A large, 16-year single-center study of patients with multivessel disease has determined that multivessel coronary artery bypass grafting achieved longer survival than not only percutaneous coronary interventions, but also conventional coronary artery bypass grafting, researchers from the Mayo Clinic reported in the August issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2016;152:369-79).

Lead author Chaim Locker, MD, and his colleagues said the use of what they called MultiArt, for multivessel arterial grafting, also known as MAG, “must increase.”

The evolution of bare-metal and then drug-eluting stents may have favored percutaneous coronary interventions (PCI) over coronary artery bypass grafting (CABG), but, Dr. Locker and his coauthors said, “Evidence is accumulating that late outcome of surgical revascularization is improved when at least two arterial grafts are used.”

The study analyzed results of 12,615 patients who had either isolated primary CABG (6,667) or PCI (5,948) from 1993 to 2009. Among the CABG patients, 5,712 had the more conventional approach involving arterial grafts into the left internal thoracic artery/saphenous vein (ITA/SV) and 955 had MAG. Patients in the PCI group had three different procedures: balloon angioplasty (1,020), drug-eluting stent (1,686), or bare-metal stent (3,242). The study excluded patients who had revascularization procedures after a heart attack.

While the overall 15-year survival for patients with CABG was lower than it was for those who had PCI (36% vs. 46%), the survival for those who had MAG was significantly higher: 65% vs. 31% for those who had left ITA/SV revascularization. 8-year survival for the MAG subgroup was also significantly higher than all other subgroups: 87% vs. 69% for left ITA/SV, 75% for bare-metal stent, 73% for balloon angioplasty, and 70% for drug-eluting stent.

Propensity matching found similar survivability for balloon angioplasty and left ITA/SV when compared with MAG: 66% for MAG vs. 57% for the former; and 64% for MAG vs. 56% for the latter. The researchers also estimated the hazard ratio during the first 5 years of follow-up and found that those who had bare-metal stents had “significantly worse” survival, compared with MAG, but that survival evened out after that. Survival in the bare-metal stent group was similar to that of the left ITA/SV group, but “significantly worse” during the first 5 years for those who had balloon angioplasty.

Dr. Locker and his colleagues acknowledged that multiple randomized studies have compared CABG and PCI over the years, but they said that in most of those studies “the enrolled patients were highly selected and likely did not represent the broader population of patients with MVD [multivessel disease] undergoing revascularization.” With the exception of the SYNTAX trial (Synergy Between PCI With Taxus and Cardiac Surgery) (N Engl J Med. 2009;360:961-72; Lancet. 2013;381:629-38), those studies did not report on the frequency of MAG within the study population. The Mayo study, on the other hand, included all treated patients, excluding those who had a previous heart attack.

However, MAG is used infrequently, Dr. Locker and his colleagues said. The average annual rate of MAG in their Mayo practice was 15.2%, higher than the 5% annual rate the Society of Thoracic Surgeons National Cardiac Surgery Database (J Thorac Cardiovasc Surg. 2012;143:273-81) reported, and higher than the 12% rate in Europe (Eur J Cardiothorac Surg. 2006;29: 486-91). The SYNTAX trial reported an annual MAG rate of 27.6% for all CABG cases.

“It seems clear that use of MultiArt should be more frequent in patients with MVD undergoing CABG,” Dr. Locker and his coauthors said. “MultiArt can be used in most patients with MVD, including diabetic patients and elderly patients, and this strategy will improve outcomes of surgical revascularization.”

Dr. Locker and his coauthors had no financial relationships to disclose.

A large, 16-year single-center study of patients with multivessel disease has determined that multivessel coronary artery bypass grafting achieved longer survival than not only percutaneous coronary interventions, but also conventional coronary artery bypass grafting, researchers from the Mayo Clinic reported in the August issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2016;152:369-79).

Lead author Chaim Locker, MD, and his colleagues said the use of what they called MultiArt, for multivessel arterial grafting, also known as MAG, “must increase.”

The evolution of bare-metal and then drug-eluting stents may have favored percutaneous coronary interventions (PCI) over coronary artery bypass grafting (CABG), but, Dr. Locker and his coauthors said, “Evidence is accumulating that late outcome of surgical revascularization is improved when at least two arterial grafts are used.”

The study analyzed results of 12,615 patients who had either isolated primary CABG (6,667) or PCI (5,948) from 1993 to 2009. Among the CABG patients, 5,712 had the more conventional approach involving arterial grafts into the left internal thoracic artery/saphenous vein (ITA/SV) and 955 had MAG. Patients in the PCI group had three different procedures: balloon angioplasty (1,020), drug-eluting stent (1,686), or bare-metal stent (3,242). The study excluded patients who had revascularization procedures after a heart attack.

While the overall 15-year survival for patients with CABG was lower than it was for those who had PCI (36% vs. 46%), the survival for those who had MAG was significantly higher: 65% vs. 31% for those who had left ITA/SV revascularization. 8-year survival for the MAG subgroup was also significantly higher than all other subgroups: 87% vs. 69% for left ITA/SV, 75% for bare-metal stent, 73% for balloon angioplasty, and 70% for drug-eluting stent.

