who are concerned the term "gender dysphoria" will unnecessarily pathologize a child.
Gender expression: How an individual demonstrates gender to others, including by way of dress, behavior, and appearance. Increasingly, the term is used in antidiscrimination documents.
Desister: Prepubescent children who present with gender dysphoria but who do not become transgender adults.
Persister: This refers to children who present with gender dysphoria and progress to a transgender adulthood.
Gender reassignment: An official - and often legal - change of gender by way of cross-sex endocrine therapy and/or gender reassignment surgery.
Transsexual: An individual who modifies the body via endocrine and/or surgical means to conform with gender identity either partially or completely.
Transwoman: A person, such as Caitlyn Jenner, who transitions from a male sex assignment to become female.
Transman: A person who transitions from a female sex assignment to become male.
Transgender: The "T" in the acronym LGBT; the popular - not scientific - inclusive term for those whose gender identity, gender expression, or behavior does not conform to that which is typically associated with the natal sex assignment.
Cisgender: From the Latin for "on the same side"; used in the transgender community to describe those whose gender identities align with their natal assignment.
Gender beliefs: Used to refer to the implicit, typically binary, cultural views on the "essential" qualities of men and women.
[email protected]
On Twitter @whitneymcknight
EXPERT ANALYSIS AT THE AMERICAN COLLEGE OF PSYCHIATRISTS ANNUAL MEETING
Study boosts surgical left atrial appendage occlusion
WASHINGTON – Surgical left atrial appendage occlusion in older patients with atrial fibrillation already undergoing cardiac surgery was associated with a 38% reduction in thromboembolism and a 15% lower risk of all-cause mortality during the subsequent year in a large observational study.
“Although randomized trial data are needed, our study demonstrates strong support for the benefits of closing the left atrial appendage at the time of cardiac surgery in patients with atrial fibrillation,” Daniel J. Friedman, MD, said at the annual meeting of the American College of Cardiology.
Thirty-seven percent of patients underwent surgical left atrial appendage occlusion (LAAO) at the time of their primary heart operation. They were slightly younger, more often female, in better cardiovascular health, and more likely to have their surgery at an academic medical center than were patients who didn’t have LAAO. Adjustment for all of these factors was made in the statistical analysis.
The primary outcome was rehospitalization for thromboembolism – that is, ischemic stroke, transient ischemic attack, or other systemic arterial embolism – within 1 year. This occurred in 1.6% of the LAAO group and 2.5% of the non-LAAO group, for an unadjusted 37% and an adjusted 38% relative risk reduction, reported Dr. Friedman, a cardiology research fellow at the Duke Clinical Research Institute in Durham, N.C.
Turning to prespecified secondary endpoints, he noted that the all-cause mortality rate at 1 year was 7.0% in the LAAO group and 10.8% in the comparison arm, for a significant adjusted 15% risk reduction in the closure group. The composite endpoint of thromboembolism, hemorrhagic stroke, or death occurred in 8.7% of the LAAO group compared with 13.5% of non-LAAO patients, representing an adjusted 30% reduction in risk.
In an exploratory analysis, Dr. Friedman and his coinvestigators determined that, in patients discharged without oral anticoagulation, LAAO was associated with a 71% reduction in risk of thromboembolism. In contrast, LAAO didn’t significantly affect thromboembolic risk in patients discharged on an oral anticoagulant.
The STS database did not include information on the methods or completeness of LAAO.
Discussant David J. Wilber, MD, urged care in attempting to translate the study findings into clinical practice.
“I must say, given the diversity of surgical occlusion techniques – everything from excision to internal sutures to external clipping and stapling – I’m really a bit surprised to see the relatively strong outcomes, with a very strong signal for reduction in thromboembolism and also an opportunity to decrease mortality. I guess I’d say I’d be a little bit cautious. I’d want to see data assessing the completeness of closure and its success long term before we take this to heart clinically,” said Dr. Wilber, professor of cardiology and pediatrics and codirector of the Cardiovascular Research Institute at Loyola University in Maywood, Ill.
Dr. Friedman shared Dr. Wilber’s reservations about applying these observational data to clinical practice.
“I think what we can say is that this study supports the concept that the left atrial appendage is important as a source of thromboembolism in atrial fibrillation, and that exclusion of the left atrial appendage can be a potentially viable treatment option for patients,” he said. “I think it’s going to be increasingly important to bring this up as a possible treatment option when we’re discussing cardiac surgery with our heart teams – and that means talking to the surgeon, the cardiologist who may be following the patient afterwards, and even the cardiothoracic anesthesiologist who’s going to be manning the transesophageal echo probe and may be able to give us some insight as to the quality of closure before the patient leaves the operating room.”
There is considerable surgical interest in LAAO for stroke prevention in AF in light of the success of the percutaneous Watchman device. However, many cardiothoracic surgeons have refrained from performing the brief occlusion procedure because of what up until now has been a lack of evidence as to safety and efficacy.
