BOSTON – Direct-acting antiretroviral therapies are safe and well tolerated in hepatitis C virus patients with comorbid psychiatric conditions, a study showed.

The finding that sustained virologic response (SVR) rates at 1 year were similar in genotype 1 HCV patients with and without psychiatric comorbidities could help end the stigma against treating this patient subgroup, stemming from when treatment with interferon risked psychiatric decompensation. That’s according to nurse practitioner Anne Moore, winner of this year’s Poster of Distinction Award at the American Association for the Study of Liver Diseases annual meeting.

Whitney McKnight/Frontline Medical News

[email protected]

On Twitter @whitneymcknight

BOSTON – Direct-acting antiretroviral therapies are safe and well tolerated in hepatitis C virus patients with comorbid psychiatric conditions, a study showed.

The finding that sustained virologic response (SVR) rates at 1 year were similar in genotype 1 HCV patients with and without psychiatric comorbidities could help end the stigma against treating this patient subgroup, stemming from when treatment with interferon risked psychiatric decompensation. That’s according to nurse practitioner Anne Moore, winner of this year’s Poster of Distinction Award at the American Association for the Study of Liver Diseases annual meeting.

Whitney McKnight/Frontline Medical News

[email protected]

On Twitter @whitneymcknight

BOSTON – Direct-acting antiretroviral therapies are safe and well tolerated in hepatitis C virus patients with comorbid psychiatric conditions, a study showed.

The finding that sustained virologic response (SVR) rates at 1 year were similar in genotype 1 HCV patients with and without psychiatric comorbidities could help end the stigma against treating this patient subgroup, stemming from when treatment with interferon risked psychiatric decompensation. That’s according to nurse practitioner Anne Moore, winner of this year’s Poster of Distinction Award at the American Association for the Study of Liver Diseases annual meeting.

Whitney McKnight/Frontline Medical News

[email protected]

On Twitter @whitneymcknight

Although patients have more assisted reproductive techniques (ART) available in recent years, management of infertility through minimally invasive surgical avenues can confront quality of life (QoL) and pathology concerns with birth rates equal to those with ART. This was a main takeaway in a packed ballroom in Orlando, Florida, at the 45th Global Congress of the AAGL. In this session, G. David Adamson, MD, brought together 3 top minimally invasive gynecologic surgeons to discuss clinical decisions in the overall and specific surgical management of: endometriomas and endometriosis, including deeply infiltrating disease; pelvic adhesions; distal tubal injury/occlusion; and proximal tubal occlusion by hysteroscopy.

Tommaso Falcone, MD, maintained that many patients (up to 85%) have pain with endometriomas, and addressing QoL for these women, with surgery versus managing their infertility only with in vitro fertilization (IVF), is an important consideration. Dr. Adamson noted that, “although there are no RCT data to guide management of endometriomas, we do have reasonable data to counsel patients on surgery versus IVF, with clinical considerations including patient age, presence of pain, and size of the endometrioma.”

Antonio Gargiulo, MD, advised attendees that when counseling patients on the role of laparoscopy in adhesiolysis to consider (1) that adhesions interfere with gamete and embryo transplant, (2) retrospective data from a small study show a positive effect of adhesiolysis in infertility, and (3) that the effect is dependent on the ASRM Adhesion Score. Regarding laparoscopy for distal tubal inclusion, he noted that case selection is important, as surgery can restore anatomic integrity but not functional integrity. In addition, he pointed out that neosalpingectomy before IVF should be considered in young women with mild hydrosalpinges when male factor infertility is present.

For proximal tubal occlusion, Dr. Gargiulo noted that hysteroscopy catheterization has diagnostic and therapeutic value, with contraindications including infection, inflammation, male factor infertility, and prior tubal surgery.

“Surgeons must offer and understand ART alternatives so that they can offer patient-centered choices,” said Dr. Gargiulo.

Finally, when does Dr. Leila Adamyan of the Federal State Institution Research Center for Obstetrics, Gynecology, and Perinatology of the V.I. Kulakov Russian Federation perform myomectomy before IVF? In the presence of:

• submucosal myoma
• myoma greater than 4 cm in size
• multiple myoma.

When sarcoma is suspected, she advises the use of endobags.

Although patients have more assisted reproductive techniques (ART) available in recent years, management of infertility through minimally invasive surgical avenues can confront quality of life (QoL) and pathology concerns with birth rates equal to those with ART. This was a main takeaway in a packed ballroom in Orlando, Florida, at the 45th Global Congress of the AAGL. In this session, G. David Adamson, MD, brought together 3 top minimally invasive gynecologic surgeons to discuss clinical decisions in the overall and specific surgical management of: endometriomas and endometriosis, including deeply infiltrating disease; pelvic adhesions; distal tubal injury/occlusion; and proximal tubal occlusion by hysteroscopy.

Tommaso Falcone, MD, maintained that many patients (up to 85%) have pain with endometriomas, and addressing QoL for these women, with surgery versus managing their infertility only with in vitro fertilization (IVF), is an important consideration. Dr. Adamson noted that, “although there are no RCT data to guide management of endometriomas, we do have reasonable data to counsel patients on surgery versus IVF, with clinical considerations including patient age, presence of pain, and size of the endometrioma.”

Antonio Gargiulo, MD, advised attendees that when counseling patients on the role of laparoscopy in adhesiolysis to consider (1) that adhesions interfere with gamete and embryo transplant, (2) retrospective data from a small study show a positive effect of adhesiolysis in infertility, and (3) that the effect is dependent on the ASRM Adhesion Score. Regarding laparoscopy for distal tubal inclusion, he noted that case selection is important, as surgery can restore anatomic integrity but not functional integrity. In addition, he pointed out that neosalpingectomy before IVF should be considered in young women with mild hydrosalpinges when male factor infertility is present.

For proximal tubal occlusion, Dr. Gargiulo noted that hysteroscopy catheterization has diagnostic and therapeutic value, with contraindications including infection, inflammation, male factor infertility, and prior tubal surgery.

“Surgeons must offer and understand ART alternatives so that they can offer patient-centered choices,” said Dr. Gargiulo.

Finally, when does Dr. Leila Adamyan of the Federal State Institution Research Center for Obstetrics, Gynecology, and Perinatology of the V.I. Kulakov Russian Federation perform myomectomy before IVF? In the presence of:

• submucosal myoma
• myoma greater than 4 cm in size
• multiple myoma.

When sarcoma is suspected, she advises the use of endobags.

Although patients have more assisted reproductive techniques (ART) available in recent years, management of infertility through minimally invasive surgical avenues can confront quality of life (QoL) and pathology concerns with birth rates equal to those with ART. This was a main takeaway in a packed ballroom in Orlando, Florida, at the 45th Global Congress of the AAGL. In this session, G. David Adamson, MD, brought together 3 top minimally invasive gynecologic surgeons to discuss clinical decisions in the overall and specific surgical management of: endometriomas and endometriosis, including deeply infiltrating disease; pelvic adhesions; distal tubal injury/occlusion; and proximal tubal occlusion by hysteroscopy.

Tommaso Falcone, MD, maintained that many patients (up to 85%) have pain with endometriomas, and addressing QoL for these women, with surgery versus managing their infertility only with in vitro fertilization (IVF), is an important consideration. Dr. Adamson noted that, “although there are no RCT data to guide management of endometriomas, we do have reasonable data to counsel patients on surgery versus IVF, with clinical considerations including patient age, presence of pain, and size of the endometrioma.”

Antonio Gargiulo, MD, advised attendees that when counseling patients on the role of laparoscopy in adhesiolysis to consider (1) that adhesions interfere with gamete and embryo transplant, (2) retrospective data from a small study show a positive effect of adhesiolysis in infertility, and (3) that the effect is dependent on the ASRM Adhesion Score. Regarding laparoscopy for distal tubal inclusion, he noted that case selection is important, as surgery can restore anatomic integrity but not functional integrity. In addition, he pointed out that neosalpingectomy before IVF should be considered in young women with mild hydrosalpinges when male factor infertility is present.

For proximal tubal occlusion, Dr. Gargiulo noted that hysteroscopy catheterization has diagnostic and therapeutic value, with contraindications including infection, inflammation, male factor infertility, and prior tubal surgery.

“Surgeons must offer and understand ART alternatives so that they can offer patient-centered choices,” said Dr. Gargiulo.

Finally, when does Dr. Leila Adamyan of the Federal State Institution Research Center for Obstetrics, Gynecology, and Perinatology of the V.I. Kulakov Russian Federation perform myomectomy before IVF? In the presence of:

• submucosal myoma
• myoma greater than 4 cm in size
• multiple myoma.

When sarcoma is suspected, she advises the use of endobags.

SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?

The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.

“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.

Normal puberty

Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).

Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.

Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).

But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.

This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.

When to be concerned

Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.

Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.

With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.

Without proper testing, however, a physician might as well be guessing at the cause of the early development.

“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.

If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.

“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.

Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.

Dr. Styne reported that he had no relevant financial disclosures.

SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?

The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.

“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.

Normal puberty

Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).

Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.

Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).

But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.

This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.

When to be concerned

Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.

Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.

With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.

Without proper testing, however, a physician might as well be guessing at the cause of the early development.

“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.

If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.

“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.

Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.

Dr. Styne reported that he had no relevant financial disclosures.

SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?

The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.

“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.

Normal puberty

Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).

Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.

Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).

But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.

This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.

When to be concerned

Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.

Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.

With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.

Without proper testing, however, a physician might as well be guessing at the cause of the early development.

“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.

If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.

“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.

Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.

Dr. Styne reported that he had no relevant financial disclosures.

WASHINGTON – The investigational anti-interleukin-23 monoclonal antibody guselkumab was safe and well tolerated, and demonstrated significant improvement on a variety of measures in patients with active psoriatic arthritis in a randomized, placebo-controlled phase IIa study.

The primary endpoint of ACR20 at 24 weeks was achieved in 58% of 100 patients randomized to receive treatment with guselkumab versus 18.4% of 49 patients who received placebo, Atul A. Deodhar, MD, reported in a late-breaking abstract presentation at the annual meeting of the American College of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

[email protected]

WASHINGTON – The investigational anti-interleukin-23 monoclonal antibody guselkumab was safe and well tolerated, and demonstrated significant improvement on a variety of measures in patients with active psoriatic arthritis in a randomized, placebo-controlled phase IIa study.

The primary endpoint of ACR20 at 24 weeks was achieved in 58% of 100 patients randomized to receive treatment with guselkumab versus 18.4% of 49 patients who received placebo, Atul A. Deodhar, MD, reported in a late-breaking abstract presentation at the annual meeting of the American College of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

[email protected]

WASHINGTON – The investigational anti-interleukin-23 monoclonal antibody guselkumab was safe and well tolerated, and demonstrated significant improvement on a variety of measures in patients with active psoriatic arthritis in a randomized, placebo-controlled phase IIa study.

The primary endpoint of ACR20 at 24 weeks was achieved in 58% of 100 patients randomized to receive treatment with guselkumab versus 18.4% of 49 patients who received placebo, Atul A. Deodhar, MD, reported in a late-breaking abstract presentation at the annual meeting of the American College of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

[email protected]

Prasterone (Intrarosa), a vaginal insert containing dehydroepiandrosterone (DHEA) to treat dyspareunia in menopause caused by vulvar and vaginal atrophy, has won Food and Drug Administration approval.

It’s the first FDA-approved product containing the active ingredient prasterone, known also as DHEA. It will be marketed by Endoceutics Inc., a Quebec-based pharmaceutical company focused on women’s health.

[email protected]

On Twitter @maryellenny

Prasterone (Intrarosa), a vaginal insert containing dehydroepiandrosterone (DHEA) to treat dyspareunia in menopause caused by vulvar and vaginal atrophy, has won Food and Drug Administration approval.

It’s the first FDA-approved product containing the active ingredient prasterone, known also as DHEA. It will be marketed by Endoceutics Inc., a Quebec-based pharmaceutical company focused on women’s health.

[email protected]

On Twitter @maryellenny

Prasterone (Intrarosa), a vaginal insert containing dehydroepiandrosterone (DHEA) to treat dyspareunia in menopause caused by vulvar and vaginal atrophy, has won Food and Drug Administration approval.

It’s the first FDA-approved product containing the active ingredient prasterone, known also as DHEA. It will be marketed by Endoceutics Inc., a Quebec-based pharmaceutical company focused on women’s health.

[email protected]

On Twitter @maryellenny

The number of new Zika cases reported among pregnant women in the United States dropped for the second week in a row, according to data from the Centers for Disease Control and Prevention.

For the week ending Nov. 10, there were 124 new cases of pregnant women with laboratory evidence of Zika virus infection reported to the CDC: 30 in the states and the District of Columbia and 94 in the U.S. territories. The previous week (Nov. 3), the number of new cases was 146, which came on the heels of a new weekly high of 288 for the week of Oct. 27.

The total number of pregnant women with Zika now stands at 3,538 for the year: 1,087 for the states and 2,451 for the territories, the CDC said.

Among all Americans, there have been 36,323 cases of Zika reported to the CDC: 4,255 have occurred in the states/D.C. and 32,068 in the territories. About 98% of territorial cases have occurred in Puerto Rico, the CDC said.

[email protected]

The number of new Zika cases reported among pregnant women in the United States dropped for the second week in a row, according to data from the Centers for Disease Control and Prevention.

For the week ending Nov. 10, there were 124 new cases of pregnant women with laboratory evidence of Zika virus infection reported to the CDC: 30 in the states and the District of Columbia and 94 in the U.S. territories. The previous week (Nov. 3), the number of new cases was 146, which came on the heels of a new weekly high of 288 for the week of Oct. 27.

The total number of pregnant women with Zika now stands at 3,538 for the year: 1,087 for the states and 2,451 for the territories, the CDC said.

Among all Americans, there have been 36,323 cases of Zika reported to the CDC: 4,255 have occurred in the states/D.C. and 32,068 in the territories. About 98% of territorial cases have occurred in Puerto Rico, the CDC said.

[email protected]

The number of new Zika cases reported among pregnant women in the United States dropped for the second week in a row, according to data from the Centers for Disease Control and Prevention.

For the week ending Nov. 10, there were 124 new cases of pregnant women with laboratory evidence of Zika virus infection reported to the CDC: 30 in the states and the District of Columbia and 94 in the U.S. territories. The previous week (Nov. 3), the number of new cases was 146, which came on the heels of a new weekly high of 288 for the week of Oct. 27.

The total number of pregnant women with Zika now stands at 3,538 for the year: 1,087 for the states and 2,451 for the territories, the CDC said.

Among all Americans, there have been 36,323 cases of Zika reported to the CDC: 4,255 have occurred in the states/D.C. and 32,068 in the territories. About 98% of territorial cases have occurred in Puerto Rico, the CDC said.

[email protected]

WASHINGTON – The mass retirement of Baby Boomer workhorses, the changing face of a Millennial workforce, and the graying of America will deliver a triple-whammy to rheumatology over the next 15 years: By 2030, the United States will be short 4,700 full-time rheumatologists – just about as many as are currently in practice.

“This is drastic,” Marcy Bolster, MD, said at the annual meeting of the American College of Rheumatology. “We need to take action now or we will not be able to meet the expected increases in patient demand.”

Dr. Bolster, director of the rheumatology fellowship training program at Massachusetts General Hospital, Boston, was one of 10 clinicians who discussed the ACR’s massive new project, “The 2015 Workforce Study of Rheumatology Specialists in the United States,” a comprehensive assessment of the current supply of rheumatologists in this country, and a sobering prediction of how many will be needed in the future.

Michele G. Sullivan/Frontline Medical News

Shortages will affect all regions, but some more than others

All of these issues are now converging at a time when patient demand is expected to soar. In the United States, about 22.5 million adults and 300,000 children have a rheumatic disease. According to the study, that number will increase by 61% by 2030.

Dr. Lawrence-Wolff used population statistics to really put the numbers needed to care for these patients into perspective. Studies in the United States, Canada, and Europe generally agree that the ideal rheumatologist:patient ratio is somewhere around 2 per 100,000 adults. “In 2005, when we were felt to be balanced in this way, our ratio was 1.67/100,000 patients.”

This ratio will look very different by 2025, she said, and the regional imbalances already seen will be magnified. These regional differences aren’t a surprise, Dr. Lawrence-Wolff noted. They directly reflect the density of academic rheumatology training centers. “Most practicing rheumatologists tend to stay in the region where they received their training,” she said, “so we have more clinicians in areas with more academic centers.”

For example, the Northeast U.S. hosts a highly enriched rheumatologist population, with a rheumatologist:patient ratio of 3.7/100,000. By 2025, this will be reduced to 1.6/100,000 – still acceptable, but more than a 50% decrease.

That same decrease will be much more drastically felt in regions that already have a paucity of rheumatologists. In the Southwest, the current ratio is 1.2/100,000; in 10 years, this will be 0.64/100,000. Even areas that are moderately well supplied now will suffer. Both the Northwest and North Central regions have a ratio of about 1.6/100,000. Both those regions will sink into the range of 0.6-0.5/100,000.

“All regions are going to decline below the 1.67 threshold by 2030,” she said. “Every single one.”
 

Troubles for pediatric rheumatology workforce

If things are concerning in the world of adult rheumatology, they’re downright alarming in the world of pediatric rheumatology, said Dr. Battafarano, who broke out the pediatric subspecialty results.

These clinicians are already scarce, with only 287 currently practicing full-time in 2015. By 2030, 461 will be needed, but the supply is expected to drop to 231.

The pediatric supply problem starts much earlier in the academic process, he said. For years, about 50% of the slots of pediatric rheumatology fellows have gone unfilled. In this world, recruitment woes will drive supply problems more than retirement. “As a whole, pediatric rheumatologists are younger,” Dr. Battafarano said, with only 32% planning to retire by 2030.

“Recruitment into adult rheumatology isn’t a problem, but on the pediatric side, it’s been very hard to recruit. This isn’t unique to rheumatology; it’s being seen in other pediatric subspecialties as well.”

Reimbursement and work overload are at the root of it, he believes.

“It translates pretty well to income. Reimbursement for chronic diseases, like what we see, is predominately Medicaid. The reimbursement rate and income for subspecialty pediatrics is definitely lower than it is in other academic subspecialties. And I have to think that time spent observing an exhausted, overworked physician isn’t helpful either.”