Propensity matching found similar survivability for balloon angioplasty and left ITA/SV when compared with MAG: 66% for MAG vs. 57% for the former; and 64% for MAG vs. 56% for the latter. The researchers also estimated the hazard ratio during the first 5 years of follow-up and found that those who had bare-metal stents had “significantly worse” survival, compared with MAG, but that survival evened out after that. Survival in the bare-metal stent group was similar to that of the left ITA/SV group, but “significantly worse” during the first 5 years for those who had balloon angioplasty.

Dr. Locker and his colleagues acknowledged that multiple randomized studies have compared CABG and PCI over the years, but they said that in most of those studies “the enrolled patients were highly selected and likely did not represent the broader population of patients with MVD [multivessel disease] undergoing revascularization.” With the exception of the SYNTAX trial (Synergy Between PCI With Taxus and Cardiac Surgery) (N Engl J Med. 2009;360:961-72; Lancet. 2013;381:629-38), those studies did not report on the frequency of MAG within the study population. The Mayo study, on the other hand, included all treated patients, excluding those who had a previous heart attack.

However, MAG is used infrequently, Dr. Locker and his colleagues said. The average annual rate of MAG in their Mayo practice was 15.2%, higher than the 5% annual rate the Society of Thoracic Surgeons National Cardiac Surgery Database (J Thorac Cardiovasc Surg. 2012;143:273-81) reported, and higher than the 12% rate in Europe (Eur J Cardiothorac Surg. 2006;29: 486-91). The SYNTAX trial reported an annual MAG rate of 27.6% for all CABG cases.

“It seems clear that use of MultiArt should be more frequent in patients with MVD undergoing CABG,” Dr. Locker and his coauthors said. “MultiArt can be used in most patients with MVD, including diabetic patients and elderly patients, and this strategy will improve outcomes of surgical revascularization.”

Dr. Locker and his coauthors had no financial relationships to disclose.

A large, 16-year single-center study of patients with multivessel disease has determined that multivessel coronary artery bypass grafting achieved longer survival than not only percutaneous coronary interventions, but also conventional coronary artery bypass grafting, researchers from the Mayo Clinic reported in the August issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2016;152:369-79).

Lead author Chaim Locker, MD, and his colleagues said the use of what they called MultiArt, for multivessel arterial grafting, also known as MAG, “must increase.”

The evolution of bare-metal and then drug-eluting stents may have favored percutaneous coronary interventions (PCI) over coronary artery bypass grafting (CABG), but, Dr. Locker and his coauthors said, “Evidence is accumulating that late outcome of surgical revascularization is improved when at least two arterial grafts are used.”

The study analyzed results of 12,615 patients who had either isolated primary CABG (6,667) or PCI (5,948) from 1993 to 2009. Among the CABG patients, 5,712 had the more conventional approach involving arterial grafts into the left internal thoracic artery/saphenous vein (ITA/SV) and 955 had MAG. Patients in the PCI group had three different procedures: balloon angioplasty (1,020), drug-eluting stent (1,686), or bare-metal stent (3,242). The study excluded patients who had revascularization procedures after a heart attack.

While the overall 15-year survival for patients with CABG was lower than it was for those who had PCI (36% vs. 46%), the survival for those who had MAG was significantly higher: 65% vs. 31% for those who had left ITA/SV revascularization. 8-year survival for the MAG subgroup was also significantly higher than all other subgroups: 87% vs. 69% for left ITA/SV, 75% for bare-metal stent, 73% for balloon angioplasty, and 70% for drug-eluting stent.

Propensity matching found similar survivability for balloon angioplasty and left ITA/SV when compared with MAG: 66% for MAG vs. 57% for the former; and 64% for MAG vs. 56% for the latter. The researchers also estimated the hazard ratio during the first 5 years of follow-up and found that those who had bare-metal stents had “significantly worse” survival, compared with MAG, but that survival evened out after that. Survival in the bare-metal stent group was similar to that of the left ITA/SV group, but “significantly worse” during the first 5 years for those who had balloon angioplasty.

Dr. Locker and his colleagues acknowledged that multiple randomized studies have compared CABG and PCI over the years, but they said that in most of those studies “the enrolled patients were highly selected and likely did not represent the broader population of patients with MVD [multivessel disease] undergoing revascularization.” With the exception of the SYNTAX trial (Synergy Between PCI With Taxus and Cardiac Surgery) (N Engl J Med. 2009;360:961-72; Lancet. 2013;381:629-38), those studies did not report on the frequency of MAG within the study population. The Mayo study, on the other hand, included all treated patients, excluding those who had a previous heart attack.

However, MAG is used infrequently, Dr. Locker and his colleagues said. The average annual rate of MAG in their Mayo practice was 15.2%, higher than the 5% annual rate the Society of Thoracic Surgeons National Cardiac Surgery Database (J Thorac Cardiovasc Surg. 2012;143:273-81) reported, and higher than the 12% rate in Europe (Eur J Cardiothorac Surg. 2006;29: 486-91). The SYNTAX trial reported an annual MAG rate of 27.6% for all CABG cases.

“It seems clear that use of MultiArt should be more frequent in patients with MVD undergoing CABG,” Dr. Locker and his coauthors said. “MultiArt can be used in most patients with MVD, including diabetic patients and elderly patients, and this strategy will improve outcomes of surgical revascularization.”

Dr. Locker and his coauthors had no financial relationships to disclose.