Asked if his study findings imply that oral anticoagulation can routinely be stopped after LAAO provided the surgeon believes the appendage has been successfully excluded from the circulation, Dr. Friedman replied that he does not.
Although the left atrial appendage has been implicated as the site of thrombus formation in 90% of thromboembolic events occurring in patients with AF, ligation of the appendage doesn’t address that other 10%. Dr. Friedman said he believes it’s appropriate to await the results of an ongoing prospective randomized trial of LAAO led by investigators at McMaster University in Hamilton, Ont.
Dr. Friedman reported having no financial conflicts regarding his study, funded by the Burroughs Welcome Fund and the Food and Drug Administration.
WASHINGTON – Surgical left atrial appendage occlusion in older patients with atrial fibrillation already undergoing cardiac surgery was associated with a 38% reduction in thromboembolism and a 15% lower risk of all-cause mortality during the subsequent year in a large observational study.
“Although randomized trial data are needed, our study demonstrates strong support for the benefits of closing the left atrial appendage at the time of cardiac surgery in patients with atrial fibrillation,” Daniel J. Friedman, MD, said at the annual meeting of the American College of Cardiology.
Thirty-seven percent of patients underwent surgical left atrial appendage occlusion (LAAO) at the time of their primary heart operation. They were slightly younger, more often female, in better cardiovascular health, and more likely to have their surgery at an academic medical center than were patients who didn’t have LAAO. Adjustment for all of these factors was made in the statistical analysis.
The primary outcome was rehospitalization for thromboembolism – that is, ischemic stroke, transient ischemic attack, or other systemic arterial embolism – within 1 year. This occurred in 1.6% of the LAAO group and 2.5% of the non-LAAO group, for an unadjusted 37% and an adjusted 38% relative risk reduction, reported Dr. Friedman, a cardiology research fellow at the Duke Clinical Research Institute in Durham, N.C.
Turning to prespecified secondary endpoints, he noted that the all-cause mortality rate at 1 year was 7.0% in the LAAO group and 10.8% in the comparison arm, for a significant adjusted 15% risk reduction in the closure group. The composite endpoint of thromboembolism, hemorrhagic stroke, or death occurred in 8.7% of the LAAO group compared with 13.5% of non-LAAO patients, representing an adjusted 30% reduction in risk.
In an exploratory analysis, Dr. Friedman and his coinvestigators determined that, in patients discharged without oral anticoagulation, LAAO was associated with a 71% reduction in risk of thromboembolism. In contrast, LAAO didn’t significantly affect thromboembolic risk in patients discharged on an oral anticoagulant.
The STS database did not include information on the methods or completeness of LAAO.
Discussant David J. Wilber, MD, urged care in attempting to translate the study findings into clinical practice.
“I must say, given the diversity of surgical occlusion techniques – everything from excision to internal sutures to external clipping and stapling – I’m really a bit surprised to see the relatively strong outcomes, with a very strong signal for reduction in thromboembolism and also an opportunity to decrease mortality. I guess I’d say I’d be a little bit cautious. I’d want to see data assessing the completeness of closure and its success long term before we take this to heart clinically,” said Dr. Wilber, professor of cardiology and pediatrics and codirector of the Cardiovascular Research Institute at Loyola University in Maywood, Ill.
Dr. Friedman shared Dr. Wilber’s reservations about applying these observational data to clinical practice.
“I think what we can say is that this study supports the concept that the left atrial appendage is important as a source of thromboembolism in atrial fibrillation, and that exclusion of the left atrial appendage can be a potentially viable treatment option for patients,” he said. “I think it’s going to be increasingly important to bring this up as a possible treatment option when we’re discussing cardiac surgery with our heart teams – and that means talking to the surgeon, the cardiologist who may be following the patient afterwards, and even the cardiothoracic anesthesiologist who’s going to be manning the transesophageal echo probe and may be able to give us some insight as to the quality of closure before the patient leaves the operating room.”
There is considerable surgical interest in LAAO for stroke prevention in AF in light of the success of the percutaneous Watchman device. However, many cardiothoracic surgeons have refrained from performing the brief occlusion procedure because of what up until now has been a lack of evidence as to safety and efficacy.
Asked if his study findings imply that oral anticoagulation can routinely be stopped after LAAO provided the surgeon believes the appendage has been successfully excluded from the circulation, Dr. Friedman replied that he does not.
Although the left atrial appendage has been implicated as the site of thrombus formation in 90% of thromboembolic events occurring in patients with AF, ligation of the appendage doesn’t address that other 10%. Dr. Friedman said he believes it’s appropriate to await the results of an ongoing prospective randomized trial of LAAO led by investigators at McMaster University in Hamilton, Ont.
Dr. Friedman reported having no financial conflicts regarding his study, funded by the Burroughs Welcome Fund and the Food and Drug Administration.
