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Dr. Geeta Arora is a locum tenens hospitalist; James Levy is a PA who hires locums as the VP of Human Resources for Indigo Health Partners in Northern Michigan. They share their experiences navigating "freelance hospital medicine," from both the medical practice and business perspective.

Dr. Geeta Arora is a locum tenens hospitalist; James Levy is a PA who hires locums as the VP of Human Resources for Indigo Health Partners in Northern Michigan. They share their experiences navigating "freelance hospital medicine," from both the medical practice and business perspective.

Dr. Geeta Arora is a locum tenens hospitalist; James Levy is a PA who hires locums as the VP of Human Resources for Indigo Health Partners in Northern Michigan. They share their experiences navigating "freelance hospital medicine," from both the medical practice and business perspective.

Only 1% of adults with asymptomatic neoplastic pancreatic cysts developed invasive pancreatic adenocarcinoma after more than 5 years of follow-up, according to a multicenter retrospective study reported in the June issue of Clinical Gastroenterology and Hepatology.

©iStock / ThinkStockPhotos.com

Furthermore, there were no malignant conversions among patients lacking American Gastroenterological Association high-risk features – that is, mural nodules, dilated pancreatic ducts, or cysts measuring more than 3 cm, said Dr. Wilson Kwong at the University of California San Diego Health Sciences in La Jolla. “There is a very low risk of malignant transformation of asymptomatic neoplastic pancreatic cysts after 5 years,” he and his associates wrote.

Up to 20% of cross-sectional imaging studies reveal incidental pancreatic cysts, the researchers noted. Cysts with neoplastic features are recommended for indefinite surveillance, even though there is little or no data on their natural history and malignant potential beyond 5- 10 years, they added. Therefore, they studied 310 patients who underwent endoscopic ultrasound of pancreatic cysts at an academic medical center, a Veterans’ Affairs hospital, and two community health care systems in California between 2002 and 2010. The most common age at enrollment was 66 years, 60% of patients were women, and the median follow-up period was 87 months (range, 60 to 189 months). A total of 90% of patients were followed for 5-10 years, while 10% were followed for more than 10 years (Clin Gastroenterol Hepatol. 2016 Feb 10. doi: 10.1016/j.cgh.2015.11.013).

Source: American Gastroenterological Association

In all, three patients developed invasive pancreatic malignancies after 6, 8, and 11 years of follow-up, for an overall conversion rate of 1%. Conversion rates by subgroup were 0% for patients with no high-risk AGA features, 1% (one case) for patients with one high-risk feature, and 15% (two cases) for patients with two high-risk features. “Because the risk of malignant transformation beyond 5 years is lower than the 1.4% mortality risk of pancreatic resection at high-volume centers, the argument can be made that discontinuing surveillance after 5 years is justified,” the researchers said. Specifically, surveillance could be discontinued after 5 years for neoplastic pancreatic cysts with up to one high-risk feature, particularly if patients have significant comorbidities that increase their risk of imminent death from other causes, they added. In contrast, healthy patients in their 60s and 70s might benefit from long-term surveillance given their longer life expectancy, they said. “Among patients with two high-risk features who remain surgically fit, discussion of surgery or surveillance beyond 5 years should be considered,” they emphasized.

A total of two patients developed high-grade dysplasia – a risk factor for invasive pancreatic cancer – but even so, the aggregate rate of cancer and high-grade dysplasia was 1.6%, only slightly higher than the fatality rate associated with pancreatic resection, the researchers noted. By excluding patients with recent acute pancreatitis (because of the likelihood of pseudocysts), they might have inadvertently excluded “a small number” of patients with pancreatic intraductal papillary mucinous neoplasms, they added.

The University of California San Diego Health Care System supported the study. The investigators had no disclosures.

Only 1% of adults with asymptomatic neoplastic pancreatic cysts developed invasive pancreatic adenocarcinoma after more than 5 years of follow-up, according to a multicenter retrospective study reported in the June issue of Clinical Gastroenterology and Hepatology.

©iStock / ThinkStockPhotos.com

Furthermore, there were no malignant conversions among patients lacking American Gastroenterological Association high-risk features – that is, mural nodules, dilated pancreatic ducts, or cysts measuring more than 3 cm, said Dr. Wilson Kwong at the University of California San Diego Health Sciences in La Jolla. “There is a very low risk of malignant transformation of asymptomatic neoplastic pancreatic cysts after 5 years,” he and his associates wrote.