The Centers for Disease Control and Prevention has confirmed that a new pocket of local Zika virus transmission has emerged in Miami Beach, adding yet another area in southern Florida for travelers to avoid.

“We now recommend [that] pregnant women should avoid travel to the designated area of Miami Beach, in addition to the designated area of Wynwood,” CDC Director Tom Frieden, MD, MPH, said during a conference call.

The announcement of a second Miami neighborhood experiencing ongoing local transmission came within 24 hours of the Miami Beach area being identified as a potential hazard, according to Dr. Frieden. Public health officials notified the public in late July about Zika virus transmission in the Wynwood neighborhood; in addition, there have been at least four other cases of independent mosquito-borne transmission of the Zika virus, but the CDC noted that these are not indicative of the disease spreading or becoming locally transmitted to a significant extent.

©Rattikankeawpun/Thinkstock.com

For those living in or near the affected areas, Dr. Frieden urged that they “do everything they can to prevent mosquito bites,” including wearing clothing that covers as much of the body as possible and using bug repellent, among other things. Those who traveled to the Miami area on or after July 14 of this year should use protection while having sex with their partners to prevent transmitting the virus that way. Women should wait until at least 8 weeks after onset of Zika virus symptoms before attempting to get pregnant.

“More broadly and not just with respect to Florida, all pregnant women anywhere in the U.S. should be evaluated for possible Zika virus exposure during each prenatal care visit,” said Dr. Frieden. “These evaluations should include an assessment of the symptoms of Zika virus disease such as fever, rash, arthralgia, and conjunctivitis, their travel history, and their potential partners’ exposure to Zika virus.”

Dr. Frieden said that the CDC will continue monitoring the situation on a daily basis and make any further announcements, along with changes to current guidelines and recommendations, as necessary.

[email protected]

The Centers for Disease Control and Prevention has confirmed that a new pocket of local Zika virus transmission has emerged in Miami Beach, adding yet another area in southern Florida for travelers to avoid.

“We now recommend [that] pregnant women should avoid travel to the designated area of Miami Beach, in addition to the designated area of Wynwood,” CDC Director Tom Frieden, MD, MPH, said during a conference call.

The announcement of a second Miami neighborhood experiencing ongoing local transmission came within 24 hours of the Miami Beach area being identified as a potential hazard, according to Dr. Frieden. Public health officials notified the public in late July about Zika virus transmission in the Wynwood neighborhood; in addition, there have been at least four other cases of independent mosquito-borne transmission of the Zika virus, but the CDC noted that these are not indicative of the disease spreading or becoming locally transmitted to a significant extent.

©Rattikankeawpun/Thinkstock.com

For those living in or near the affected areas, Dr. Frieden urged that they “do everything they can to prevent mosquito bites,” including wearing clothing that covers as much of the body as possible and using bug repellent, among other things. Those who traveled to the Miami area on or after July 14 of this year should use protection while having sex with their partners to prevent transmitting the virus that way. Women should wait until at least 8 weeks after onset of Zika virus symptoms before attempting to get pregnant.

“More broadly and not just with respect to Florida, all pregnant women anywhere in the U.S. should be evaluated for possible Zika virus exposure during each prenatal care visit,” said Dr. Frieden. “These evaluations should include an assessment of the symptoms of Zika virus disease such as fever, rash, arthralgia, and conjunctivitis, their travel history, and their potential partners’ exposure to Zika virus.”

Dr. Frieden said that the CDC will continue monitoring the situation on a daily basis and make any further announcements, along with changes to current guidelines and recommendations, as necessary.

[email protected]

The Centers for Disease Control and Prevention has confirmed that a new pocket of local Zika virus transmission has emerged in Miami Beach, adding yet another area in southern Florida for travelers to avoid.

“We now recommend [that] pregnant women should avoid travel to the designated area of Miami Beach, in addition to the designated area of Wynwood,” CDC Director Tom Frieden, MD, MPH, said during a conference call.

The announcement of a second Miami neighborhood experiencing ongoing local transmission came within 24 hours of the Miami Beach area being identified as a potential hazard, according to Dr. Frieden. Public health officials notified the public in late July about Zika virus transmission in the Wynwood neighborhood; in addition, there have been at least four other cases of independent mosquito-borne transmission of the Zika virus, but the CDC noted that these are not indicative of the disease spreading or becoming locally transmitted to a significant extent.

©Rattikankeawpun/Thinkstock.com

For those living in or near the affected areas, Dr. Frieden urged that they “do everything they can to prevent mosquito bites,” including wearing clothing that covers as much of the body as possible and using bug repellent, among other things. Those who traveled to the Miami area on or after July 14 of this year should use protection while having sex with their partners to prevent transmitting the virus that way. Women should wait until at least 8 weeks after onset of Zika virus symptoms before attempting to get pregnant.

“More broadly and not just with respect to Florida, all pregnant women anywhere in the U.S. should be evaluated for possible Zika virus exposure during each prenatal care visit,” said Dr. Frieden. “These evaluations should include an assessment of the symptoms of Zika virus disease such as fever, rash, arthralgia, and conjunctivitis, their travel history, and their potential partners’ exposure to Zika virus.”

Dr. Frieden said that the CDC will continue monitoring the situation on a daily basis and make any further announcements, along with changes to current guidelines and recommendations, as necessary.