WASHINGTON – Surgical left atrial appendage occlusion in older patients with atrial fibrillation already undergoing cardiac surgery was associated with a 38% reduction in thromboembolism and a 15% lower risk of all-cause mortality during the subsequent year in a large observational study.
“Although randomized trial data are needed, our study demonstrates strong support for the benefits of closing the left atrial appendage at the time of cardiac surgery in patients with atrial fibrillation,” Daniel J. Friedman, MD, said at the annual meeting of the American College of Cardiology.
Thirty-seven percent of patients underwent surgical left atrial appendage occlusion (LAAO) at the time of their primary heart operation. They were slightly younger, more often female, in better cardiovascular health, and more likely to have their surgery at an academic medical center than were patients who didn’t have LAAO. Adjustment for all of these factors was made in the statistical analysis.
The primary outcome was rehospitalization for thromboembolism – that is, ischemic stroke, transient ischemic attack, or other systemic arterial embolism – within 1 year. This occurred in 1.6% of the LAAO group and 2.5% of the non-LAAO group, for an unadjusted 37% and an adjusted 38% relative risk reduction, reported Dr. Friedman, a cardiology research fellow at the Duke Clinical Research Institute in Durham, N.C.
Turning to prespecified secondary endpoints, he noted that the all-cause mortality rate at 1 year was 7.0% in the LAAO group and 10.8% in the comparison arm, for a significant adjusted 15% risk reduction in the closure group. The composite endpoint of thromboembolism, hemorrhagic stroke, or death occurred in 8.7% of the LAAO group compared with 13.5% of non-LAAO patients, representing an adjusted 30% reduction in risk.
In an exploratory analysis, Dr. Friedman and his coinvestigators determined that, in patients discharged without oral anticoagulation, LAAO was associated with a 71% reduction in risk of thromboembolism. In contrast, LAAO didn’t significantly affect thromboembolic risk in patients discharged on an oral anticoagulant.
The STS database did not include information on the methods or completeness of LAAO.
Discussant David J. Wilber, MD, urged care in attempting to translate the study findings into clinical practice.
“I must say, given the diversity of surgical occlusion techniques – everything from excision to internal sutures to external clipping and stapling – I’m really a bit surprised to see the relatively strong outcomes, with a very strong signal for reduction in thromboembolism and also an opportunity to decrease mortality. I guess I’d say I’d be a little bit cautious. I’d want to see data assessing the completeness of closure and its success long term before we take this to heart clinically,” said Dr. Wilber, professor of cardiology and pediatrics and codirector of the Cardiovascular Research Institute at Loyola University in Maywood, Ill.
Dr. Friedman shared Dr. Wilber’s reservations about applying these observational data to clinical practice.
“I think what we can say is that this study supports the concept that the left atrial appendage is important as a source of thromboembolism in atrial fibrillation, and that exclusion of the left atrial appendage can be a potentially viable treatment option for patients,” he said. “I think it’s going to be increasingly important to bring this up as a possible treatment option when we’re discussing cardiac surgery with our heart teams – and that means talking to the surgeon, the cardiologist who may be following the patient afterwards, and even the cardiothoracic anesthesiologist who’s going to be manning the transesophageal echo probe and may be able to give us some insight as to the quality of closure before the patient leaves the operating room.”
There is considerable surgical interest in LAAO for stroke prevention in AF in light of the success of the percutaneous Watchman device. However, many cardiothoracic surgeons have refrained from performing the brief occlusion procedure because of what up until now has been a lack of evidence as to safety and efficacy.
Asked if his study findings imply that oral anticoagulation can routinely be stopped after LAAO provided the surgeon believes the appendage has been successfully excluded from the circulation, Dr. Friedman replied that he does not.
Although the left atrial appendage has been implicated as the site of thrombus formation in 90% of thromboembolic events occurring in patients with AF, ligation of the appendage doesn’t address that other 10%. Dr. Friedman said he believes it’s appropriate to await the results of an ongoing prospective randomized trial of LAAO led by investigators at McMaster University in Hamilton, Ont.
Dr. Friedman reported having no financial conflicts regarding his study, funded by the Burroughs Welcome Fund and the Food and Drug Administration.
At ACC 17
Key clinical point:
Major finding: The ancillary surgical procedure was associated with a 38% reduction in thromboembolism and a 15% lower risk of all-cause mortality at 1 year, compared with no appendage closure.
Data source: A retrospective comparative effectiveness study using the Society of Thoracic Surgeons database of more than 10,000 Medicare recipients with atrial fibrillation who underwent cardiac surgery, 37% of whom underwent surgical left atrial appendage occlusion during their primary operation.
Disclosures: The presenter reported having no financial conflicts. The Burroughs Welcome Fund and the Food and Drug Administration funded the study.
Hospitalists seek tools for more efficient admissions
Moving patients safely and efficiently through the admission process is always a priority for hospitalists. Is there a way to optimize and standardize the process?