Up to 20% of cross-sectional imaging studies reveal incidental pancreatic cysts, the researchers noted. Cysts with neoplastic features are recommended for indefinite surveillance, even though there is little or no data on their natural history and malignant potential beyond 5- 10 years, they added. Therefore, they studied 310 patients who underwent endoscopic ultrasound of pancreatic cysts at an academic medical center, a Veterans’ Affairs hospital, and two community health care systems in California between 2002 and 2010. The most common age at enrollment was 66 years, 60% of patients were women, and the median follow-up period was 87 months (range, 60 to 189 months). A total of 90% of patients were followed for 5-10 years, while 10% were followed for more than 10 years (Clin Gastroenterol Hepatol. 2016 Feb 10. doi: 10.1016/j.cgh.2015.11.013).

Source: American Gastroenterological Association

In all, three patients developed invasive pancreatic malignancies after 6, 8, and 11 years of follow-up, for an overall conversion rate of 1%. Conversion rates by subgroup were 0% for patients with no high-risk AGA features, 1% (one case) for patients with one high-risk feature, and 15% (two cases) for patients with two high-risk features. “Because the risk of malignant transformation beyond 5 years is lower than the 1.4% mortality risk of pancreatic resection at high-volume centers, the argument can be made that discontinuing surveillance after 5 years is justified,” the researchers said. Specifically, surveillance could be discontinued after 5 years for neoplastic pancreatic cysts with up to one high-risk feature, particularly if patients have significant comorbidities that increase their risk of imminent death from other causes, they added. In contrast, healthy patients in their 60s and 70s might benefit from long-term surveillance given their longer life expectancy, they said. “Among patients with two high-risk features who remain surgically fit, discussion of surgery or surveillance beyond 5 years should be considered,” they emphasized.

A total of two patients developed high-grade dysplasia – a risk factor for invasive pancreatic cancer – but even so, the aggregate rate of cancer and high-grade dysplasia was 1.6%, only slightly higher than the fatality rate associated with pancreatic resection, the researchers noted. By excluding patients with recent acute pancreatitis (because of the likelihood of pseudocysts), they might have inadvertently excluded “a small number” of patients with pancreatic intraductal papillary mucinous neoplasms, they added.

The University of California San Diego Health Care System supported the study. The investigators had no disclosures.

Only 1% of adults with asymptomatic neoplastic pancreatic cysts developed invasive pancreatic adenocarcinoma after more than 5 years of follow-up, according to a multicenter retrospective study reported in the June issue of Clinical Gastroenterology and Hepatology.

©iStock / ThinkStockPhotos.com

Furthermore, there were no malignant conversions among patients lacking American Gastroenterological Association high-risk features – that is, mural nodules, dilated pancreatic ducts, or cysts measuring more than 3 cm, said Dr. Wilson Kwong at the University of California San Diego Health Sciences in La Jolla. “There is a very low risk of malignant transformation of asymptomatic neoplastic pancreatic cysts after 5 years,” he and his associates wrote.

Up to 20% of cross-sectional imaging studies reveal incidental pancreatic cysts, the researchers noted. Cysts with neoplastic features are recommended for indefinite surveillance, even though there is little or no data on their natural history and malignant potential beyond 5- 10 years, they added. Therefore, they studied 310 patients who underwent endoscopic ultrasound of pancreatic cysts at an academic medical center, a Veterans’ Affairs hospital, and two community health care systems in California between 2002 and 2010. The most common age at enrollment was 66 years, 60% of patients were women, and the median follow-up period was 87 months (range, 60 to 189 months). A total of 90% of patients were followed for 5-10 years, while 10% were followed for more than 10 years (Clin Gastroenterol Hepatol. 2016 Feb 10. doi: 10.1016/j.cgh.2015.11.013).

Source: American Gastroenterological Association

In all, three patients developed invasive pancreatic malignancies after 6, 8, and 11 years of follow-up, for an overall conversion rate of 1%. Conversion rates by subgroup were 0% for patients with no high-risk AGA features, 1% (one case) for patients with one high-risk feature, and 15% (two cases) for patients with two high-risk features. “Because the risk of malignant transformation beyond 5 years is lower than the 1.4% mortality risk of pancreatic resection at high-volume centers, the argument can be made that discontinuing surveillance after 5 years is justified,” the researchers said. Specifically, surveillance could be discontinued after 5 years for neoplastic pancreatic cysts with up to one high-risk feature, particularly if patients have significant comorbidities that increase their risk of imminent death from other causes, they added. In contrast, healthy patients in their 60s and 70s might benefit from long-term surveillance given their longer life expectancy, they said. “Among patients with two high-risk features who remain surgically fit, discussion of surgery or surveillance beyond 5 years should be considered,” they emphasized.