[email protected]

SAN DIEGO – A top endocrinologist cautioned diabetes educators that research is linking nighttime hypoglycemia to a variety of ills, and technology isn’t providing much hope – yet.

Patients with nocturnal low blood sugar “say this is the hardest thing they have to deal with. It upsets their whole day and they feel terrible,” said Anthony L. McCall, MD, PhD, James M. Moss Professor of Diabetes at the University of Virginia, Charlottesville, and vice president of clinical science with the Endocrine Society.

Dr. McCall told an audience at the annual meeting of the American Association of Diabetes Educators that half of hypoglycemia is nocturnal and unrecognized despite its dangers. According to him, hypoglycemia represents a blood glucose level of at or under 70 mg/dL (3.9 mmol/L). This is higher than the threshold for hypoglycemia in nondiabetics and those with well controlled diabetes.

Even as few as two values in a week in the range of the 60s (mg/dL) can go unrecognized and lead to full-blown hypoglycemia-associated autonomic failure, he said. There are other possible risks: “impaired sleep quality, daytime drowsiness, mood changes, risk for nocturnal falls,” he said.

Cognitive dysfunction is possible, especially in children, he added. “Neurological dysfunction may be temporary, but those who can answer simple questions may not be OK.”

There’s a potential for a vicious cycle here, he said, because people with diabetes can also develop impaired hypoglycemia awareness, making it less likely they’ll notice the low blood sugar levels that contribute to autonomic failure.

Dr. McCall reported that nighttime hypoglycemia may also:

• Trigger neurologic symptoms like those of strokes or temporary ischemic attacks. “Someone’s got check to their blood sugar,” he says.

• Lengthen the QT interval and boost the risk of irregular heartbeats.

• Contribute to “dead in bed” syndrome in which young people with type 1 diabetes are discovered dead despite not having any complications or showing signs of convulsion.

What can be done to help these patients? One approach is to combat impaired hypoglycemia awareness. Bedtime snacks, caffeine, and uncooked cornstarch are among the many nutrition supplements (and medications) that have shown inconsistent results at best on this front, Dr. McCall said. If they work, he said, they often lead to hyperglycemia.

Another strategy is to look for factors that raise the risk of nighttime hypoglycemia, such as basal insulin overtreatment, long periods between meals, delayed effects of exercise, and higher insulin sensitivity overnight.

Insulin pumps may be helpful, he said, and he generally favors their use. However, he cautioned that it’s hard to show that they reduce hypoglycemia, and some patients don’t use them properly.

Data have been mixed until recently regarding real-time continuous glucose monitoring, he said, and the devices must be worn 75%-85% of the time to show benefit. As for sensor-augmented insulin pumps, he said they’ve shown mixed results.

Dr. McCall said the artificial pancreas, once it makes it to market, could mark the beginning of a new era. “This was around the corner 40 years ago. But it’s closer now,” he said. “I have great hope that we’re going to do better.”

Dr. McCall reported being a consultant to Sanofi regarding new insulin studies and serving on the advisory board of DexCom/Google regarding the use of continuous glucose monitoring.

SAN DIEGO – A top endocrinologist cautioned diabetes educators that research is linking nighttime hypoglycemia to a variety of ills, and technology isn’t providing much hope – yet.

Patients with nocturnal low blood sugar “say this is the hardest thing they have to deal with. It upsets their whole day and they feel terrible,” said Anthony L. McCall, MD, PhD, James M. Moss Professor of Diabetes at the University of Virginia, Charlottesville, and vice president of clinical science with the Endocrine Society.

Dr. McCall told an audience at the annual meeting of the American Association of Diabetes Educators that half of hypoglycemia is nocturnal and unrecognized despite its dangers. According to him, hypoglycemia represents a blood glucose level of at or under 70 mg/dL (3.9 mmol/L). This is higher than the threshold for hypoglycemia in nondiabetics and those with well controlled diabetes.

Even as few as two values in a week in the range of the 60s (mg/dL) can go unrecognized and lead to full-blown hypoglycemia-associated autonomic failure, he said. There are other possible risks: “impaired sleep quality, daytime drowsiness, mood changes, risk for nocturnal falls,” he said.

Cognitive dysfunction is possible, especially in children, he added. “Neurological dysfunction may be temporary, but those who can answer simple questions may not be OK.”

There’s a potential for a vicious cycle here, he said, because people with diabetes can also develop impaired hypoglycemia awareness, making it less likely they’ll notice the low blood sugar levels that contribute to autonomic failure.

Dr. McCall reported that nighttime hypoglycemia may also:

• Trigger neurologic symptoms like those of strokes or temporary ischemic attacks. “Someone’s got check to their blood sugar,” he says.

• Lengthen the QT interval and boost the risk of irregular heartbeats.

• Contribute to “dead in bed” syndrome in which young people with type 1 diabetes are discovered dead despite not having any complications or showing signs of convulsion.

What can be done to help these patients? One approach is to combat impaired hypoglycemia awareness. Bedtime snacks, caffeine, and uncooked cornstarch are among the many nutrition supplements (and medications) that have shown inconsistent results at best on this front, Dr. McCall said. If they work, he said, they often lead to hyperglycemia.