“In hopes of improving admission efficiency, while simultaneously increasing quality of care, we decided to use Lean/Six Sigma methodology to streamline our admission process,” says Escher Howard-Williams, MD, lead author of an abstract called “Standardizing the Admission Process Using Lean/Six Sigma One Piece Flow.”1
A basic tenet of the methodology is called “one piece flow” (OPF), the idea that standardized processes are more efficient and less prone to error when completed from start to finish without interruption. In the study, hospitalists committed to performing all patient admissions in OPF, focusing on one patient from initiation of chart review through exam, order entry and documentation, without interruption. Researchers then analyzed times, including time to call back to ED, time at initiation of chart review, time of evaluation of patient, time orders were placed, and time of sign-out note completed, before and after implementation of OPF. They found a substantial reduction in time of the admission process across all time points with OPF.
“When you are trying to improve quality of care in your institution, dissecting the overall work flow will allow you to discover areas that hinder the overall process,” Dr. Howard-Williams says. “Reframing your process to focus on providing excellent quality care will allow you to find workable solutions to improve the quality of care and efficiency in your practice. As part of this process, developing a team with an appropriate variety of members lays the foundation for success.”
Dr. Howard-Williams hopes that the study will inspire others to reflect on their own practices.
“If, during that reflection, they can identify areas that they would like to improve quality, we would encourage them to join us,” she says. “They will have the opportunity to build their personal work flow maps, find choke points and devise a plan for moving forward with new solutions.”
Reference
1. Howard-Williams E, Liles A, Stephens J, lanza-Kaduce K. Standardizing the admission process using Lean/Six Sigma One Piece Flow [abstract]. J Hosp Med. 2016;11(suppl 1). Available at: http://www.shmabstracts.com/abstract/standardizing-the-admission-process-using-lean-six-sigma-one-piece-flow/. Accessed March 7, 2017.
Moving patients safely and efficiently through the admission process is always a priority for hospitalists. Is there a way to optimize and standardize the process?
“In hopes of improving admission efficiency, while simultaneously increasing quality of care, we decided to use Lean/Six Sigma methodology to streamline our admission process,” says Escher Howard-Williams, MD, lead author of an abstract called “Standardizing the Admission Process Using Lean/Six Sigma One Piece Flow.”1
A basic tenet of the methodology is called “one piece flow” (OPF), the idea that standardized processes are more efficient and less prone to error when completed from start to finish without interruption. In the study, hospitalists committed to performing all patient admissions in OPF, focusing on one patient from initiation of chart review through exam, order entry and documentation, without interruption. Researchers then analyzed times, including time to call back to ED, time at initiation of chart review, time of evaluation of patient, time orders were placed, and time of sign-out note completed, before and after implementation of OPF. They found a substantial reduction in time of the admission process across all time points with OPF.
“When you are trying to improve quality of care in your institution, dissecting the overall work flow will allow you to discover areas that hinder the overall process,” Dr. Howard-Williams says. “Reframing your process to focus on providing excellent quality care will allow you to find workable solutions to improve the quality of care and efficiency in your practice. As part of this process, developing a team with an appropriate variety of members lays the foundation for success.”
Dr. Howard-Williams hopes that the study will inspire others to reflect on their own practices.
“If, during that reflection, they can identify areas that they would like to improve quality, we would encourage them to join us,” she says. “They will have the opportunity to build their personal work flow maps, find choke points and devise a plan for moving forward with new solutions.”
Reference
1. Howard-Williams E, Liles A, Stephens J, lanza-Kaduce K. Standardizing the admission process using Lean/Six Sigma One Piece Flow [abstract]. J Hosp Med. 2016;11(suppl 1). Available at: http://www.shmabstracts.com/abstract/standardizing-the-admission-process-using-lean-six-sigma-one-piece-flow/. Accessed March 7, 2017.
Moving patients safely and efficiently through the admission process is always a priority for hospitalists. Is there a way to optimize and standardize the process?
“In hopes of improving admission efficiency, while simultaneously increasing quality of care, we decided to use Lean/Six Sigma methodology to streamline our admission process,” says Escher Howard-Williams, MD, lead author of an abstract called “Standardizing the Admission Process Using Lean/Six Sigma One Piece Flow.”1
A basic tenet of the methodology is called “one piece flow” (OPF), the idea that standardized processes are more efficient and less prone to error when completed from start to finish without interruption. In the study, hospitalists committed to performing all patient admissions in OPF, focusing on one patient from initiation of chart review through exam, order entry and documentation, without interruption. Researchers then analyzed times, including time to call back to ED, time at initiation of chart review, time of evaluation of patient, time orders were placed, and time of sign-out note completed, before and after implementation of OPF. They found a substantial reduction in time of the admission process across all time points with OPF.