A total of two patients developed high-grade dysplasia – a risk factor for invasive pancreatic cancer – but even so, the aggregate rate of cancer and high-grade dysplasia was 1.6%, only slightly higher than the fatality rate associated with pancreatic resection, the researchers noted. By excluding patients with recent acute pancreatitis (because of the likelihood of pseudocysts), they might have inadvertently excluded “a small number” of patients with pancreatic intraductal papillary mucinous neoplasms, they added.

The University of California San Diego Health Care System supported the study. The investigators had no disclosures.

BALTIMORE – The use of ex vivo lung perfusion (EVLP) may allow for the safe transplantation of lungs preserved for more than 12 hours, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.

A research team at the University of Toronto evaluated the outcomes of transplant patients who received a lung with a preservation time of over 12 hours between January 2006 and April 2015 and compared them to the general lung transplant population. Median hospital and ICU length of stay were similar between the two groups, and Kaplan-Meier survival curves between the two groups did not show any difference. Preservation time, donor P_O2, and use of EVLP were not significant variables affecting survival.

Dr. Bartley P. Griffith, chief of cardiac surgery at the University of Maryland, Baltimore, and a discussant on the paper at the meeting, said that the findings of the study open up the possibility of a more “planned” approach to transplantation.

“Anything that not only extends preservation time, but perhaps even improves quality of preservation, would be a godsend,” Dr. Griffith said in a video interview. He cautioned that the “devil is in the details,” and that the data had to be examined closely. Nevertheless, Dr. Griffith said transplant surgeons should be grateful for the important work done by the University of Toronto team.

Dr. Griffith reported no relevant financial disclosures.

[email protected]

On Twitter @richpizzi

BALTIMORE – The use of ex vivo lung perfusion (EVLP) may allow for the safe transplantation of lungs preserved for more than 12 hours, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.

A research team at the University of Toronto evaluated the outcomes of transplant patients who received a lung with a preservation time of over 12 hours between January 2006 and April 2015 and compared them to the general lung transplant population. Median hospital and ICU length of stay were similar between the two groups, and Kaplan-Meier survival curves between the two groups did not show any difference. Preservation time, donor P_O2, and use of EVLP were not significant variables affecting survival.

Dr. Bartley P. Griffith, chief of cardiac surgery at the University of Maryland, Baltimore, and a discussant on the paper at the meeting, said that the findings of the study open up the possibility of a more “planned” approach to transplantation.

“Anything that not only extends preservation time, but perhaps even improves quality of preservation, would be a godsend,” Dr. Griffith said in a video interview. He cautioned that the “devil is in the details,” and that the data had to be examined closely. Nevertheless, Dr. Griffith said transplant surgeons should be grateful for the important work done by the University of Toronto team.

Dr. Griffith reported no relevant financial disclosures.

[email protected]

On Twitter @richpizzi

BALTIMORE – The use of ex vivo lung perfusion (EVLP) may allow for the safe transplantation of lungs preserved for more than 12 hours, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.

A research team at the University of Toronto evaluated the outcomes of transplant patients who received a lung with a preservation time of over 12 hours between January 2006 and April 2015 and compared them to the general lung transplant population. Median hospital and ICU length of stay were similar between the two groups, and Kaplan-Meier survival curves between the two groups did not show any difference. Preservation time, donor P_O2, and use of EVLP were not significant variables affecting survival.

Dr. Bartley P. Griffith, chief of cardiac surgery at the University of Maryland, Baltimore, and a discussant on the paper at the meeting, said that the findings of the study open up the possibility of a more “planned” approach to transplantation.

“Anything that not only extends preservation time, but perhaps even improves quality of preservation, would be a godsend,” Dr. Griffith said in a video interview. He cautioned that the “devil is in the details,” and that the data had to be examined closely. Nevertheless, Dr. Griffith said transplant surgeons should be grateful for the important work done by the University of Toronto team.

Dr. Griffith reported no relevant financial disclosures.

[email protected]

On Twitter @richpizzi

WASHINGTON – Hysterectomy has long been the first-line therapy for complex atypical endometrial hyperplasia in patients who don’t desire to preserve their fertility. Is it time to consider hormone treatment in a larger population of patients?

That’s the question that experts debated at the annual meeting of the American College of Obstetricians and Gynecologists.

Dr. Amanda Nickles Fader, associate professor and director of the Kelly Gynecologic Oncology Service* at the Johns Hopkins Hospital, Baltimore, said in an interview that changing patient demographics – particularly the growing number of overweight and obese women – are driving the need to consider the use of progestin in more cases. The obesity epidemic translates into younger women developing the condition, and it creates the potential for more complications in surgery, she said. Endometrial hyperplasia is very sensitive to hormone therapy, specifically progestin agents, with 75%-90% response rates with up-front treatment, Dr. Fader added.

But Dr. David Cohn, director of the division of gynecologic oncology at the Ohio State University, Columbus, said in an interview that surgery remains the standard of care because it is curative. Hormone treatment is appropriate in selected patients, but it is currently understudied and questions remain about the duration of treatment and about the type of hormones to use, he said.

Dr. Cohn and Dr. Fader both reported having no relevant financial disclosures.

[email protected]

On Twitter @maryellenny

 *Correction, 5/17/2016: An earlier version of this story misstated Dr. Fader's title. 

WASHINGTON – Hysterectomy has long been the first-line therapy for complex atypical endometrial hyperplasia in patients who don’t desire to preserve their fertility. Is it time to consider hormone treatment in a larger population of patients?

That’s the question that experts debated at the annual meeting of the American College of Obstetricians and Gynecologists.

Dr. Amanda Nickles Fader, associate professor and director of the Kelly Gynecologic Oncology Service* at the Johns Hopkins Hospital, Baltimore, said in an interview that changing patient demographics – particularly the growing number of overweight and obese women – are driving the need to consider the use of progestin in more cases. The obesity epidemic translates into younger women developing the condition, and it creates the potential for more complications in surgery, she said. Endometrial hyperplasia is very sensitive to hormone therapy, specifically progestin agents, with 75%-90% response rates with up-front treatment, Dr. Fader added.

But Dr. David Cohn, director of the division of gynecologic oncology at the Ohio State University, Columbus, said in an interview that surgery remains the standard of care because it is curative. Hormone treatment is appropriate in selected patients, but it is currently understudied and questions remain about the duration of treatment and about the type of hormones to use, he said.

Dr. Cohn and Dr. Fader both reported having no relevant financial disclosures.

[email protected]

On Twitter @maryellenny

 *Correction, 5/17/2016: An earlier version of this story misstated Dr. Fader's title. 

WASHINGTON – Hysterectomy has long been the first-line therapy for complex atypical endometrial hyperplasia in patients who don’t desire to preserve their fertility. Is it time to consider hormone treatment in a larger population of patients?

That’s the question that experts debated at the annual meeting of the American College of Obstetricians and Gynecologists.

Dr. Amanda Nickles Fader, associate professor and director of the Kelly Gynecologic Oncology Service* at the Johns Hopkins Hospital, Baltimore, said in an interview that changing patient demographics – particularly the growing number of overweight and obese women – are driving the need to consider the use of progestin in more cases. The obesity epidemic translates into younger women developing the condition, and it creates the potential for more complications in surgery, she said. Endometrial hyperplasia is very sensitive to hormone therapy, specifically progestin agents, with 75%-90% response rates with up-front treatment, Dr. Fader added.

But Dr. David Cohn, director of the division of gynecologic oncology at the Ohio State University, Columbus, said in an interview that surgery remains the standard of care because it is curative. Hormone treatment is appropriate in selected patients, but it is currently understudied and questions remain about the duration of treatment and about the type of hormones to use, he said.

Dr. Cohn and Dr. Fader both reported having no relevant financial disclosures.

[email protected]

On Twitter @maryellenny

 *Correction, 5/17/2016: An earlier version of this story misstated Dr. Fader's title. 

Drs. Vineet Arora and Hyung "Harry" Cho offer  insight on how mentorship—giving, and receiving—is an essential part of all stages of an hospitalist career, in academic or community-based HM.

Drs. Vineet Arora and Hyung "Harry" Cho offer  insight on how mentorship—giving, and receiving—is an essential part of all stages of an hospitalist career, in academic or community-based HM.

Drs. Vineet Arora and Hyung "Harry" Cho offer  insight on how mentorship—giving, and receiving—is an essential part of all stages of an hospitalist career, in academic or community-based HM.

Two academic hospitalists talk about why they teach, what they're learning from their students, and what they see as the future of hospital medicine. Since academic HM is the new-hospitalist pipeline, hearing what they're seeing in their student and resident trainee corps is a snapshot of HM's sustainability.

Two academic hospitalists talk about why they teach, what they're learning from their students, and what they see as the future of hospital medicine. Since academic HM is the new-hospitalist pipeline, hearing what they're seeing in their student and resident trainee corps is a snapshot of HM's sustainability.

Two academic hospitalists talk about why they teach, what they're learning from their students, and what they see as the future of hospital medicine. Since academic HM is the new-hospitalist pipeline, hearing what they're seeing in their student and resident trainee corps is a snapshot of HM's sustainability.