Another strategy is to look for factors that raise the risk of nighttime hypoglycemia, such as basal insulin overtreatment, long periods between meals, delayed effects of exercise, and higher insulin sensitivity overnight.

Insulin pumps may be helpful, he said, and he generally favors their use. However, he cautioned that it’s hard to show that they reduce hypoglycemia, and some patients don’t use them properly.

Data have been mixed until recently regarding real-time continuous glucose monitoring, he said, and the devices must be worn 75%-85% of the time to show benefit. As for sensor-augmented insulin pumps, he said they’ve shown mixed results.

Dr. McCall said the artificial pancreas, once it makes it to market, could mark the beginning of a new era. “This was around the corner 40 years ago. But it’s closer now,” he said. “I have great hope that we’re going to do better.”

Dr. McCall reported being a consultant to Sanofi regarding new insulin studies and serving on the advisory board of DexCom/Google regarding the use of continuous glucose monitoring.

SAN DIEGO – A top endocrinologist cautioned diabetes educators that research is linking nighttime hypoglycemia to a variety of ills, and technology isn’t providing much hope – yet.

Patients with nocturnal low blood sugar “say this is the hardest thing they have to deal with. It upsets their whole day and they feel terrible,” said Anthony L. McCall, MD, PhD, James M. Moss Professor of Diabetes at the University of Virginia, Charlottesville, and vice president of clinical science with the Endocrine Society.

Dr. McCall told an audience at the annual meeting of the American Association of Diabetes Educators that half of hypoglycemia is nocturnal and unrecognized despite its dangers. According to him, hypoglycemia represents a blood glucose level of at or under 70 mg/dL (3.9 mmol/L). This is higher than the threshold for hypoglycemia in nondiabetics and those with well controlled diabetes.

Even as few as two values in a week in the range of the 60s (mg/dL) can go unrecognized and lead to full-blown hypoglycemia-associated autonomic failure, he said. There are other possible risks: “impaired sleep quality, daytime drowsiness, mood changes, risk for nocturnal falls,” he said.

Cognitive dysfunction is possible, especially in children, he added. “Neurological dysfunction may be temporary, but those who can answer simple questions may not be OK.”

There’s a potential for a vicious cycle here, he said, because people with diabetes can also develop impaired hypoglycemia awareness, making it less likely they’ll notice the low blood sugar levels that contribute to autonomic failure.

Dr. McCall reported that nighttime hypoglycemia may also:

• Trigger neurologic symptoms like those of strokes or temporary ischemic attacks. “Someone’s got check to their blood sugar,” he says.

• Lengthen the QT interval and boost the risk of irregular heartbeats.

• Contribute to “dead in bed” syndrome in which young people with type 1 diabetes are discovered dead despite not having any complications or showing signs of convulsion.

What can be done to help these patients? One approach is to combat impaired hypoglycemia awareness. Bedtime snacks, caffeine, and uncooked cornstarch are among the many nutrition supplements (and medications) that have shown inconsistent results at best on this front, Dr. McCall said. If they work, he said, they often lead to hyperglycemia.

Another strategy is to look for factors that raise the risk of nighttime hypoglycemia, such as basal insulin overtreatment, long periods between meals, delayed effects of exercise, and higher insulin sensitivity overnight.

Insulin pumps may be helpful, he said, and he generally favors their use. However, he cautioned that it’s hard to show that they reduce hypoglycemia, and some patients don’t use them properly.

Data have been mixed until recently regarding real-time continuous glucose monitoring, he said, and the devices must be worn 75%-85% of the time to show benefit. As for sensor-augmented insulin pumps, he said they’ve shown mixed results.

Dr. McCall said the artificial pancreas, once it makes it to market, could mark the beginning of a new era. “This was around the corner 40 years ago. But it’s closer now,” he said. “I have great hope that we’re going to do better.”

Dr. McCall reported being a consultant to Sanofi regarding new insulin studies and serving on the advisory board of DexCom/Google regarding the use of continuous glucose monitoring.

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

EXPERT COMMENTARY

Although RRSO is routinely recommended to decrease the risk of ovarian as well as breast cancer in women who harbor BRCA mutations, whether or not surgery should include hysterectomy has not been clear. Shu and colleagues prospectively evaluated the risk of uterine cancer in BRCA1 and BRCA2 mutation carriers who underwent RRSO without hysterectomy at 1 of 9 centers in the United States or the United Kingdom, comparing it with rates expected from national surveillance data.

Details of the study

Among 1,083 women (median age, 45.6 years at the time of RRSO; median follow-up, 5.1 years), 8 incident uterine cancers were observed (4.3 were expected; observed to expected [O:E] ratio, 1.9; P = .09). In an analysis stratified by tumor subtype, no elevated risk for endometrioid endometrial cancer or sarcoma was noted. Five serous and/or serous-like endometrial cancers were observed after RRSO. Four were found in BRCA1 carriers and 1 in a BRCA2 carrier, with the O:E ratio of 22.2 (P<.001) for BRCA1 and 6.4 (P = .15) for BRCA2 carriers.

Details of the accompanying editorial

Commenting on the study, Leath and colleagues noted that while the number of cases was small, the study demonstrated a link between the presence of BRCA mutations (particularly BRCA1 mutations) and a "small but not null risk of endometrial cancer." Many of these uterine cancers have a serous histology, a concern due to the likelihood of worse outcomes compared with the more common endometrioid variant.
 