“When you are trying to improve quality of care in your institution, dissecting the overall work flow will allow you to discover areas that hinder the overall process,” Dr. Howard-Williams says. “Reframing your process to focus on providing excellent quality care will allow you to find workable solutions to improve the quality of care and efficiency in your practice. As part of this process, developing a team with an appropriate variety of members lays the foundation for success.”
Dr. Howard-Williams hopes that the study will inspire others to reflect on their own practices.
“If, during that reflection, they can identify areas that they would like to improve quality, we would encourage them to join us,” she says. “They will have the opportunity to build their personal work flow maps, find choke points and devise a plan for moving forward with new solutions.”
Reference
1. Howard-Williams E, Liles A, Stephens J, lanza-Kaduce K. Standardizing the admission process using Lean/Six Sigma One Piece Flow [abstract]. J Hosp Med. 2016;11(suppl 1). Available at: http://www.shmabstracts.com/abstract/standardizing-the-admission-process-using-lean-six-sigma-one-piece-flow/. Accessed March 7, 2017.
Using shock index in the ED to predict hospital admission and inpatient mortality
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Gorsuch keeps cards close during nomination hearing
Throughout his marathon confirmation hearing, U.S. Supreme Court nominee Neil Gorsuch remained tight-lipped about how he might rule on major health care issues if confirmed to the country’s highest court, pledging to look at the facts of each case and rule according to the law.
The Senate Committee on the Judiciary wrapped up its nearly week-long questioning of Judge Gorsuch on March 23. Inquiries during the hearing ranged from Judge Gorsuch’s stance on abortion, to his support of religious freedom, to whether he would uphold President Trump’s controversial Executive Order on travel and immigration. Through it all, Judge Gorsuch, who presides over Denver’s 10th Circuit, kept his composure and refused to offer insight into which way he would lean when deciding such hot-button issues. 
“If I were to start telling you which are my favorite [Supreme Court] precedents or which are my least favorite precedents, or if I viewed precedents in that fashion, I would be tipping my hand and suggesting to litigants that I’ve already made up my mind about their cases. That’s not a fair judge. I didn’t want that kind of judge when I was a lawyer, and I don’t want to be that kind of judge now.”
During the hearing, the case of Roe v. Wade was brought up repeatedly, and multiple senators from both parties questioned whether Judge Gorsuch would vote to overturn the right to an abortion. Sen. Lindsey Graham, (R-S.C.) discussed recent legislation he supports that would prohibit abortion if the probable postfertilization age of the fetus is 20 weeks or greater.
“We’re one of seven nations that allow wholesale, on demand, unlimited abortion at 20 weeks. I’d like to get out of that club,” Sen. Graham said during the hearing. “I’m just letting everybody know that if this legislation passes, it will be challenged before you and you will have to look at a new theory of how the state can protect the unborn ... Here’s what I think. You will read the briefs, look at the facts, and make a decision, am I fair to conclude that?”
“Senator, I can promise you no more than that, and I guarantee no less than that in every single case that comes before me,” Judge Gorsuch responded.
Sen. Dianne Feinstein (D-Calif.) queried whether Judge Gorsuch considered Roe to be “super precedent.”
“Senator, [the ruling] has been reaffirmed many times,” Judge Gorsuch responded, stressing that all Supreme Court precedent deserves respect and consideration when deciding new challenges.
The judge defended his 10th Circuit decision that found in favor of Hobby Lobby Stores after the company objected to the Affordable Care Act’s contraceptive coverage requirements based on religious grounds. In a separate case, Judge Gorsuch dissented from a ruling not to rehear a challenge by the Little Sisters of the Poor against certain contraceptive coverage provisions.
“Senator, our job there was to apply the statute as best we could understand its purpose as expressed in its text,” Judge Gorsuch said. “And I think every judge who faced that case – everyone – found it a hard case and did their level best and that’s all any judge can promise or guarantee. I respect all of my colleagues who addressed that case.”
The subject of religious freedom also was addressed during questions regarding President Trump’s Executive Order on travel and immigration and whether Judge Gorsuch would uphold the Executive Order if it came before the high court.
“President Trump promised a Muslim ban,” Sen. Patrick J. Leahy (D-Vt.) said during the hearing. “He still has on his website to this day that he’s called for a total and complete shutdown of Muslims entering the United States. And a Republican congressman recently said the best thing the president can do for his Muslim ban is to make sure he has Gorsuch on the Supreme Court.”
Judge Gorsuch called the unnamed congressman’s remark “silly,” adding that the congressman had “no idea” how Judge Gorsuch would rule in any case that comes before him. Sen. Leahy went on to ask Judge Gorsuch whether the president has the authority to block Jews from coming to the country or ban residents of Israel.
“We have a Constitution,” Judge Gorsuch replied. “And it does guarantee free exercise [of religion]. It also guarantees equal protection of the laws and a whole lot else besides, and the Supreme Court has held that due process rights extend even to undocumented persons in this country. I will apply the law faithfully and fearlessly and without regard to persons.”