The mandatory 3-year pediatric rheumatology fellowship may also be a deal killer for some potential recruits, Dr. Battafarano said. The prevailing thought has always been to include a year of academic research in the pediatric track, which extends it beyond the 2-year fellowship that adult rheumatologists experience.

“So you marry the 3-year fellowship with workload, quality of life, student debt, and income and you get a combination that’s just less appealing than some other areas.”

Adjusting that fellowship track is one way to potentially improve the pediatric supply picture, he said. “One of the things I recommended is adding a 2-year clinical track. There are ways to do research that can be folded into a clinical setting that wouldn’t require an entire year. The majority of adult fellowships are 2 years with concurrent research, so there is already a precedent.”

In fact, Dr. Lawrence-Wolff is doing just that, he said. “She will do clinical research that’s integrated into her practice, but her primary role is to learn to be a clinical rheumatologist.”
 

Ideas for stretching rheumatologic care

Dr. Battafarano had some other practical suggestions for improving recruitment into the field. “We have to offer some incentives. I’d like to see us exploring the potential of loan repayment and visa programs.”

Overall, expanding the musculoskeletal expertise of primary care providers should also be on the table, Dr. Lawrence-Wolff said. “It’s possible that we can help our primary care colleagues extend rheumatology care by treating things like osteoarthritis and gout.”

Rheumatologists also can’t afford to ignore the expanding-role of mid-level providers, she said. “We would like to recruit more nurse practitioners and physician assistants into the specialty. The numbers we hope will go up, even if the percentage remains the same as it is, about 2%-5%.”

Skillfully leveraging these clinicians’ strengths will be the key to successfully employing them.

“We see different ways to utilize them to stretch our care. One suggestion is having them in the clinic to see more patients per day, but also to use them to see lower-level patients so the rheumatologist can take care of the more complex cases.”

They could also serve patients who have multiple regularly scheduled checkups for chronic illness. “If you have a patient who needs to be seen four times a year, the NP or PA can see that person, check the labs and determine if the patent is stable, and doesn’t really need to see the rheumatologist.”

Technology will invariably come into play as well, Dr. Battafarano said.

“We envision this as a multipronged approach that includes telehealth and ‘E-consults,’ although we don’t precisely know what that will look like. But other specialties – and primary care as well – are going through very similar trends here. We are all talking about working with other providers to reach more patients, and telemedicine is a key area of investigation. We really are all in the same boat.”

Finally, Dr. Battafarano urges his fellow senior clinicians to consider severing professional ties gradually. “It’s not just a dearth of bodies we’re facing, but a sudden depletion of valuable experience and clinical wisdom. In my practice, for example, the three of us each have more than 30 years’ experience. That’s close to a century of experience, and two of them want to retire. It’s such a brain-drain on a terrific practice to lose our colleagues overnight.”

For some reason, he said, the locum tenens model has never really caught on in rheumatology, and he’d like to see that idea explored and embraced. It’s a perfect way to keep experienced hands in the mix, both seeing patients and mentoring young rheumatologists, he added.

“Even if we’re in our 60s and 70s, we’re not brain-dead yet. A lot of us want to keep contributing, just not full-time.”

None of the clinicians quoted in this article had any relevant financial disclosures.

[email protected]

On Twitter @alz_gal

WASHINGTON – The mass retirement of Baby Boomer workhorses, the changing face of a Millennial workforce, and the graying of America will deliver a triple-whammy to rheumatology over the next 15 years: By 2030, the United States will be short 4,700 full-time rheumatologists – just about as many as are currently in practice.

“This is drastic,” Marcy Bolster, MD, said at the annual meeting of the American College of Rheumatology. “We need to take action now or we will not be able to meet the expected increases in patient demand.”

Dr. Bolster, director of the rheumatology fellowship training program at Massachusetts General Hospital, Boston, was one of 10 clinicians who discussed the ACR’s massive new project, “The 2015 Workforce Study of Rheumatology Specialists in the United States,” a comprehensive assessment of the current supply of rheumatologists in this country, and a sobering prediction of how many will be needed in the future.

Michele G. Sullivan/Frontline Medical News

Shortages will affect all regions, but some more than others

All of these issues are now converging at a time when patient demand is expected to soar. In the United States, about 22.5 million adults and 300,000 children have a rheumatic disease. According to the study, that number will increase by 61% by 2030.

Dr. Lawrence-Wolff used population statistics to really put the numbers needed to care for these patients into perspective. Studies in the United States, Canada, and Europe generally agree that the ideal rheumatologist:patient ratio is somewhere around 2 per 100,000 adults. “In 2005, when we were felt to be balanced in this way, our ratio was 1.67/100,000 patients.”

This ratio will look very different by 2025, she said, and the regional imbalances already seen will be magnified. These regional differences aren’t a surprise, Dr. Lawrence-Wolff noted. They directly reflect the density of academic rheumatology training centers. “Most practicing rheumatologists tend to stay in the region where they received their training,” she said, “so we have more clinicians in areas with more academic centers.”

For example, the Northeast U.S. hosts a highly enriched rheumatologist population, with a rheumatologist:patient ratio of 3.7/100,000. By 2025, this will be reduced to 1.6/100,000 – still acceptable, but more than a 50% decrease.

That same decrease will be much more drastically felt in regions that already have a paucity of rheumatologists. In the Southwest, the current ratio is 1.2/100,000; in 10 years, this will be 0.64/100,000. Even areas that are moderately well supplied now will suffer. Both the Northwest and North Central regions have a ratio of about 1.6/100,000. Both those regions will sink into the range of 0.6-0.5/100,000.

“All regions are going to decline below the 1.67 threshold by 2030,” she said. “Every single one.”
 

Troubles for pediatric rheumatology workforce

If things are concerning in the world of adult rheumatology, they’re downright alarming in the world of pediatric rheumatology, said Dr. Battafarano, who broke out the pediatric subspecialty results.

These clinicians are already scarce, with only 287 currently practicing full-time in 2015. By 2030, 461 will be needed, but the supply is expected to drop to 231.

The pediatric supply problem starts much earlier in the academic process, he said. For years, about 50% of the slots of pediatric rheumatology fellows have gone unfilled. In this world, recruitment woes will drive supply problems more than retirement. “As a whole, pediatric rheumatologists are younger,” Dr. Battafarano said, with only 32% planning to retire by 2030.

“Recruitment into adult rheumatology isn’t a problem, but on the pediatric side, it’s been very hard to recruit. This isn’t unique to rheumatology; it’s being seen in other pediatric subspecialties as well.”

Reimbursement and work overload are at the root of it, he believes.

“It translates pretty well to income. Reimbursement for chronic diseases, like what we see, is predominately Medicaid. The reimbursement rate and income for subspecialty pediatrics is definitely lower than it is in other academic subspecialties. And I have to think that time spent observing an exhausted, overworked physician isn’t helpful either.”

The mandatory 3-year pediatric rheumatology fellowship may also be a deal killer for some potential recruits, Dr. Battafarano said. The prevailing thought has always been to include a year of academic research in the pediatric track, which extends it beyond the 2-year fellowship that adult rheumatologists experience.

“So you marry the 3-year fellowship with workload, quality of life, student debt, and income and you get a combination that’s just less appealing than some other areas.”

Adjusting that fellowship track is one way to potentially improve the pediatric supply picture, he said. “One of the things I recommended is adding a 2-year clinical track. There are ways to do research that can be folded into a clinical setting that wouldn’t require an entire year. The majority of adult fellowships are 2 years with concurrent research, so there is already a precedent.”

In fact, Dr. Lawrence-Wolff is doing just that, he said. “She will do clinical research that’s integrated into her practice, but her primary role is to learn to be a clinical rheumatologist.”
 

Ideas for stretching rheumatologic care

Dr. Battafarano had some other practical suggestions for improving recruitment into the field. “We have to offer some incentives. I’d like to see us exploring the potential of loan repayment and visa programs.”

Overall, expanding the musculoskeletal expertise of primary care providers should also be on the table, Dr. Lawrence-Wolff said. “It’s possible that we can help our primary care colleagues extend rheumatology care by treating things like osteoarthritis and gout.”

Rheumatologists also can’t afford to ignore the expanding-role of mid-level providers, she said. “We would like to recruit more nurse practitioners and physician assistants into the specialty. The numbers we hope will go up, even if the percentage remains the same as it is, about 2%-5%.”

Skillfully leveraging these clinicians’ strengths will be the key to successfully employing them.

“We see different ways to utilize them to stretch our care. One suggestion is having them in the clinic to see more patients per day, but also to use them to see lower-level patients so the rheumatologist can take care of the more complex cases.”

They could also serve patients who have multiple regularly scheduled checkups for chronic illness. “If you have a patient who needs to be seen four times a year, the NP or PA can see that person, check the labs and determine if the patent is stable, and doesn’t really need to see the rheumatologist.”

Technology will invariably come into play as well, Dr. Battafarano said.

“We envision this as a multipronged approach that includes telehealth and ‘E-consults,’ although we don’t precisely know what that will look like. But other specialties – and primary care as well – are going through very similar trends here. We are all talking about working with other providers to reach more patients, and telemedicine is a key area of investigation. We really are all in the same boat.”

Finally, Dr. Battafarano urges his fellow senior clinicians to consider severing professional ties gradually. “It’s not just a dearth of bodies we’re facing, but a sudden depletion of valuable experience and clinical wisdom. In my practice, for example, the three of us each have more than 30 years’ experience. That’s close to a century of experience, and two of them want to retire. It’s such a brain-drain on a terrific practice to lose our colleagues overnight.”