The authors suggest that clinicians make patients with BRCA mutations undergoing RRSO aware of the potential risks and benefits of concomitant hysterectomy and work to make an individualized decision based on the limitations of available data. They state, "Perhaps it is time to consider that the line for risk-reducing gynecologic surgery in patients with BRCA mutations not stop at the ovaries and fallopian tubes. Thus, concomitant hysterectomy with RRSO, when performed with a minimally invasive surgical approach, particularly for women with a BRCA1 mutation, should be able to be performed with minimum morbidity and allow for use of estrogen-only hormone therapy after surgery, if needed."

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

EXPERT COMMENTARY

Although RRSO is routinely recommended to decrease the risk of ovarian as well as breast cancer in women who harbor BRCA mutations, whether or not surgery should include hysterectomy has not been clear. Shu and colleagues prospectively evaluated the risk of uterine cancer in BRCA1 and BRCA2 mutation carriers who underwent RRSO without hysterectomy at 1 of 9 centers in the United States or the United Kingdom, comparing it with rates expected from national surveillance data.

Details of the study

Among 1,083 women (median age, 45.6 years at the time of RRSO; median follow-up, 5.1 years), 8 incident uterine cancers were observed (4.3 were expected; observed to expected [O:E] ratio, 1.9; P = .09). In an analysis stratified by tumor subtype, no elevated risk for endometrioid endometrial cancer or sarcoma was noted. Five serous and/or serous-like endometrial cancers were observed after RRSO. Four were found in BRCA1 carriers and 1 in a BRCA2 carrier, with the O:E ratio of 22.2 (P<.001) for BRCA1 and 6.4 (P = .15) for BRCA2 carriers.

Details of the accompanying editorial

Commenting on the study, Leath and colleagues noted that while the number of cases was small, the study demonstrated a link between the presence of BRCA mutations (particularly BRCA1 mutations) and a "small but not null risk of endometrial cancer." Many of these uterine cancers have a serous histology, a concern due to the likelihood of worse outcomes compared with the more common endometrioid variant.
 
The authors suggest that clinicians make patients with BRCA mutations undergoing RRSO aware of the potential risks and benefits of concomitant hysterectomy and work to make an individualized decision based on the limitations of available data. They state, "Perhaps it is time to consider that the line for risk-reducing gynecologic surgery in patients with BRCA mutations not stop at the ovaries and fallopian tubes. Thus, concomitant hysterectomy with RRSO, when performed with a minimally invasive surgical approach, particularly for women with a BRCA1 mutation, should be able to be performed with minimum morbidity and allow for use of estrogen-only hormone therapy after surgery, if needed."

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

EXPERT COMMENTARY

Although RRSO is routinely recommended to decrease the risk of ovarian as well as breast cancer in women who harbor BRCA mutations, whether or not surgery should include hysterectomy has not been clear. Shu and colleagues prospectively evaluated the risk of uterine cancer in BRCA1 and BRCA2 mutation carriers who underwent RRSO without hysterectomy at 1 of 9 centers in the United States or the United Kingdom, comparing it with rates expected from national surveillance data.

Details of the study

Among 1,083 women (median age, 45.6 years at the time of RRSO; median follow-up, 5.1 years), 8 incident uterine cancers were observed (4.3 were expected; observed to expected [O:E] ratio, 1.9; P = .09). In an analysis stratified by tumor subtype, no elevated risk for endometrioid endometrial cancer or sarcoma was noted. Five serous and/or serous-like endometrial cancers were observed after RRSO. Four were found in BRCA1 carriers and 1 in a BRCA2 carrier, with the O:E ratio of 22.2 (P<.001) for BRCA1 and 6.4 (P = .15) for BRCA2 carriers.

Details of the accompanying editorial

Commenting on the study, Leath and colleagues noted that while the number of cases was small, the study demonstrated a link between the presence of BRCA mutations (particularly BRCA1 mutations) and a "small but not null risk of endometrial cancer." Many of these uterine cancers have a serous histology, a concern due to the likelihood of worse outcomes compared with the more common endometrioid variant.
 
The authors suggest that clinicians make patients with BRCA mutations undergoing RRSO aware of the potential risks and benefits of concomitant hysterectomy and work to make an individualized decision based on the limitations of available data. They state, "Perhaps it is time to consider that the line for risk-reducing gynecologic surgery in patients with BRCA mutations not stop at the ovaries and fallopian tubes. Thus, concomitant hysterectomy with RRSO, when performed with a minimally invasive surgical approach, particularly for women with a BRCA1 mutation, should be able to be performed with minimum morbidity and allow for use of estrogen-only hormone therapy after surgery, if needed."

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

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Doctors examine a patient

Photo courtesy of NCI

New research has revealed sociodemographic factors that appear to influence survival in younger patients with multiple myeloma (MM).

The study, which included more than 10,000 MM patients under the age of 65, suggested that marital status, insurance status, and county-level income all affect a patient’s chance of survival.

However, race/ethnicity and county-level educational achievement were not associated with overall survival (OS).

Luciano Costa, MD, PhD, of the University of Alabama at Birmingham, and his colleagues reported these findings in Cancer.