A vote by the Senate Judiciary Committee is expected April 3 followed by a Senate floor vote later that week. Supreme Court justices require 60 votes for confirmation. Republicans control the Senate 52-48, so eight Democrats are needed to confirm Judge Gorsuch. Senate Minority Leader Charles E. Schumer (D-N.Y.) vowed on March 23 to oppose Judge Gorsuch and asked other Democrats to join him, setting up a potential filibuster against Judge Gorsuch’s confirmation.
[email protected]
On Twitter @legal_med
Throughout his marathon confirmation hearing, U.S. Supreme Court nominee Neil Gorsuch remained tight-lipped about how he might rule on major health care issues if confirmed to the country’s highest court, pledging to look at the facts of each case and rule according to the law.
The Senate Committee on the Judiciary wrapped up its nearly week-long questioning of Judge Gorsuch on March 23. Inquiries during the hearing ranged from Judge Gorsuch’s stance on abortion, to his support of religious freedom, to whether he would uphold President Trump’s controversial Executive Order on travel and immigration. Through it all, Judge Gorsuch, who presides over Denver’s 10th Circuit, kept his composure and refused to offer insight into which way he would lean when deciding such hot-button issues.
“If I were to start telling you which are my favorite [Supreme Court] precedents or which are my least favorite precedents, or if I viewed precedents in that fashion, I would be tipping my hand and suggesting to litigants that I’ve already made up my mind about their cases. That’s not a fair judge. I didn’t want that kind of judge when I was a lawyer, and I don’t want to be that kind of judge now.”
During the hearing, the case of Roe v. Wade was brought up repeatedly, and multiple senators from both parties questioned whether Judge Gorsuch would vote to overturn the right to an abortion. Sen. Lindsey Graham, (R-S.C.) discussed recent legislation he supports that would prohibit abortion if the probable postfertilization age of the fetus is 20 weeks or greater.
“We’re one of seven nations that allow wholesale, on demand, unlimited abortion at 20 weeks. I’d like to get out of that club,” Sen. Graham said during the hearing. “I’m just letting everybody know that if this legislation passes, it will be challenged before you and you will have to look at a new theory of how the state can protect the unborn ... Here’s what I think. You will read the briefs, look at the facts, and make a decision, am I fair to conclude that?”
“Senator, I can promise you no more than that, and I guarantee no less than that in every single case that comes before me,” Judge Gorsuch responded.
Sen. Dianne Feinstein (D-Calif.) queried whether Judge Gorsuch considered Roe to be “super precedent.”
“Senator, [the ruling] has been reaffirmed many times,” Judge Gorsuch responded, stressing that all Supreme Court precedent deserves respect and consideration when deciding new challenges.
The judge defended his 10th Circuit decision that found in favor of Hobby Lobby Stores after the company objected to the Affordable Care Act’s contraceptive coverage requirements based on religious grounds. In a separate case, Judge Gorsuch dissented from a ruling not to rehear a challenge by the Little Sisters of the Poor against certain contraceptive coverage provisions.
“Senator, our job there was to apply the statute as best we could understand its purpose as expressed in its text,” Judge Gorsuch said. “And I think every judge who faced that case – everyone – found it a hard case and did their level best and that’s all any judge can promise or guarantee. I respect all of my colleagues who addressed that case.”
The subject of religious freedom also was addressed during questions regarding President Trump’s Executive Order on travel and immigration and whether Judge Gorsuch would uphold the Executive Order if it came before the high court.
“President Trump promised a Muslim ban,” Sen. Patrick J. Leahy (D-Vt.) said during the hearing. “He still has on his website to this day that he’s called for a total and complete shutdown of Muslims entering the United States. And a Republican congressman recently said the best thing the president can do for his Muslim ban is to make sure he has Gorsuch on the Supreme Court.”
Judge Gorsuch called the unnamed congressman’s remark “silly,” adding that the congressman had “no idea” how Judge Gorsuch would rule in any case that comes before him. Sen. Leahy went on to ask Judge Gorsuch whether the president has the authority to block Jews from coming to the country or ban residents of Israel.
“We have a Constitution,” Judge Gorsuch replied. “And it does guarantee free exercise [of religion]. It also guarantees equal protection of the laws and a whole lot else besides, and the Supreme Court has held that due process rights extend even to undocumented persons in this country. I will apply the law faithfully and fearlessly and without regard to persons.”
A vote by the Senate Judiciary Committee is expected April 3 followed by a Senate floor vote later that week. Supreme Court justices require 60 votes for confirmation. Republicans control the Senate 52-48, so eight Democrats are needed to confirm Judge Gorsuch. Senate Minority Leader Charles E. Schumer (D-N.Y.) vowed on March 23 to oppose Judge Gorsuch and asked other Democrats to join him, setting up a potential filibuster against Judge Gorsuch’s confirmation.
[email protected]
On Twitter @legal_med
Throughout his marathon confirmation hearing, U.S. Supreme Court nominee Neil Gorsuch remained tight-lipped about how he might rule on major health care issues if confirmed to the country’s highest court, pledging to look at the facts of each case and rule according to the law.
The Senate Committee on the Judiciary wrapped up its nearly week-long questioning of Judge Gorsuch on March 23. Inquiries during the hearing ranged from Judge Gorsuch’s stance on abortion, to his support of religious freedom, to whether he would uphold President Trump’s controversial Executive Order on travel and immigration. Through it all, Judge Gorsuch, who presides over Denver’s 10th Circuit, kept his composure and refused to offer insight into which way he would lean when deciding such hot-button issues.
“If I were to start telling you which are my favorite [Supreme Court] precedents or which are my least favorite precedents, or if I viewed precedents in that fashion, I would be tipping my hand and suggesting to litigants that I’ve already made up my mind about their cases. That’s not a fair judge. I didn’t want that kind of judge when I was a lawyer, and I don’t want to be that kind of judge now.”
During the hearing, the case of Roe v. Wade was brought up repeatedly, and multiple senators from both parties questioned whether Judge Gorsuch would vote to overturn the right to an abortion. Sen. Lindsey Graham, (R-S.C.) discussed recent legislation he supports that would prohibit abortion if the probable postfertilization age of the fetus is 20 weeks or greater.
“We’re one of seven nations that allow wholesale, on demand, unlimited abortion at 20 weeks. I’d like to get out of that club,” Sen. Graham said during the hearing. “I’m just letting everybody know that if this legislation passes, it will be challenged before you and you will have to look at a new theory of how the state can protect the unborn ... Here’s what I think. You will read the briefs, look at the facts, and make a decision, am I fair to conclude that?”
“Senator, I can promise you no more than that, and I guarantee no less than that in every single case that comes before me,” Judge Gorsuch responded.
Sen. Dianne Feinstein (D-Calif.) queried whether Judge Gorsuch considered Roe to be “super precedent.”
“Senator, [the ruling] has been reaffirmed many times,” Judge Gorsuch responded, stressing that all Supreme Court precedent deserves respect and consideration when deciding new challenges.
The judge defended his 10th Circuit decision that found in favor of Hobby Lobby Stores after the company objected to the Affordable Care Act’s contraceptive coverage requirements based on religious grounds. In a separate case, Judge Gorsuch dissented from a ruling not to rehear a challenge by the Little Sisters of the Poor against certain contraceptive coverage provisions.
“Senator, our job there was to apply the statute as best we could understand its purpose as expressed in its text,” Judge Gorsuch said. “And I think every judge who faced that case – everyone – found it a hard case and did their level best and that’s all any judge can promise or guarantee. I respect all of my colleagues who addressed that case.”
The subject of religious freedom also was addressed during questions regarding President Trump’s Executive Order on travel and immigration and whether Judge Gorsuch would uphold the Executive Order if it came before the high court.
“President Trump promised a Muslim ban,” Sen. Patrick J. Leahy (D-Vt.) said during the hearing. “He still has on his website to this day that he’s called for a total and complete shutdown of Muslims entering the United States. And a Republican congressman recently said the best thing the president can do for his Muslim ban is to make sure he has Gorsuch on the Supreme Court.”
Judge Gorsuch called the unnamed congressman’s remark “silly,” adding that the congressman had “no idea” how Judge Gorsuch would rule in any case that comes before him. Sen. Leahy went on to ask Judge Gorsuch whether the president has the authority to block Jews from coming to the country or ban residents of Israel.
“We have a Constitution,” Judge Gorsuch replied. “And it does guarantee free exercise [of religion]. It also guarantees equal protection of the laws and a whole lot else besides, and the Supreme Court has held that due process rights extend even to undocumented persons in this country. I will apply the law faithfully and fearlessly and without regard to persons.”
A vote by the Senate Judiciary Committee is expected April 3 followed by a Senate floor vote later that week. Supreme Court justices require 60 votes for confirmation. Republicans control the Senate 52-48, so eight Democrats are needed to confirm Judge Gorsuch. Senate Minority Leader Charles E. Schumer (D-N.Y.) vowed on March 23 to oppose Judge Gorsuch and asked other Democrats to join him, setting up a potential filibuster against Judge Gorsuch’s confirmation.
[email protected]
On Twitter @legal_med
Enlisting social networks for better health outcomes
As a hospitalist, you typically have little, if any, contact with patients outside the hospital and, at most, you’ll only spend a couple of hours a year in front of any particular patient. The vast majority of the determinants of your patients’ health occur when you’re not there.
In a commentary in the New England Journal of Medicine entitled “Engineering Social Incentives for Health,” lead author David A. Asch, MD, MBA, addresses that issue.1
“The motivation for the piece is that the people who are in a position to influence a patient’s health are their friends and family, and yet so much of how we have structured health care is between a clinician and a patient,” he says. “We often fail to engage the people in patients’ everyday lives, who can be quite willing partners in improving health care. There are all sorts of things they can do to help patients with hard-to-control diabetes or ... heart failure, or anything that might have put them in the hospital in the first place.”
The column describes a ladder of social engineering strategies, from very simple to complex. One example on the simple end might be to help a patient remember a daily medication by having him place the medication bottle where his partner can see him taking – or not taking – it. (The alternative is that medications are taken in a private place, such in the bathroom, where no one might be watching over the routine to keep the patient on track.)
Moving up the ladder, a hospitalist might help set up a network of other patients with heart failure, so that they can help each other in a kind of peer mentorship.
“These peer-to-peer connections might require Web-based platforms or social support groups, so that kind of activity is a lot more complicated, but the general theme is: Can hospitalists think about ways to constructively engage the social networks that already surround patients, so they don’t need to invoke the health system to do it?”
It’s long been known that people with more social support do better: People who are married do better; people who have more friends do better. “Up until now, it’s just been an observation,” Dr. Asch says. “I think we’re at a point where we could begin to prescribe social support in the way we might prescribe a diuretic. I’d like to try it out at least. I think that’s the call to action.”
Reference
1. Asch D, Rosin R. Engineering social incentives for health. NEJM. 2016;375:2511-2513.
As a hospitalist, you typically have little, if any, contact with patients outside the hospital and, at most, you’ll only spend a couple of hours a year in front of any particular patient. The vast majority of the determinants of your patients’ health occur when you’re not there.
In a commentary in the New England Journal of Medicine entitled “Engineering Social Incentives for Health,” lead author David A. Asch, MD, MBA, addresses that issue.1
“The motivation for the piece is that the people who are in a position to influence a patient’s health are their friends and family, and yet so much of how we have structured health care is between a clinician and a patient,” he says. “We often fail to engage the people in patients’ everyday lives, who can be quite willing partners in improving health care. There are all sorts of things they can do to help patients with hard-to-control diabetes or ... heart failure, or anything that might have put them in the hospital in the first place.”
The column describes a ladder of social engineering strategies, from very simple to complex. One example on the simple end might be to help a patient remember a daily medication by having him place the medication bottle where his partner can see him taking – or not taking – it. (The alternative is that medications are taken in a private place, such in the bathroom, where no one might be watching over the routine to keep the patient on track.)
Moving up the ladder, a hospitalist might help set up a network of other patients with heart failure, so that they can help each other in a kind of peer mentorship.
“These peer-to-peer connections might require Web-based platforms or social support groups, so that kind of activity is a lot more complicated, but the general theme is: Can hospitalists think about ways to constructively engage the social networks that already surround patients, so they don’t need to invoke the health system to do it?”
It’s long been known that people with more social support do better: People who are married do better; people who have more friends do better. “Up until now, it’s just been an observation,” Dr. Asch says. “I think we’re at a point where we could begin to prescribe social support in the way we might prescribe a diuretic. I’d like to try it out at least. I think that’s the call to action.”
Reference
1. Asch D, Rosin R. Engineering social incentives for health. NEJM. 2016;375:2511-2513.
As a hospitalist, you typically have little, if any, contact with patients outside the hospital and, at most, you’ll only spend a couple of hours a year in front of any particular patient. The vast majority of the determinants of your patients’ health occur when you’re not there.
In a commentary in the New England Journal of Medicine entitled “Engineering Social Incentives for Health,” lead author David A. Asch, MD, MBA, addresses that issue.1
“The motivation for the piece is that the people who are in a position to influence a patient’s health are their friends and family, and yet so much of how we have structured health care is between a clinician and a patient,” he says. “We often fail to engage the people in patients’ everyday lives, who can be quite willing partners in improving health care. There are all sorts of things they can do to help patients with hard-to-control diabetes or ... heart failure, or anything that might have put them in the hospital in the first place.”
The column describes a ladder of social engineering strategies, from very simple to complex. One example on the simple end might be to help a patient remember a daily medication by having him place the medication bottle where his partner can see him taking – or not taking – it. (The alternative is that medications are taken in a private place, such in the bathroom, where no one might be watching over the routine to keep the patient on track.)
Moving up the ladder, a hospitalist might help set up a network of other patients with heart failure, so that they can help each other in a kind of peer mentorship.
“These peer-to-peer connections might require Web-based platforms or social support groups, so that kind of activity is a lot more complicated, but the general theme is: Can hospitalists think about ways to constructively engage the social networks that already surround patients, so they don’t need to invoke the health system to do it?”
It’s long been known that people with more social support do better: People who are married do better; people who have more friends do better. “Up until now, it’s just been an observation,” Dr. Asch says. “I think we’re at a point where we could begin to prescribe social support in the way we might prescribe a diuretic. I’d like to try it out at least. I think that’s the call to action.”
Reference
1. Asch D, Rosin R. Engineering social incentives for health. NEJM. 2016;375:2511-2513.