For some reason, he said, the locum tenens model has never really caught on in rheumatology, and he’d like to see that idea explored and embraced. It’s a perfect way to keep experienced hands in the mix, both seeing patients and mentoring young rheumatologists, he added.

“Even if we’re in our 60s and 70s, we’re not brain-dead yet. A lot of us want to keep contributing, just not full-time.”

None of the clinicians quoted in this article had any relevant financial disclosures.

[email protected]

On Twitter @alz_gal

WASHINGTON – The mass retirement of Baby Boomer workhorses, the changing face of a Millennial workforce, and the graying of America will deliver a triple-whammy to rheumatology over the next 15 years: By 2030, the United States will be short 4,700 full-time rheumatologists – just about as many as are currently in practice.

“This is drastic,” Marcy Bolster, MD, said at the annual meeting of the American College of Rheumatology. “We need to take action now or we will not be able to meet the expected increases in patient demand.”

Dr. Bolster, director of the rheumatology fellowship training program at Massachusetts General Hospital, Boston, was one of 10 clinicians who discussed the ACR’s massive new project, “The 2015 Workforce Study of Rheumatology Specialists in the United States,” a comprehensive assessment of the current supply of rheumatologists in this country, and a sobering prediction of how many will be needed in the future.

Michele G. Sullivan/Frontline Medical News

Shortages will affect all regions, but some more than others

All of these issues are now converging at a time when patient demand is expected to soar. In the United States, about 22.5 million adults and 300,000 children have a rheumatic disease. According to the study, that number will increase by 61% by 2030.

Dr. Lawrence-Wolff used population statistics to really put the numbers needed to care for these patients into perspective. Studies in the United States, Canada, and Europe generally agree that the ideal rheumatologist:patient ratio is somewhere around 2 per 100,000 adults. “In 2005, when we were felt to be balanced in this way, our ratio was 1.67/100,000 patients.”

This ratio will look very different by 2025, she said, and the regional imbalances already seen will be magnified. These regional differences aren’t a surprise, Dr. Lawrence-Wolff noted. They directly reflect the density of academic rheumatology training centers. “Most practicing rheumatologists tend to stay in the region where they received their training,” she said, “so we have more clinicians in areas with more academic centers.”

For example, the Northeast U.S. hosts a highly enriched rheumatologist population, with a rheumatologist:patient ratio of 3.7/100,000. By 2025, this will be reduced to 1.6/100,000 – still acceptable, but more than a 50% decrease.

That same decrease will be much more drastically felt in regions that already have a paucity of rheumatologists. In the Southwest, the current ratio is 1.2/100,000; in 10 years, this will be 0.64/100,000. Even areas that are moderately well supplied now will suffer. Both the Northwest and North Central regions have a ratio of about 1.6/100,000. Both those regions will sink into the range of 0.6-0.5/100,000.

“All regions are going to decline below the 1.67 threshold by 2030,” she said. “Every single one.”
 

Troubles for pediatric rheumatology workforce

If things are concerning in the world of adult rheumatology, they’re downright alarming in the world of pediatric rheumatology, said Dr. Battafarano, who broke out the pediatric subspecialty results.

These clinicians are already scarce, with only 287 currently practicing full-time in 2015. By 2030, 461 will be needed, but the supply is expected to drop to 231.

The pediatric supply problem starts much earlier in the academic process, he said. For years, about 50% of the slots of pediatric rheumatology fellows have gone unfilled. In this world, recruitment woes will drive supply problems more than retirement. “As a whole, pediatric rheumatologists are younger,” Dr. Battafarano said, with only 32% planning to retire by 2030.

“Recruitment into adult rheumatology isn’t a problem, but on the pediatric side, it’s been very hard to recruit. This isn’t unique to rheumatology; it’s being seen in other pediatric subspecialties as well.”

Reimbursement and work overload are at the root of it, he believes.

“It translates pretty well to income. Reimbursement for chronic diseases, like what we see, is predominately Medicaid. The reimbursement rate and income for subspecialty pediatrics is definitely lower than it is in other academic subspecialties. And I have to think that time spent observing an exhausted, overworked physician isn’t helpful either.”

The mandatory 3-year pediatric rheumatology fellowship may also be a deal killer for some potential recruits, Dr. Battafarano said. The prevailing thought has always been to include a year of academic research in the pediatric track, which extends it beyond the 2-year fellowship that adult rheumatologists experience.

“So you marry the 3-year fellowship with workload, quality of life, student debt, and income and you get a combination that’s just less appealing than some other areas.”

Adjusting that fellowship track is one way to potentially improve the pediatric supply picture, he said. “One of the things I recommended is adding a 2-year clinical track. There are ways to do research that can be folded into a clinical setting that wouldn’t require an entire year. The majority of adult fellowships are 2 years with concurrent research, so there is already a precedent.”

In fact, Dr. Lawrence-Wolff is doing just that, he said. “She will do clinical research that’s integrated into her practice, but her primary role is to learn to be a clinical rheumatologist.”
 

Ideas for stretching rheumatologic care

Dr. Battafarano had some other practical suggestions for improving recruitment into the field. “We have to offer some incentives. I’d like to see us exploring the potential of loan repayment and visa programs.”

Overall, expanding the musculoskeletal expertise of primary care providers should also be on the table, Dr. Lawrence-Wolff said. “It’s possible that we can help our primary care colleagues extend rheumatology care by treating things like osteoarthritis and gout.”

Rheumatologists also can’t afford to ignore the expanding-role of mid-level providers, she said. “We would like to recruit more nurse practitioners and physician assistants into the specialty. The numbers we hope will go up, even if the percentage remains the same as it is, about 2%-5%.”

Skillfully leveraging these clinicians’ strengths will be the key to successfully employing them.

“We see different ways to utilize them to stretch our care. One suggestion is having them in the clinic to see more patients per day, but also to use them to see lower-level patients so the rheumatologist can take care of the more complex cases.”

They could also serve patients who have multiple regularly scheduled checkups for chronic illness. “If you have a patient who needs to be seen four times a year, the NP or PA can see that person, check the labs and determine if the patent is stable, and doesn’t really need to see the rheumatologist.”

Technology will invariably come into play as well, Dr. Battafarano said.

“We envision this as a multipronged approach that includes telehealth and ‘E-consults,’ although we don’t precisely know what that will look like. But other specialties – and primary care as well – are going through very similar trends here. We are all talking about working with other providers to reach more patients, and telemedicine is a key area of investigation. We really are all in the same boat.”

Finally, Dr. Battafarano urges his fellow senior clinicians to consider severing professional ties gradually. “It’s not just a dearth of bodies we’re facing, but a sudden depletion of valuable experience and clinical wisdom. In my practice, for example, the three of us each have more than 30 years’ experience. That’s close to a century of experience, and two of them want to retire. It’s such a brain-drain on a terrific practice to lose our colleagues overnight.”

For some reason, he said, the locum tenens model has never really caught on in rheumatology, and he’d like to see that idea explored and embraced. It’s a perfect way to keep experienced hands in the mix, both seeing patients and mentoring young rheumatologists, he added.

“Even if we’re in our 60s and 70s, we’re not brain-dead yet. A lot of us want to keep contributing, just not full-time.”

None of the clinicians quoted in this article had any relevant financial disclosures.

[email protected]

On Twitter @alz_gal

First-year residents may be permitted to work up to 24 consecutive hours – 8 hours longer than they can now – under a proposal from a task force of the Accreditation Council for Graduate Medical Education (ACGME).

The ACGME Duty Hour Task Force proposes to raise first-year trainees’ work hour limit from 16 hours, reverting to the 24-hour maximum that remained in effect until 2011 – and the existing limit in place for all other residents.

“There is better team continuity of care provided with less micromanagement of resident duty hours,” said Thomas J. Nasca, MD, ACGME chief executive and vice chairman of the task force.

The ACGME instituted the 16-hour cap for first-year residents in the wake of a December 2008 report released by the Institute of Medicine (IOM), “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.” The ACGME also prohibited 30-hour shifts, which some trainees had been clocking.

“Every 5 years, the ACGME reviews its program requirements,” Dr. Nasca said. “That’s a promise we made to the community and to the public” in July 2003. The most recent changes occurred in July 2011.

Since then, some faculty have contended that shorter work hour limits for the first-year residents are accelerating the frequency of patient transitions and disrupting continuity of care. Many educators also noted that residents would gain more knowledge by monitoring a hospitalized patient during the initial 24 hours.

The proposed changes are “encouraging and courageous,” according to R. James Valentine, MD, FACS, president of the Western Surgical Association.

“This is a real world scenario,” said Dr. Valentine, professor of vascular surgery at Vanderbilt University, Nashville, Tenn. “Medicine is such a complex system. It is not easily constrained by time limitations.”

Requiring a physician to transition a patient’s care at a specific time may help promote the trainee’s well-being; however, it also “robs the resident of the opportunity to see the disease progress and to see the response to the treatment that is being offered. The new rules help strike a balance between bedside education and rest,” he added.

The proposed revisions to training requirements also include phasing out the term “duty” hours in favor of “clinical experience and education,” highlighting that residents’ responsibility to patients takes precedence over any adherence to a schedule or clock. Working a certain number of hospital hours is only one aspect of delivering safe and quality care, the ACGME Duty Hour Task Force noted in its proposal.

The proposal does not change the following, which all are averaged over a period of 4 weeks: a maximum of 80 hours per week, 1 day free from clinical experience or education in 7, and in-house call no more often than every third night.

“It is important to note that the absence of a common 16-hour limit does not imply that programs may no longer configure their clinical schedules in 16-hour increments if that is the preferred option for a given setting or clinical context,” Dr. Nasca wrote in a Nov. 4 letter to the graduate medical education community.

In its December 2008 report, the IOM noted that revamping residents’ work hours alone offered no guarantee of patient safety. It called for increased supervision by seasoned physicians, restrictions on patient caseloads based on residents’ levels of experience and specialty, overlap in schedules around shift changes to decrease the possibility of error in transitioning patients from one provider to another, and broad-based research to examine the outcomes from these changes.

“Surgical residents, when they’re operating, come under very direct supervision by attending physicians,” said Jay Bhattacharya, MD, professor of medicine at Stanford (Calif.) University, who served on the 2008 IOM committee. “That supervision is generally pretty good. Even for a tired resident, the supervision makes it so that the fatigue the trainee faces doesn’t endanger the patient.”

Acknowledging the emerging evidence that physicians are at heightened risk for burnout and perhaps depression, the proposal underscores the need for residency programs and institutions to prioritize the well-being of residents as well as nurses and other hospital personnel.

“Burnout and depression impair a physician’s ability to provide excellent care. Self-care is an important aspect of professionalism, and a skill that must be learned and nurtured under the guidance and role modeling of faculty members,” Dr. Nasca wrote in his Nov. 4 letter.

If the proposal is approved by the ACGME board of directors in February, the changes will be rolled out in July.

The proposal is open to public comment through Dec. 19; comments will be reviewed and considered before a final set of proposed requirements are sent to the ACGME board for approval.

“We’re here to serve the public, and so the focus is on the comments that reflect the most recent and comprehensive evidence and educational outcomes rather than the individual opinions we receive,” Dr. Nasca said.
 

First-year residents may be permitted to work up to 24 consecutive hours – 8 hours longer than they can now – under a proposal from a task force of the Accreditation Council for Graduate Medical Education (ACGME).

The ACGME Duty Hour Task Force proposes to raise first-year trainees’ work hour limit from 16 hours, reverting to the 24-hour maximum that remained in effect until 2011 – and the existing limit in place for all other residents.

“There is better team continuity of care provided with less micromanagement of resident duty hours,” said Thomas J. Nasca, MD, ACGME chief executive and vice chairman of the task force.

The ACGME instituted the 16-hour cap for first-year residents in the wake of a December 2008 report released by the Institute of Medicine (IOM), “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.” The ACGME also prohibited 30-hour shifts, which some trainees had been clocking.

“Every 5 years, the ACGME reviews its program requirements,” Dr. Nasca said. “That’s a promise we made to the community and to the public” in July 2003. The most recent changes occurred in July 2011.

Since then, some faculty have contended that shorter work hour limits for the first-year residents are accelerating the frequency of patient transitions and disrupting continuity of care. Many educators also noted that residents would gain more knowledge by monitoring a hospitalized patient during the initial 24 hours.

The proposed changes are “encouraging and courageous,” according to R. James Valentine, MD, FACS, president of the Western Surgical Association.

“This is a real world scenario,” said Dr. Valentine, professor of vascular surgery at Vanderbilt University, Nashville, Tenn. “Medicine is such a complex system. It is not easily constrained by time limitations.”

Requiring a physician to transition a patient’s care at a specific time may help promote the trainee’s well-being; however, it also “robs the resident of the opportunity to see the disease progress and to see the response to the treatment that is being offered. The new rules help strike a balance between bedside education and rest,” he added.

The proposed revisions to training requirements also include phasing out the term “duty” hours in favor of “clinical experience and education,” highlighting that residents’ responsibility to patients takes precedence over any adherence to a schedule or clock. Working a certain number of hospital hours is only one aspect of delivering safe and quality care, the ACGME Duty Hour Task Force noted in its proposal.

The proposal does not change the following, which all are averaged over a period of 4 weeks: a maximum of 80 hours per week, 1 day free from clinical experience or education in 7, and in-house call no more often than every third night.

“It is important to note that the absence of a common 16-hour limit does not imply that programs may no longer configure their clinical schedules in 16-hour increments if that is the preferred option for a given setting or clinical context,” Dr. Nasca wrote in a Nov. 4 letter to the graduate medical education community.

In its December 2008 report, the IOM noted that revamping residents’ work hours alone offered no guarantee of patient safety. It called for increased supervision by seasoned physicians, restrictions on patient caseloads based on residents’ levels of experience and specialty, overlap in schedules around shift changes to decrease the possibility of error in transitioning patients from one provider to another, and broad-based research to examine the outcomes from these changes.

“Surgical residents, when they’re operating, come under very direct supervision by attending physicians,” said Jay Bhattacharya, MD, professor of medicine at Stanford (Calif.) University, who served on the 2008 IOM committee. “That supervision is generally pretty good. Even for a tired resident, the supervision makes it so that the fatigue the trainee faces doesn’t endanger the patient.”

Acknowledging the emerging evidence that physicians are at heightened risk for burnout and perhaps depression, the proposal underscores the need for residency programs and institutions to prioritize the well-being of residents as well as nurses and other hospital personnel.

“Burnout and depression impair a physician’s ability to provide excellent care. Self-care is an important aspect of professionalism, and a skill that must be learned and nurtured under the guidance and role modeling of faculty members,” Dr. Nasca wrote in his Nov. 4 letter.

If the proposal is approved by the ACGME board of directors in February, the changes will be rolled out in July.

The proposal is open to public comment through Dec. 19; comments will be reviewed and considered before a final set of proposed requirements are sent to the ACGME board for approval.

“We’re here to serve the public, and so the focus is on the comments that reflect the most recent and comprehensive evidence and educational outcomes rather than the individual opinions we receive,” Dr. Nasca said.
 

First-year residents may be permitted to work up to 24 consecutive hours – 8 hours longer than they can now – under a proposal from a task force of the Accreditation Council for Graduate Medical Education (ACGME).

The ACGME Duty Hour Task Force proposes to raise first-year trainees’ work hour limit from 16 hours, reverting to the 24-hour maximum that remained in effect until 2011 – and the existing limit in place for all other residents.

“There is better team continuity of care provided with less micromanagement of resident duty hours,” said Thomas J. Nasca, MD, ACGME chief executive and vice chairman of the task force.

The ACGME instituted the 16-hour cap for first-year residents in the wake of a December 2008 report released by the Institute of Medicine (IOM), “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.” The ACGME also prohibited 30-hour shifts, which some trainees had been clocking.

“Every 5 years, the ACGME reviews its program requirements,” Dr. Nasca said. “That’s a promise we made to the community and to the public” in July 2003. The most recent changes occurred in July 2011.

Since then, some faculty have contended that shorter work hour limits for the first-year residents are accelerating the frequency of patient transitions and disrupting continuity of care. Many educators also noted that residents would gain more knowledge by monitoring a hospitalized patient during the initial 24 hours.

The proposed changes are “encouraging and courageous,” according to R. James Valentine, MD, FACS, president of the Western Surgical Association.

“This is a real world scenario,” said Dr. Valentine, professor of vascular surgery at Vanderbilt University, Nashville, Tenn. “Medicine is such a complex system. It is not easily constrained by time limitations.”

Requiring a physician to transition a patient’s care at a specific time may help promote the trainee’s well-being; however, it also “robs the resident of the opportunity to see the disease progress and to see the response to the treatment that is being offered. The new rules help strike a balance between bedside education and rest,” he added.

The proposed revisions to training requirements also include phasing out the term “duty” hours in favor of “clinical experience and education,” highlighting that residents’ responsibility to patients takes precedence over any adherence to a schedule or clock. Working a certain number of hospital hours is only one aspect of delivering safe and quality care, the ACGME Duty Hour Task Force noted in its proposal.

The proposal does not change the following, which all are averaged over a period of 4 weeks: a maximum of 80 hours per week, 1 day free from clinical experience or education in 7, and in-house call no more often than every third night.

“It is important to note that the absence of a common 16-hour limit does not imply that programs may no longer configure their clinical schedules in 16-hour increments if that is the preferred option for a given setting or clinical context,” Dr. Nasca wrote in a Nov. 4 letter to the graduate medical education community.

In its December 2008 report, the IOM noted that revamping residents’ work hours alone offered no guarantee of patient safety. It called for increased supervision by seasoned physicians, restrictions on patient caseloads based on residents’ levels of experience and specialty, overlap in schedules around shift changes to decrease the possibility of error in transitioning patients from one provider to another, and broad-based research to examine the outcomes from these changes.

“Surgical residents, when they’re operating, come under very direct supervision by attending physicians,” said Jay Bhattacharya, MD, professor of medicine at Stanford (Calif.) University, who served on the 2008 IOM committee. “That supervision is generally pretty good. Even for a tired resident, the supervision makes it so that the fatigue the trainee faces doesn’t endanger the patient.”

Acknowledging the emerging evidence that physicians are at heightened risk for burnout and perhaps depression, the proposal underscores the need for residency programs and institutions to prioritize the well-being of residents as well as nurses and other hospital personnel.

“Burnout and depression impair a physician’s ability to provide excellent care. Self-care is an important aspect of professionalism, and a skill that must be learned and nurtured under the guidance and role modeling of faculty members,” Dr. Nasca wrote in his Nov. 4 letter.

If the proposal is approved by the ACGME board of directors in February, the changes will be rolled out in July.

The proposal is open to public comment through Dec. 19; comments will be reviewed and considered before a final set of proposed requirements are sent to the ACGME board for approval.

“We’re here to serve the public, and so the focus is on the comments that reflect the most recent and comprehensive evidence and educational outcomes rather than the individual opinions we receive,” Dr. Nasca said.
 

SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.

Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).

©Thinkstock

Understanding the problem

Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.

“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).

The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.

Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).

What pediatricians can do

“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”

The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.

She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”

“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”

At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.

Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”

Dr. Gonzalez had no disclosures.

SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.

Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).

©Thinkstock

Understanding the problem

Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.

“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).

The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.

Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).

What pediatricians can do

“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”

The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.

She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”

“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”

At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.

Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”

Dr. Gonzalez had no disclosures.

SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.

Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).

©Thinkstock

Understanding the problem

Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.

“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).

The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.

Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).

What pediatricians can do

“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”

The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.

She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”

“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”

At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.

Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”

Dr. Gonzalez had no disclosures.

Risk factors for dislocation after reverse total shoulder arthroplasty (RTSA) are not clearly defined. Prosthetic dislocation can result in poor patient satisfaction, worse functional outcomes, and return to the operating room.^1-3 As a result, identification of modifiable risk factors for complications represents an important research initiative for shoulder surgeons.

There is a paucity of literature devoted to the study of dislocation after RTSA. Chalmers and colleagues⁴ found a 2.9% (11/385) incidence of early dislocation within 3 months after index surgery—an improvement over the 15.8% reported for early instability over the period 2004–2006.⁵ As prosthesis design has improved and surgeons have become more comfortable with the RTSA prosthesis, surgical indications have expanded,^6,7 and dislocation rates appear to have decreased. Although the most common indication for RTSA continues to be cuff tear arthropathy (CTA),⁶ there has been increased use in rheumatoid arthritis^8-10; proximal humerus fractures, especially in cases of poor bone quality and unreliable fixation of tuberosities^11-13; and failed previous shoulder reconstruction.^14,15 As RTSA is performed more often, limiting the complications will become more important for both patient care and economics.

We conducted a study to analyze dislocation rates at our institution and to identify both modifiable and nonmodifiable risk factors for dislocation after RTSA. By identifying risk factors for dislocation, we will be able to implement additional perioperative clinical measures to reduce the incidence of dislocation.

Materials and Methods

This retrospective study of dislocation after RTSA was conducted at the Rothman Institute of Orthopedics and Methodist Hospital (Thomas Jefferson University Hospitals, Philadelphia, PA). After obtaining Institutional Review Board approval for the study, we searched our institution’s electronic database of shoulder arthroplasties to identify all RTSAs performed at our 2 large-volume urban institutions between September 27, 2010 and December 31, 2013. For the record search, International Classification of Diseases, Ninth Revision (ICD-9) codes were used (Table 1).

The medical records of each patient were used to identify independent variables that could be associated with dislocation rate. Demographic variables included sex, age, and race. Preoperative clinical data included body mass index (BMI), etiology of shoulder disease leading to RTSA, individual comorbidities, and Charlson Comorbidity Index (CCI)¹⁶ modified to be used with ICD-9 codes.¹⁷ In addition, prior shoulder surgery history and arthroplasty type (primary or revision) were determined. Postoperative considerations were time to dislocation, mechanism of dislocation, and intervention(s) needed for dislocation. Although the institutional database did not include operative variables such as prosthesis type and surgical approach, all 6 surgeons in this study were using a standard deltopectoral approach in beach-chair position with a Grammont style prosthesis for RTSA cases.

Descriptive statistics for RTSA patients and the dislocation subpopulation were compiled. Bivariate analysis was used to evaluate which of the previously described variables influenced dislocation rates. Last, multivariate logistic regression analysis was performed to evaluate which factors were independent predictors of dislocation. We included demographic variables (age, sex, ethnicity), clinical variables (BMI, individual comorbidities, CCI), and surgical variables (primary vs revision, diagnosis at time of surgery). All statistical analyses were performed with Excel 2013 (Microsoft) and SPSS Statistics Version 20.0 (SPSS Inc.).

Results

From the database, we identified 487 patients who underwent 510 RTSAs during the study period. These surgeries were performed by 6 shoulder and elbow fellowship–trained surgeons. Of the 510 RTSAs, 393 (77.1%) were primary cases, and 117 (22.9%) were revision cases.

Of the 510 shoulders that underwent RTSA, 15 (2.9%; 14 patients) dislocated. Of these 15 cases, 5 were primary (1.3% of all primary cases) and 10 were revision (8.5% of all revision cases). Mean time from index surgery to diagnosis of dislocation was 58.2 days (range, 0-319 days). One dislocation occurred immediately after surgery, 2 after falls, 4 from patient-identified low-energy mechanisms of injury, and 8 without known inciting events. Nine dislocations (60%) did not have a subscapularis repair (7 were irreparable, 2 underwent subscapularis peel without repair), and the other 6 were repaired primarily (Table 2).

Discussion

With more RTSAs being performed, evaluation of their common complications becomes increasingly important.¹⁸ We found a 3.0% rate of dislocation after RTSA, which is consistent with the most recently reported incidence⁴ and falls within the previously described range of 0% to 8.6%.^19-26 Of the clinical risk factors identified in this study, those previously described were prior surgery, subscapularis insufficiency, higher BMI, and male sex.⁴ However, our finding of lower risk of dislocation after RTSA for primary rotator cuff pathology was not previously described. Although Chalmers and colleagues⁴ did not report this lower risk, 3 (27.3%) of their 11 patients with dislocation had primary CTA, compared with 1 (6.7%) of 15 patients in the present study.⁴ Our literature review did not identify any studies that independently reported the dislocation rate in patients who underwent RTSA for rotator cuff failure.

The risk factors of subscapularis irreparability and revision surgery suggest the importance of the soft-tissue envelope and bony anatomy in dislocation prevention. Previous analyses have suggested implant malpositioning,^27,28 poor subscapularis quality,²⁹ and inadequate muscle tensioning^5,30-32 as risk factors for RTSA. Patients with an irreparable subscapularis tendon have often had multiple surgeries with compromise to the muscle/soft-tissue envelope or bony anatomy of the shoulder. A biomechanical study by Gutiérrez and colleagues³¹ found the compressive forces of the soft tissue at the glenohumeral joint to be the most important contributor to stability in the RTSA prosthesis. In clinical studies, the role of the subscapularis in preventing instability after RTSA remains unclear. Edwards and colleagues²⁹ prospectively compared dislocation rates in patients with reparable and irreparable subscapularis tendons during RTSA and found a higher rate of dislocation in the irreparable subscapularis group. Of note, patients in the irreparable subscapularis group also had more complex diagnoses, including proximal humeral nonunion, fixed glenohumeral dislocation, and failed prior arthroplasty. Clark and colleagues³³ retrospectively analyzed subscapularis repair in 2 RTSA groups and found no appreciable effect on complication rate, dislocation events, range-of-motion gains, or pain relief.

Our finding that higher BMI is an independent risk factor was previously described.⁴ The association is unclear but could be related to implant positioning, difficulty in intraoperative assessment of muscle tensioning, or body habitus that may generate a lever arm for impingement and dislocation when the arm is in adduction. Last, our finding that male sex is a risk factor for dislocation approached significance, and this relationship was previously reported.⁴ This could be attributable to a higher rate of activity or of indolent infection in male patients.^34,35Besides studying risk factors for dislocation after RTSA, we investigated treatment. None of our patients were treated successfully and definitively with closed reduction in the clinic. This finding diverges from findings in studies by Teusink and colleagues² and Chalmers and colleagues,⁴who respectively reported 62% and 44% rates of success with closed reduction. Our cohort of 14 patients with 15 dislocations required a total of 17 trips to the operating room after dislocation. This significantly higher rate of return to the operating room suggests that dislocation after RTSA may be a more costly and morbid problem than has been previously described.

This study had several weaknesses. Despite its large consecutive series of patients, the study was retrospective, and several variables that would be documented and controlled in a prospective study could not be measured here. Specifically, neither preoperative physical examination nor patient-specific assessments of pain or function were consistently obtained. Similarly, postoperative patient-specific instruments of outcomes evaluation were not obtained consistently, so results of patients with dislocation could not be compared with those of a control group. In addition, preoperative and postoperative radiographs were not consistently present in our electronic medical records, so the influence of preoperative bony anatomy, intraoperative limb lengthening, and any implant malpositioning could not be determined. Furthermore, operative details, such as reparability of the subscapularis, were not fully available for the control group and could not be included in statistical analysis. In addition, that the known dislocation risk factor of male sex⁴ was identified here but was not significant in multivariate regression analysis suggests that this study may not have been adequately powered to identify a significant difference in dislocation rate between the sexes. Last, though our results suggested associations between the aforementioned variables and dislocation after RTSA, a truly causative relationship could not be confirmed with this study design or analysis. Therefore, our study findings are hypothesis-generating and may indicate a benefit to greater deltoid tensioning, use of retentive liners, or more conservative rehabilitation protocols for high-risk patients.

Conclusion

Dislocation after RTSA is an uncommon complication that often requires a return to the operating room. This study identified a modifiable risk factor (higher BMI) and 3 nonmodifiable risk factors (male sex, subscapularis insufficiency, revision surgery) for dislocation after RTSA. In contrast, patients who undergo RTSA for primary rotator cuff pathology are unlikely to dislocate after surgery. This low risk of dislocation after RTSA for primary cuff pathology was not previously described. Patients in the higher risk category may benefit from preoperative lifestyle modification, intraoperative techniques for increasing stability, and more conservative therapy after surgery. In addition, unlike previous investigations, this study did not find closed reduction in the clinic alone to be successful in definitively treating this patient population.

Am J Orthop. 2016;45(7):E444-E450. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Risk factors for dislocation after reverse total shoulder arthroplasty (RTSA) are not clearly defined. Prosthetic dislocation can result in poor patient satisfaction, worse functional outcomes, and return to the operating room.^1-3 As a result, identification of modifiable risk factors for complications represents an important research initiative for shoulder surgeons.

There is a paucity of literature devoted to the study of dislocation after RTSA. Chalmers and colleagues⁴ found a 2.9% (11/385) incidence of early dislocation within 3 months after index surgery—an improvement over the 15.8% reported for early instability over the period 2004–2006.⁵ As prosthesis design has improved and surgeons have become more comfortable with the RTSA prosthesis, surgical indications have expanded,^6,7 and dislocation rates appear to have decreased. Although the most common indication for RTSA continues to be cuff tear arthropathy (CTA),⁶ there has been increased use in rheumatoid arthritis^8-10; proximal humerus fractures, especially in cases of poor bone quality and unreliable fixation of tuberosities^11-13; and failed previous shoulder reconstruction.^14,15 As RTSA is performed more often, limiting the complications will become more important for both patient care and economics.

We conducted a study to analyze dislocation rates at our institution and to identify both modifiable and nonmodifiable risk factors for dislocation after RTSA. By identifying risk factors for dislocation, we will be able to implement additional perioperative clinical measures to reduce the incidence of dislocation.

Materials and Methods

This retrospective study of dislocation after RTSA was conducted at the Rothman Institute of Orthopedics and Methodist Hospital (Thomas Jefferson University Hospitals, Philadelphia, PA). After obtaining Institutional Review Board approval for the study, we searched our institution’s electronic database of shoulder arthroplasties to identify all RTSAs performed at our 2 large-volume urban institutions between September 27, 2010 and December 31, 2013. For the record search, International Classification of Diseases, Ninth Revision (ICD-9) codes were used (Table 1).

The medical records of each patient were used to identify independent variables that could be associated with dislocation rate. Demographic variables included sex, age, and race. Preoperative clinical data included body mass index (BMI), etiology of shoulder disease leading to RTSA, individual comorbidities, and Charlson Comorbidity Index (CCI)¹⁶ modified to be used with ICD-9 codes.¹⁷ In addition, prior shoulder surgery history and arthroplasty type (primary or revision) were determined. Postoperative considerations were time to dislocation, mechanism of dislocation, and intervention(s) needed for dislocation. Although the institutional database did not include operative variables such as prosthesis type and surgical approach, all 6 surgeons in this study were using a standard deltopectoral approach in beach-chair position with a Grammont style prosthesis for RTSA cases.

Descriptive statistics for RTSA patients and the dislocation subpopulation were compiled. Bivariate analysis was used to evaluate which of the previously described variables influenced dislocation rates. Last, multivariate logistic regression analysis was performed to evaluate which factors were independent predictors of dislocation. We included demographic variables (age, sex, ethnicity), clinical variables (BMI, individual comorbidities, CCI), and surgical variables (primary vs revision, diagnosis at time of surgery). All statistical analyses were performed with Excel 2013 (Microsoft) and SPSS Statistics Version 20.0 (SPSS Inc.).

Results

From the database, we identified 487 patients who underwent 510 RTSAs during the study period. These surgeries were performed by 6 shoulder and elbow fellowship–trained surgeons. Of the 510 RTSAs, 393 (77.1%) were primary cases, and 117 (22.9%) were revision cases.

Of the 510 shoulders that underwent RTSA, 15 (2.9%; 14 patients) dislocated. Of these 15 cases, 5 were primary (1.3% of all primary cases) and 10 were revision (8.5% of all revision cases). Mean time from index surgery to diagnosis of dislocation was 58.2 days (range, 0-319 days). One dislocation occurred immediately after surgery, 2 after falls, 4 from patient-identified low-energy mechanisms of injury, and 8 without known inciting events. Nine dislocations (60%) did not have a subscapularis repair (7 were irreparable, 2 underwent subscapularis peel without repair), and the other 6 were repaired primarily (Table 2).

Discussion

With more RTSAs being performed, evaluation of their common complications becomes increasingly important.¹⁸ We found a 3.0% rate of dislocation after RTSA, which is consistent with the most recently reported incidence⁴ and falls within the previously described range of 0% to 8.6%.^19-26 Of the clinical risk factors identified in this study, those previously described were prior surgery, subscapularis insufficiency, higher BMI, and male sex.⁴ However, our finding of lower risk of dislocation after RTSA for primary rotator cuff pathology was not previously described. Although Chalmers and colleagues⁴ did not report this lower risk, 3 (27.3%) of their 11 patients with dislocation had primary CTA, compared with 1 (6.7%) of 15 patients in the present study.⁴ Our literature review did not identify any studies that independently reported the dislocation rate in patients who underwent RTSA for rotator cuff failure.

The risk factors of subscapularis irreparability and revision surgery suggest the importance of the soft-tissue envelope and bony anatomy in dislocation prevention. Previous analyses have suggested implant malpositioning,^27,28 poor subscapularis quality,²⁹ and inadequate muscle tensioning^5,30-32 as risk factors for RTSA. Patients with an irreparable subscapularis tendon have often had multiple surgeries with compromise to the muscle/soft-tissue envelope or bony anatomy of the shoulder. A biomechanical study by Gutiérrez and colleagues³¹ found the compressive forces of the soft tissue at the glenohumeral joint to be the most important contributor to stability in the RTSA prosthesis. In clinical studies, the role of the subscapularis in preventing instability after RTSA remains unclear. Edwards and colleagues²⁹ prospectively compared dislocation rates in patients with reparable and irreparable subscapularis tendons during RTSA and found a higher rate of dislocation in the irreparable subscapularis group. Of note, patients in the irreparable subscapularis group also had more complex diagnoses, including proximal humeral nonunion, fixed glenohumeral dislocation, and failed prior arthroplasty. Clark and colleagues³³ retrospectively analyzed subscapularis repair in 2 RTSA groups and found no appreciable effect on complication rate, dislocation events, range-of-motion gains, or pain relief.

Our finding that higher BMI is an independent risk factor was previously described.⁴ The association is unclear but could be related to implant positioning, difficulty in intraoperative assessment of muscle tensioning, or body habitus that may generate a lever arm for impingement and dislocation when the arm is in adduction. Last, our finding that male sex is a risk factor for dislocation approached significance, and this relationship was previously reported.⁴ This could be attributable to a higher rate of activity or of indolent infection in male patients.^34,35Besides studying risk factors for dislocation after RTSA, we investigated treatment. None of our patients were treated successfully and definitively with closed reduction in the clinic. This finding diverges from findings in studies by Teusink and colleagues² and Chalmers and colleagues,⁴who respectively reported 62% and 44% rates of success with closed reduction. Our cohort of 14 patients with 15 dislocations required a total of 17 trips to the operating room after dislocation. This significantly higher rate of return to the operating room suggests that dislocation after RTSA may be a more costly and morbid problem than has been previously described.

This study had several weaknesses. Despite its large consecutive series of patients, the study was retrospective, and several variables that would be documented and controlled in a prospective study could not be measured here. Specifically, neither preoperative physical examination nor patient-specific assessments of pain or function were consistently obtained. Similarly, postoperative patient-specific instruments of outcomes evaluation were not obtained consistently, so results of patients with dislocation could not be compared with those of a control group. In addition, preoperative and postoperative radiographs were not consistently present in our electronic medical records, so the influence of preoperative bony anatomy, intraoperative limb lengthening, and any implant malpositioning could not be determined. Furthermore, operative details, such as reparability of the subscapularis, were not fully available for the control group and could not be included in statistical analysis. In addition, that the known dislocation risk factor of male sex⁴ was identified here but was not significant in multivariate regression analysis suggests that this study may not have been adequately powered to identify a significant difference in dislocation rate between the sexes. Last, though our results suggested associations between the aforementioned variables and dislocation after RTSA, a truly causative relationship could not be confirmed with this study design or analysis. Therefore, our study findings are hypothesis-generating and may indicate a benefit to greater deltoid tensioning, use of retentive liners, or more conservative rehabilitation protocols for high-risk patients.

Conclusion

Dislocation after RTSA is an uncommon complication that often requires a return to the operating room. This study identified a modifiable risk factor (higher BMI) and 3 nonmodifiable risk factors (male sex, subscapularis insufficiency, revision surgery) for dislocation after RTSA. In contrast, patients who undergo RTSA for primary rotator cuff pathology are unlikely to dislocate after surgery. This low risk of dislocation after RTSA for primary cuff pathology was not previously described. Patients in the higher risk category may benefit from preoperative lifestyle modification, intraoperative techniques for increasing stability, and more conservative therapy after surgery. In addition, unlike previous investigations, this study did not find closed reduction in the clinic alone to be successful in definitively treating this patient population.

Am J Orthop. 2016;45(7):E444-E450. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Risk factors for dislocation after reverse total shoulder arthroplasty (RTSA) are not clearly defined. Prosthetic dislocation can result in poor patient satisfaction, worse functional outcomes, and return to the operating room.^1-3 As a result, identification of modifiable risk factors for complications represents an important research initiative for shoulder surgeons.

There is a paucity of literature devoted to the study of dislocation after RTSA. Chalmers and colleagues⁴ found a 2.9% (11/385) incidence of early dislocation within 3 months after index surgery—an improvement over the 15.8% reported for early instability over the period 2004–2006.⁵ As prosthesis design has improved and surgeons have become more comfortable with the RTSA prosthesis, surgical indications have expanded,^6,7 and dislocation rates appear to have decreased. Although the most common indication for RTSA continues to be cuff tear arthropathy (CTA),⁶ there has been increased use in rheumatoid arthritis^8-10; proximal humerus fractures, especially in cases of poor bone quality and unreliable fixation of tuberosities^11-13; and failed previous shoulder reconstruction.^14,15 As RTSA is performed more often, limiting the complications will become more important for both patient care and economics.

We conducted a study to analyze dislocation rates at our institution and to identify both modifiable and nonmodifiable risk factors for dislocation after RTSA. By identifying risk factors for dislocation, we will be able to implement additional perioperative clinical measures to reduce the incidence of dislocation.

Materials and Methods

This retrospective study of dislocation after RTSA was conducted at the Rothman Institute of Orthopedics and Methodist Hospital (Thomas Jefferson University Hospitals, Philadelphia, PA). After obtaining Institutional Review Board approval for the study, we searched our institution’s electronic database of shoulder arthroplasties to identify all RTSAs performed at our 2 large-volume urban institutions between September 27, 2010 and December 31, 2013. For the record search, International Classification of Diseases, Ninth Revision (ICD-9) codes were used (Table 1).

The medical records of each patient were used to identify independent variables that could be associated with dislocation rate. Demographic variables included sex, age, and race. Preoperative clinical data included body mass index (BMI), etiology of shoulder disease leading to RTSA, individual comorbidities, and Charlson Comorbidity Index (CCI)¹⁶ modified to be used with ICD-9 codes.¹⁷ In addition, prior shoulder surgery history and arthroplasty type (primary or revision) were determined. Postoperative considerations were time to dislocation, mechanism of dislocation, and intervention(s) needed for dislocation. Although the institutional database did not include operative variables such as prosthesis type and surgical approach, all 6 surgeons in this study were using a standard deltopectoral approach in beach-chair position with a Grammont style prosthesis for RTSA cases.

Descriptive statistics for RTSA patients and the dislocation subpopulation were compiled. Bivariate analysis was used to evaluate which of the previously described variables influenced dislocation rates. Last, multivariate logistic regression analysis was performed to evaluate which factors were independent predictors of dislocation. We included demographic variables (age, sex, ethnicity), clinical variables (BMI, individual comorbidities, CCI), and surgical variables (primary vs revision, diagnosis at time of surgery). All statistical analyses were performed with Excel 2013 (Microsoft) and SPSS Statistics Version 20.0 (SPSS Inc.).

Results

From the database, we identified 487 patients who underwent 510 RTSAs during the study period. These surgeries were performed by 6 shoulder and elbow fellowship–trained surgeons. Of the 510 RTSAs, 393 (77.1%) were primary cases, and 117 (22.9%) were revision cases.

Of the 510 shoulders that underwent RTSA, 15 (2.9%; 14 patients) dislocated. Of these 15 cases, 5 were primary (1.3% of all primary cases) and 10 were revision (8.5% of all revision cases). Mean time from index surgery to diagnosis of dislocation was 58.2 days (range, 0-319 days). One dislocation occurred immediately after surgery, 2 after falls, 4 from patient-identified low-energy mechanisms of injury, and 8 without known inciting events. Nine dislocations (60%) did not have a subscapularis repair (7 were irreparable, 2 underwent subscapularis peel without repair), and the other 6 were repaired primarily (Table 2).

Discussion

With more RTSAs being performed, evaluation of their common complications becomes increasingly important.¹⁸ We found a 3.0% rate of dislocation after RTSA, which is consistent with the most recently reported incidence⁴ and falls within the previously described range of 0% to 8.6%.^19-26 Of the clinical risk factors identified in this study, those previously described were prior surgery, subscapularis insufficiency, higher BMI, and male sex.⁴ However, our finding of lower risk of dislocation after RTSA for primary rotator cuff pathology was not previously described. Although Chalmers and colleagues⁴ did not report this lower risk, 3 (27.3%) of their 11 patients with dislocation had primary CTA, compared with 1 (6.7%) of 15 patients in the present study.⁴ Our literature review did not identify any studies that independently reported the dislocation rate in patients who underwent RTSA for rotator cuff failure.

The risk factors of subscapularis irreparability and revision surgery suggest the importance of the soft-tissue envelope and bony anatomy in dislocation prevention. Previous analyses have suggested implant malpositioning,^27,28 poor subscapularis quality,²⁹ and inadequate muscle tensioning^5,30-32 as risk factors for RTSA. Patients with an irreparable subscapularis tendon have often had multiple surgeries with compromise to the muscle/soft-tissue envelope or bony anatomy of the shoulder. A biomechanical study by Gutiérrez and colleagues³¹ found the compressive forces of the soft tissue at the glenohumeral joint to be the most important contributor to stability in the RTSA prosthesis. In clinical studies, the role of the subscapularis in preventing instability after RTSA remains unclear. Edwards and colleagues²⁹ prospectively compared dislocation rates in patients with reparable and irreparable subscapularis tendons during RTSA and found a higher rate of dislocation in the irreparable subscapularis group. Of note, patients in the irreparable subscapularis group also had more complex diagnoses, including proximal humeral nonunion, fixed glenohumeral dislocation, and failed prior arthroplasty. Clark and colleagues³³ retrospectively analyzed subscapularis repair in 2 RTSA groups and found no appreciable effect on complication rate, dislocation events, range-of-motion gains, or pain relief.

Our finding that higher BMI is an independent risk factor was previously described.⁴ The association is unclear but could be related to implant positioning, difficulty in intraoperative assessment of muscle tensioning, or body habitus that may generate a lever arm for impingement and dislocation when the arm is in adduction. Last, our finding that male sex is a risk factor for dislocation approached significance, and this relationship was previously reported.⁴ This could be attributable to a higher rate of activity or of indolent infection in male patients.^34,35Besides studying risk factors for dislocation after RTSA, we investigated treatment. None of our patients were treated successfully and definitively with closed reduction in the clinic. This finding diverges from findings in studies by Teusink and colleagues² and Chalmers and colleagues,⁴who respectively reported 62% and 44% rates of success with closed reduction. Our cohort of 14 patients with 15 dislocations required a total of 17 trips to the operating room after dislocation. This significantly higher rate of return to the operating room suggests that dislocation after RTSA may be a more costly and morbid problem than has been previously described.

This study had several weaknesses. Despite its large consecutive series of patients, the study was retrospective, and several variables that would be documented and controlled in a prospective study could not be measured here. Specifically, neither preoperative physical examination nor patient-specific assessments of pain or function were consistently obtained. Similarly, postoperative patient-specific instruments of outcomes evaluation were not obtained consistently, so results of patients with dislocation could not be compared with those of a control group. In addition, preoperative and postoperative radiographs were not consistently present in our electronic medical records, so the influence of preoperative bony anatomy, intraoperative limb lengthening, and any implant malpositioning could not be determined. Furthermore, operative details, such as reparability of the subscapularis, were not fully available for the control group and could not be included in statistical analysis. In addition, that the known dislocation risk factor of male sex⁴ was identified here but was not significant in multivariate regression analysis suggests that this study may not have been adequately powered to identify a significant difference in dislocation rate between the sexes. Last, though our results suggested associations between the aforementioned variables and dislocation after RTSA, a truly causative relationship could not be confirmed with this study design or analysis. Therefore, our study findings are hypothesis-generating and may indicate a benefit to greater deltoid tensioning, use of retentive liners, or more conservative rehabilitation protocols for high-risk patients.

Conclusion

Dislocation after RTSA is an uncommon complication that often requires a return to the operating room. This study identified a modifiable risk factor (higher BMI) and 3 nonmodifiable risk factors (male sex, subscapularis insufficiency, revision surgery) for dislocation after RTSA. In contrast, patients who undergo RTSA for primary rotator cuff pathology are unlikely to dislocate after surgery. This low risk of dislocation after RTSA for primary cuff pathology was not previously described. Patients in the higher risk category may benefit from preoperative lifestyle modification, intraoperative techniques for increasing stability, and more conservative therapy after surgery. In addition, unlike previous investigations, this study did not find closed reduction in the clinic alone to be successful in definitively treating this patient population.

Am J Orthop. 2016;45(7):E444-E450. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.