The researchers analyzed data on patients who were diagnosed with MM before the age of 65, between 2007 and 2012. There were 10,161 cases of MM, and the median follow-up was 27 months (range, 0-71 months).

The sociodemographic variables assessed were marital status, insurance status, median household income in the county of residence, and county-level educational achievement.

The researchers also looked at race/ethnicity, which was defined as a self-reported construct including Hispanic, non-Hispanic black, non-Hispanic white, and “other.”

The researchers found that patients had an increased risk of death if they were not married, did not have private insurance (were uninsured or on Medicaid), or lived in a low-income area (belonging to the lowest 2 income quartiles).

The 4-year estimated OS rate was 71.1% for patients who did not have any of these adverse sociodemographic factors, but it was 63.2% for patients with 1 factor, 53.4% for patients with 2 factors, and 46.5% for patients with all 3 factors (P<0.001).

The researchers did find that Hispanic and non-Hispanic black individuals had more adverse sociodemographic factors and worse OS than non-Hispanic whites and people belonging to the “other” category.

However, when the population was stratified by the cumulative number of sociodemographic factors and the researchers adjusted for confounders, there was no consistent association between race/ethnicity and OS.

The researchers said this suggests the apparent impact of race/ethnicity on OS may be due to the disparate distribution of sociodemographic factors observed among the different races/ethnicities rather than the race/ethnicity construct itself.

“This [study] strongly suggests that there is a huge disparity in outcomes that could potentially be overcome by improving access and affordability of treatments,” Dr Costa said.

“With the recent emphasis on comparative effectiveness in oncology, it also becomes crucial that all variables affecting outcomes—including sociodemographic factors—are accounted for when comparisons between different therapeutic approaches and healthcare systems are made.”

Doctors examine a patient

Photo courtesy of NCI

New research has revealed sociodemographic factors that appear to influence survival in younger patients with multiple myeloma (MM).

The study, which included more than 10,000 MM patients under the age of 65, suggested that marital status, insurance status, and county-level income all affect a patient’s chance of survival.

However, race/ethnicity and county-level educational achievement were not associated with overall survival (OS).

Luciano Costa, MD, PhD, of the University of Alabama at Birmingham, and his colleagues reported these findings in Cancer.

The researchers analyzed data on patients who were diagnosed with MM before the age of 65, between 2007 and 2012. There were 10,161 cases of MM, and the median follow-up was 27 months (range, 0-71 months).

The sociodemographic variables assessed were marital status, insurance status, median household income in the county of residence, and county-level educational achievement.

The researchers also looked at race/ethnicity, which was defined as a self-reported construct including Hispanic, non-Hispanic black, non-Hispanic white, and “other.”

The researchers found that patients had an increased risk of death if they were not married, did not have private insurance (were uninsured or on Medicaid), or lived in a low-income area (belonging to the lowest 2 income quartiles).

The 4-year estimated OS rate was 71.1% for patients who did not have any of these adverse sociodemographic factors, but it was 63.2% for patients with 1 factor, 53.4% for patients with 2 factors, and 46.5% for patients with all 3 factors (P<0.001).

The researchers did find that Hispanic and non-Hispanic black individuals had more adverse sociodemographic factors and worse OS than non-Hispanic whites and people belonging to the “other” category.

However, when the population was stratified by the cumulative number of sociodemographic factors and the researchers adjusted for confounders, there was no consistent association between race/ethnicity and OS.

The researchers said this suggests the apparent impact of race/ethnicity on OS may be due to the disparate distribution of sociodemographic factors observed among the different races/ethnicities rather than the race/ethnicity construct itself.

“This [study] strongly suggests that there is a huge disparity in outcomes that could potentially be overcome by improving access and affordability of treatments,” Dr Costa said.

“With the recent emphasis on comparative effectiveness in oncology, it also becomes crucial that all variables affecting outcomes—including sociodemographic factors—are accounted for when comparisons between different therapeutic approaches and healthcare systems are made.”

Doctors examine a patient

Photo courtesy of NCI

New research has revealed sociodemographic factors that appear to influence survival in younger patients with multiple myeloma (MM).

The study, which included more than 10,000 MM patients under the age of 65, suggested that marital status, insurance status, and county-level income all affect a patient’s chance of survival.

However, race/ethnicity and county-level educational achievement were not associated with overall survival (OS).

Luciano Costa, MD, PhD, of the University of Alabama at Birmingham, and his colleagues reported these findings in Cancer.

The researchers analyzed data on patients who were diagnosed with MM before the age of 65, between 2007 and 2012. There were 10,161 cases of MM, and the median follow-up was 27 months (range, 0-71 months).

The sociodemographic variables assessed were marital status, insurance status, median household income in the county of residence, and county-level educational achievement.

The researchers also looked at race/ethnicity, which was defined as a self-reported construct including Hispanic, non-Hispanic black, non-Hispanic white, and “other.”

The researchers found that patients had an increased risk of death if they were not married, did not have private insurance (were uninsured or on Medicaid), or lived in a low-income area (belonging to the lowest 2 income quartiles).

The 4-year estimated OS rate was 71.1% for patients who did not have any of these adverse sociodemographic factors, but it was 63.2% for patients with 1 factor, 53.4% for patients with 2 factors, and 46.5% for patients with all 3 factors (P<0.001).

The researchers did find that Hispanic and non-Hispanic black individuals had more adverse sociodemographic factors and worse OS than non-Hispanic whites and people belonging to the “other” category.

However, when the population was stratified by the cumulative number of sociodemographic factors and the researchers adjusted for confounders, there was no consistent association between race/ethnicity and OS.

The researchers said this suggests the apparent impact of race/ethnicity on OS may be due to the disparate distribution of sociodemographic factors observed among the different races/ethnicities rather than the race/ethnicity construct itself.

“This [study] strongly suggests that there is a huge disparity in outcomes that could potentially be overcome by improving access and affordability of treatments,” Dr Costa said.

“With the recent emphasis on comparative effectiveness in oncology, it also becomes crucial that all variables affecting outcomes—including sociodemographic factors—are accounted for when comparisons between different therapeutic approaches and healthcare systems are made.”

Macrophage in a mouse

Image from Flickr

The US Food and Drug Administration (FDA) has granted orphan drug designation for dusquetide as a treatment for macrophage activation syndrome (MAS).

Dusquetide is an innate defense regulator, a new class of short, synthetic peptides that accelerate bacterial clearance and resolution of tissue damage while modulating inflammation following exposure to bacterial pathogens, radiation, chemotherapy, and other agents.

According to researchers, dusquetide has demonstrated preclinical efficacy and safety in several animal models.

In a mouse model of MAS, dusquetide was shown to reduce pancytopenia, inhibit IL-12 responses, and improve body weight maintenance.

SGX942, the drug product containing dusquetide, has demonstrated safety in a phase 1 study of 84 healthy volunteers.

In addition, SGX942 has demonstrated preliminary efficacy and safety in an exploratory phase 2 study of 111 patients with oral mucositis due to chemoradiation therapy for head and neck cancer.

SGX942 is being developed by Solgenix, Inc.

About orphan designation

The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.

The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the drug is approved.

About MAS

MAS is a life-threatening complication of rheumatic disease that, for unknown reasons, frequently occurs in individuals with systemic juvenile idiopathic arthritis. MAS also occurs in patients with systemic lupus erythematosus, Kawasaki disease, adult-onset Still’s disease, and various vasculitic syndromes.

MAS is characterized by pancytopenia, liver insufficiency, coagulopathy, and neurologic symptoms.

MAS is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and well-differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction. 

Macrophage in a mouse

Image from Flickr

The US Food and Drug Administration (FDA) has granted orphan drug designation for dusquetide as a treatment for macrophage activation syndrome (MAS).

Dusquetide is an innate defense regulator, a new class of short, synthetic peptides that accelerate bacterial clearance and resolution of tissue damage while modulating inflammation following exposure to bacterial pathogens, radiation, chemotherapy, and other agents.

According to researchers, dusquetide has demonstrated preclinical efficacy and safety in several animal models.

In a mouse model of MAS, dusquetide was shown to reduce pancytopenia, inhibit IL-12 responses, and improve body weight maintenance.

SGX942, the drug product containing dusquetide, has demonstrated safety in a phase 1 study of 84 healthy volunteers.

In addition, SGX942 has demonstrated preliminary efficacy and safety in an exploratory phase 2 study of 111 patients with oral mucositis due to chemoradiation therapy for head and neck cancer.

SGX942 is being developed by Solgenix, Inc.

About orphan designation

The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.

The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the drug is approved.

About MAS

MAS is a life-threatening complication of rheumatic disease that, for unknown reasons, frequently occurs in individuals with systemic juvenile idiopathic arthritis. MAS also occurs in patients with systemic lupus erythematosus, Kawasaki disease, adult-onset Still’s disease, and various vasculitic syndromes.

MAS is characterized by pancytopenia, liver insufficiency, coagulopathy, and neurologic symptoms.

MAS is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and well-differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction. 

Macrophage in a mouse

Image from Flickr

The US Food and Drug Administration (FDA) has granted orphan drug designation for dusquetide as a treatment for macrophage activation syndrome (MAS).

Dusquetide is an innate defense regulator, a new class of short, synthetic peptides that accelerate bacterial clearance and resolution of tissue damage while modulating inflammation following exposure to bacterial pathogens, radiation, chemotherapy, and other agents.

According to researchers, dusquetide has demonstrated preclinical efficacy and safety in several animal models.

In a mouse model of MAS, dusquetide was shown to reduce pancytopenia, inhibit IL-12 responses, and improve body weight maintenance.

SGX942, the drug product containing dusquetide, has demonstrated safety in a phase 1 study of 84 healthy volunteers.

In addition, SGX942 has demonstrated preliminary efficacy and safety in an exploratory phase 2 study of 111 patients with oral mucositis due to chemoradiation therapy for head and neck cancer.

SGX942 is being developed by Solgenix, Inc.

About orphan designation

The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.

The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the drug is approved.

About MAS

MAS is a life-threatening complication of rheumatic disease that, for unknown reasons, frequently occurs in individuals with systemic juvenile idiopathic arthritis. MAS also occurs in patients with systemic lupus erythematosus, Kawasaki disease, adult-onset Still’s disease, and various vasculitic syndromes.

MAS is characterized by pancytopenia, liver insufficiency, coagulopathy, and neurologic symptoms.

MAS is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and well-differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction.