Mixed Topics

A massive collaborative project spanning four continents and 744 research centers has revealed driver mutations in both protein-coding and noncoding regions of 38 cancer types.

Pan-Cancer Analysis of Whole Genomes

The Pan-Cancer Analysis of Whole Genomes (PCAWG) is an integrative analysis of the whole-genome sequences from 2,658 donors across 38 common tumor types. The findings are expected to add exponentially to what’s currently known about the complex genetics of cancer, and they point to possible strategies for improving cancer prevention, diagnosis, and care.

Six articles summarizing the findings are presented in a series of papers in Nature, and 16 more appear in affiliated publications.

“It’s humbling that it was only 14 years ago that the genomics community sequenced its very first cancer exome, and it was able to identify mutations within the roughly 20,000 protein-coding genes in the human cell,” investigator Lincoln Stein, MD, PhD, of the Ontario Institute for Cancer Research in Toronto, said in a telephone briefing.

Exome sequencing, however, covers only protein-coding genomic regions, which constitute only about 1% of the entire genome, “so assembling an accurate portrait of the cancer genome using just the exome data is like trying to put together a 100,000-piece jigsaw puzzle when you’re missing 99% of the pieces and there’s no puzzle box with a completed picture to guide you,” Dr. Stein said.

Members of the PCAWG from centers in North America, Europe, Asia, and Australia screened 2,658 whole-cancer genomes and matched samples of noncancerous tissues from the same individuals, along with 1,188 transcriptomes cataloging the sequences and expression of RNA transcripts in a given tumor. The 6-year project netted more than 800 terabytes of genomic data, roughly equivalent to the digital holdings of the U.S. Library of Congress multiplied by 11.

The findings are summarized in papers focusing on cancer drivers, noncoding changes, mutational signatures, structural variants, cancer evolution over time, and RNA alterations.
 

Driver mutations

Investigators found that the average cancer genome contains four or five driver mutations located in both coding and noncoding regions. They also found, however, that in approximately 5% of cases no driver mutations could be identified.

A substantial proportion of tumors displayed “hallmarks of genomic catastrophes.” About 22% of tumors exhibited chromothripsis, a mutational process marked by hundreds or even thousands of clustered chromosomal rearrangements. About 18% showed chromoplexy, which is characterized by scattering and rearrangement of multiple strands of DNA from one or more chromosomes.

Analyzing driver point mutations and structural variants in noncoding regions, the investigators found the usual suspects – previously reported culprits – as well as novel candidates.

For example, they identified point mutations in the five prime region of the tumor suppressor gene TP53 and the three prime untranslated regions of NFKBIZ (a nuclear factor kappa B inhibitor) and TOB1 (an antiproliferative protein), focal deletion in BRD4 (a transcriptional and epigenetic regulator), and rearrangements in chromosomal loci in members of the AKR1C family of enzymes thought to play a role in disease progression.

In addition, investigators identified mutations in noncoding regions of TERT, a telomerase gene. These mutations result in ramped-up expression of telomerase, which in turn promotes uncontrollable division of tumor cells.
 

Mutational signatures

In a related line of research, PCAWG investigators identified new DNA mutational signatures ranging from single nucleotide polymorphisms to insertions and deletions, as well as to structural variants – rearrangements of large sections of the genome.

“The substantial size of our dataset, compared with previous analyses, enabled the discovery of new signatures, the separation of overlapping signatures, and the decomposition of signatures into components that may represent associated – but distinct – DNA damage, repair, and/or replication mechanisms. By estimating the contribution of each signature to the mutational catalogs of individual cancer genomes, we revealed associations of signatures to exogenous or endogenous exposures, as well as to defective DNA maintenance processes,” the investigators wrote.

They also acknowledged, however, that “many signatures are of unknown cause.”
 

Cancer evolution

One of the six main studies focused on the evolution of cancer over time. Instead of providing a “snapshot” of the genome as captured by sequencing tissue from a single biopsy, consortium investigators created full-length features of the “life history and evolution of mutational processes and driver mutation sequences.”

They found that early cancer development was marked by relatively few mutations in driver genes and by identifiable copy-number gains, including trisomy 7 in glioblastoma, and an abnormal mirroring of the arms (isochromosome) of chromosome 17 in medulloblastoma.

In 40% of the samples, however, there were significant changes in the mutational spectrum as the cancers grew, leading to a near quadrupling of driver genes and increased genomic instability in later-stage tumors.

“Copy-number alterations often occur in mitotic crises and lead to simultaneous gains of chromosomal segments,” the investigators wrote. “Timing analyses suggest that driver mutations often precede diagnosis by many years, if not decades. Together, these results determine the evolutionary trajectories of cancer and highlight opportunities for early cancer detection.”
 

Implications for cancer care

“When I used to treat patients with cancer, I was always completely amazed and puzzled by how two patients could have what looked like the same tumor. It would look the same under the microscope, have the same size, and the two patients would receive exactly the same treatment, but the two patients would have completely opposite outcomes; one would survive, and one would die. What this analysis … has done is really laid bare the reasons for that unpredictability in clinical outcomes,” Peter Campbell, MD, PhD, of the Wellcome Sanger Institute in Hinxton, England, said during the telebriefing.

“The most striking finding out of all of the suite of papers is just how different one person’s cancer genome is from another person’s. We see thousands of different combinations of mutations that can cause the cancer, and more than 80 different underlying processes generating the mutations in a cancer, and that leads to very different shapes and patterns in the genome that result,” he added.

On a positive note, the research shows that one or more driver mutations can be identified in about 95% of all cancer patients, and it elucidates the sequence of events leading to oncogenesis and tumor evolution, providing opportunities for earlier identification and potential interventions to prevent cancer, Dr. Campbell said.

The PCAWG was a collaborative multinational effort with multiple funding sources and many investigators.

SOURCE: Nature. 2020 Feb 5. https://www.nature.com/collections/pcawg/

A massive collaborative project spanning four continents and 744 research centers has revealed driver mutations in both protein-coding and noncoding regions of 38 cancer types.

Pan-Cancer Analysis of Whole Genomes

The Pan-Cancer Analysis of Whole Genomes (PCAWG) is an integrative analysis of the whole-genome sequences from 2,658 donors across 38 common tumor types. The findings are expected to add exponentially to what’s currently known about the complex genetics of cancer, and they point to possible strategies for improving cancer prevention, diagnosis, and care.

Six articles summarizing the findings are presented in a series of papers in Nature, and 16 more appear in affiliated publications.

“It’s humbling that it was only 14 years ago that the genomics community sequenced its very first cancer exome, and it was able to identify mutations within the roughly 20,000 protein-coding genes in the human cell,” investigator Lincoln Stein, MD, PhD, of the Ontario Institute for Cancer Research in Toronto, said in a telephone briefing.

Exome sequencing, however, covers only protein-coding genomic regions, which constitute only about 1% of the entire genome, “so assembling an accurate portrait of the cancer genome using just the exome data is like trying to put together a 100,000-piece jigsaw puzzle when you’re missing 99% of the pieces and there’s no puzzle box with a completed picture to guide you,” Dr. Stein said.

Members of the PCAWG from centers in North America, Europe, Asia, and Australia screened 2,658 whole-cancer genomes and matched samples of noncancerous tissues from the same individuals, along with 1,188 transcriptomes cataloging the sequences and expression of RNA transcripts in a given tumor. The 6-year project netted more than 800 terabytes of genomic data, roughly equivalent to the digital holdings of the U.S. Library of Congress multiplied by 11.

The findings are summarized in papers focusing on cancer drivers, noncoding changes, mutational signatures, structural variants, cancer evolution over time, and RNA alterations.
 

Driver mutations

Investigators found that the average cancer genome contains four or five driver mutations located in both coding and noncoding regions. They also found, however, that in approximately 5% of cases no driver mutations could be identified.

A substantial proportion of tumors displayed “hallmarks of genomic catastrophes.” About 22% of tumors exhibited chromothripsis, a mutational process marked by hundreds or even thousands of clustered chromosomal rearrangements. About 18% showed chromoplexy, which is characterized by scattering and rearrangement of multiple strands of DNA from one or more chromosomes.

Analyzing driver point mutations and structural variants in noncoding regions, the investigators found the usual suspects – previously reported culprits – as well as novel candidates.

For example, they identified point mutations in the five prime region of the tumor suppressor gene TP53 and the three prime untranslated regions of NFKBIZ (a nuclear factor kappa B inhibitor) and TOB1 (an antiproliferative protein), focal deletion in BRD4 (a transcriptional and epigenetic regulator), and rearrangements in chromosomal loci in members of the AKR1C family of enzymes thought to play a role in disease progression.

In addition, investigators identified mutations in noncoding regions of TERT, a telomerase gene. These mutations result in ramped-up expression of telomerase, which in turn promotes uncontrollable division of tumor cells.
 

Mutational signatures

In a related line of research, PCAWG investigators identified new DNA mutational signatures ranging from single nucleotide polymorphisms to insertions and deletions, as well as to structural variants – rearrangements of large sections of the genome.

“The substantial size of our dataset, compared with previous analyses, enabled the discovery of new signatures, the separation of overlapping signatures, and the decomposition of signatures into components that may represent associated – but distinct – DNA damage, repair, and/or replication mechanisms. By estimating the contribution of each signature to the mutational catalogs of individual cancer genomes, we revealed associations of signatures to exogenous or endogenous exposures, as well as to defective DNA maintenance processes,” the investigators wrote.

They also acknowledged, however, that “many signatures are of unknown cause.”
 

Cancer evolution

One of the six main studies focused on the evolution of cancer over time. Instead of providing a “snapshot” of the genome as captured by sequencing tissue from a single biopsy, consortium investigators created full-length features of the “life history and evolution of mutational processes and driver mutation sequences.”

They found that early cancer development was marked by relatively few mutations in driver genes and by identifiable copy-number gains, including trisomy 7 in glioblastoma, and an abnormal mirroring of the arms (isochromosome) of chromosome 17 in medulloblastoma.

In 40% of the samples, however, there were significant changes in the mutational spectrum as the cancers grew, leading to a near quadrupling of driver genes and increased genomic instability in later-stage tumors.

“Copy-number alterations often occur in mitotic crises and lead to simultaneous gains of chromosomal segments,” the investigators wrote. “Timing analyses suggest that driver mutations often precede diagnosis by many years, if not decades. Together, these results determine the evolutionary trajectories of cancer and highlight opportunities for early cancer detection.”
 

Implications for cancer care

“When I used to treat patients with cancer, I was always completely amazed and puzzled by how two patients could have what looked like the same tumor. It would look the same under the microscope, have the same size, and the two patients would receive exactly the same treatment, but the two patients would have completely opposite outcomes; one would survive, and one would die. What this analysis … has done is really laid bare the reasons for that unpredictability in clinical outcomes,” Peter Campbell, MD, PhD, of the Wellcome Sanger Institute in Hinxton, England, said during the telebriefing.

“The most striking finding out of all of the suite of papers is just how different one person’s cancer genome is from another person’s. We see thousands of different combinations of mutations that can cause the cancer, and more than 80 different underlying processes generating the mutations in a cancer, and that leads to very different shapes and patterns in the genome that result,” he added.

On a positive note, the research shows that one or more driver mutations can be identified in about 95% of all cancer patients, and it elucidates the sequence of events leading to oncogenesis and tumor evolution, providing opportunities for earlier identification and potential interventions to prevent cancer, Dr. Campbell said.

The PCAWG was a collaborative multinational effort with multiple funding sources and many investigators.

SOURCE: Nature. 2020 Feb 5. https://www.nature.com/collections/pcawg/

A massive collaborative project spanning four continents and 744 research centers has revealed driver mutations in both protein-coding and noncoding regions of 38 cancer types.

Pan-Cancer Analysis of Whole Genomes

The Pan-Cancer Analysis of Whole Genomes (PCAWG) is an integrative analysis of the whole-genome sequences from 2,658 donors across 38 common tumor types. The findings are expected to add exponentially to what’s currently known about the complex genetics of cancer, and they point to possible strategies for improving cancer prevention, diagnosis, and care.

Six articles summarizing the findings are presented in a series of papers in Nature, and 16 more appear in affiliated publications.

“It’s humbling that it was only 14 years ago that the genomics community sequenced its very first cancer exome, and it was able to identify mutations within the roughly 20,000 protein-coding genes in the human cell,” investigator Lincoln Stein, MD, PhD, of the Ontario Institute for Cancer Research in Toronto, said in a telephone briefing.

Exome sequencing, however, covers only protein-coding genomic regions, which constitute only about 1% of the entire genome, “so assembling an accurate portrait of the cancer genome using just the exome data is like trying to put together a 100,000-piece jigsaw puzzle when you’re missing 99% of the pieces and there’s no puzzle box with a completed picture to guide you,” Dr. Stein said.

Members of the PCAWG from centers in North America, Europe, Asia, and Australia screened 2,658 whole-cancer genomes and matched samples of noncancerous tissues from the same individuals, along with 1,188 transcriptomes cataloging the sequences and expression of RNA transcripts in a given tumor. The 6-year project netted more than 800 terabytes of genomic data, roughly equivalent to the digital holdings of the U.S. Library of Congress multiplied by 11.

The findings are summarized in papers focusing on cancer drivers, noncoding changes, mutational signatures, structural variants, cancer evolution over time, and RNA alterations.
 

Driver mutations

Investigators found that the average cancer genome contains four or five driver mutations located in both coding and noncoding regions. They also found, however, that in approximately 5% of cases no driver mutations could be identified.

A substantial proportion of tumors displayed “hallmarks of genomic catastrophes.” About 22% of tumors exhibited chromothripsis, a mutational process marked by hundreds or even thousands of clustered chromosomal rearrangements. About 18% showed chromoplexy, which is characterized by scattering and rearrangement of multiple strands of DNA from one or more chromosomes.

Analyzing driver point mutations and structural variants in noncoding regions, the investigators found the usual suspects – previously reported culprits – as well as novel candidates.

For example, they identified point mutations in the five prime region of the tumor suppressor gene TP53 and the three prime untranslated regions of NFKBIZ (a nuclear factor kappa B inhibitor) and TOB1 (an antiproliferative protein), focal deletion in BRD4 (a transcriptional and epigenetic regulator), and rearrangements in chromosomal loci in members of the AKR1C family of enzymes thought to play a role in disease progression.

In addition, investigators identified mutations in noncoding regions of TERT, a telomerase gene. These mutations result in ramped-up expression of telomerase, which in turn promotes uncontrollable division of tumor cells.
 

Mutational signatures

In a related line of research, PCAWG investigators identified new DNA mutational signatures ranging from single nucleotide polymorphisms to insertions and deletions, as well as to structural variants – rearrangements of large sections of the genome.

“The substantial size of our dataset, compared with previous analyses, enabled the discovery of new signatures, the separation of overlapping signatures, and the decomposition of signatures into components that may represent associated – but distinct – DNA damage, repair, and/or replication mechanisms. By estimating the contribution of each signature to the mutational catalogs of individual cancer genomes, we revealed associations of signatures to exogenous or endogenous exposures, as well as to defective DNA maintenance processes,” the investigators wrote.

They also acknowledged, however, that “many signatures are of unknown cause.”
 

Cancer evolution

One of the six main studies focused on the evolution of cancer over time. Instead of providing a “snapshot” of the genome as captured by sequencing tissue from a single biopsy, consortium investigators created full-length features of the “life history and evolution of mutational processes and driver mutation sequences.”

They found that early cancer development was marked by relatively few mutations in driver genes and by identifiable copy-number gains, including trisomy 7 in glioblastoma, and an abnormal mirroring of the arms (isochromosome) of chromosome 17 in medulloblastoma.

In 40% of the samples, however, there were significant changes in the mutational spectrum as the cancers grew, leading to a near quadrupling of driver genes and increased genomic instability in later-stage tumors.

“Copy-number alterations often occur in mitotic crises and lead to simultaneous gains of chromosomal segments,” the investigators wrote. “Timing analyses suggest that driver mutations often precede diagnosis by many years, if not decades. Together, these results determine the evolutionary trajectories of cancer and highlight opportunities for early cancer detection.”
 

Implications for cancer care

“When I used to treat patients with cancer, I was always completely amazed and puzzled by how two patients could have what looked like the same tumor. It would look the same under the microscope, have the same size, and the two patients would receive exactly the same treatment, but the two patients would have completely opposite outcomes; one would survive, and one would die. What this analysis … has done is really laid bare the reasons for that unpredictability in clinical outcomes,” Peter Campbell, MD, PhD, of the Wellcome Sanger Institute in Hinxton, England, said during the telebriefing.

“The most striking finding out of all of the suite of papers is just how different one person’s cancer genome is from another person’s. We see thousands of different combinations of mutations that can cause the cancer, and more than 80 different underlying processes generating the mutations in a cancer, and that leads to very different shapes and patterns in the genome that result,” he added.

On a positive note, the research shows that one or more driver mutations can be identified in about 95% of all cancer patients, and it elucidates the sequence of events leading to oncogenesis and tumor evolution, providing opportunities for earlier identification and potential interventions to prevent cancer, Dr. Campbell said.

The PCAWG was a collaborative multinational effort with multiple funding sources and many investigators.

SOURCE: Nature. 2020 Feb 5. https://www.nature.com/collections/pcawg/

The first international public survey on cancer perceptions and attitudes in a decade shows that, in spite of progress, low socioeconomic status and lack of education continue to jeopardize the health of the world’s most vulnerable populations.

The survey was commissioned by the Union for International Cancer Control (UICC) to mark the 20th anniversary of World Cancer Day on Feb. 4, 2020.

The survey, which was conducted by Ipsos, was taken by more than 15,000 people in 20 countries. It shows that people of lower socioeconomic status are less likely than those in higher-income households to recognize the risk factors for cancer or to make lifestyle changes. With the exception of tobacco use, people with low educational attainment also showed less cancer awareness and were less likely to engage in preventive behaviors than those with a university degree.

It is “unacceptable that millions of people have a greater chance of developing cancer in their lifetime because they are simply not aware of the cancer risks to avoid and the healthy behaviors to adopt – information that many of us take for granted. And this is true around the world,” Cary Adams, MBA, CEO of the UICC, commented in a statement.

The survey was conducted from Oct. 25 to Nov., 2019, and included 15,427 participants from Australia, Bolivia, Brazil, Canada, China, France, Germany, Great Britain, India, Israel, Japan, Kenya, Mexico, the Philippines, Saudi Arabia, South Africa, Spain, Sweden, Turkey, and the United States.

The vast majority of those surveyed – 87% – said they were aware of the major risk factors for cancer, while only 6% said they were not.

The cancer risk factors that were most recognized were tobacco use (63%), ultraviolet light exposure (54%), and exposure to secondhand tobacco smoke (50%).

The cancer risks that were least recognized included being overweight (29%), a lack of exercise (28%), and exposure to certain viruses or bacteria (28%).

The difference in awareness across the social spectrum was striking. “Emerging from the survey are the apparent and glaring inequities faced by socioeconomically disadvantaged groups,” the authors said.

“Much more must be done to ensure that everyone has an equal chance to reduce their risk of preventable cancer,” commented Sonali Johnson, PhD, head of knowledge, advocacy, and policy at the UICC in Geneva, Switzerland.

“We’ve seen in the results that those surveyed with a lower education and those on lower incomes appear less aware of the main risk factors associated with cancer and thus are less likely to proactively take the steps needed to reduce their cancer risk as compared to those from a high income household or those with a university education,” Dr. Johnson said in an interview.

Does increased cancer awareness translate into behavioral change for the better? This question can only be answered by more research, the survey authors said. They reported that 7 of 10 survey respondents (69%) said they had made a behavioral change to reduce their cancer risk within the past 12 months. Most said they were eating more healthfully.

Slightly fewer than one-quarter reported that they had not taken any preventive measures in the past year.

When it comes to raising cancer awareness, World Cancer Day is “a powerful tool to remind every person that they can play a crucial role in reducing the impact of cancer,” said Dr. Johnson.
 

Health care providers are “crucial”

Reacting to the findings of the survey, the European Society for Medical Oncology (ESMO) emphasized the key role that physicians play in cancer prevention.

“Research speaks very clearly for prevention,” said ESMO President Solange Peters, MD, PhD. “With the number of cancer cases expected to rise to 29.5 million by 2040, we must act now. ESMO is committed to educating doctors on all aspects of cancer control, which should begin well before a cancer diagnosis.

“In the face of this emergency, which is rendered even more salient by the results of the report, we must work to enlarge the basis of doctors who are properly educated and trained in key prevention measures,” Dr. Peters added. “General practitioners and organ specialists are in the front line to guide and support patients on their quest for healthy lifestyles and reliable ways to detect cancer early.”

In a comment, Dr. Johnson acknowledged the role physicians play in health promotion and informing patients about noncommunicable disease risks, including those related to cancer. However, she emphasized that nurses, pharmacists, community health workers, midwives, and other health care providers who deliver primary care “are crucial around the world to imparting health information and offering services.”

Frontline health care workers can assess patients’ cancer knowledge and health literacy, determine the barriers to health care, and assess “how best to engage with people across the life course,” Dr. Johnson explained. “Rather than just focusing on physicians, we must work with all those involved in primary care, especially as primary care services are scaled up to achieve universal health coverage.”

Call on governments to do more

The authors noted that, although there is wide awareness of the cancer risks from tobacco use, adults younger than 35 years were less likely than those older than 50 to identify tobacco as a cancer risk factor. They described this finding as “most concerning” and said it “underscores the ongoing need to raise awareness about cancer risk factors in every new generation.”

Almost 60% of survey respondents, regardless of age, education, or income, expressed concern about being diagnosed with cancer in the future or having cancer recur.

In Kenya, where the death toll from cancer rose 30% from 2014 to 2018, people appeared to be the most worried about cancer, with four of five survey respondents (82%) expressing concern.

Survey respondents from Saudi Arabia appeared the least concerned, with one of three people saying they were worried.

Notably, 84% of survey respondents said that governments should be doing more to increase cancer prevention and awareness; 33% demanded that governments improve the affordability of cancer care.

“It is understandable that people turn to their governments for support,” Dr. Johnson commented. “Affordability is a big challenge for low-income settings.”

Data from the World Health Organization show that, for every U.S. $1 invested in low- and middle-income countries, the return is U.S. $3.20, Johnson pointed out. “We really need to convince decision makers ... and see the right investments being made. It is important to ensure that the health system strengthening takes place in tandem with prevention services.”

Governments have begun making commitments to tackle noncommunicable diseases and cancer, Dr. Johnson commented. He highlighted the WHO’s Global Action Plan for Healthy Lives and Well-being for All and the updated cancer resolution adopted at the 2017 World Health Assembly.

“Education, training, and awareness-raising efforts need to be backed by strong and progressive health policies that prioritize prevention and help reduce the consumption of known cancer-causing products such as tobacco, sugary food, and beverages,” she said. “Countries should also invest proactively in national cancer control planning and the establishment of population-based registries to ensure the most effective resource allocation that benefits all groups.”

Up-to-date information on cancer risks and cancer prevention must be delivered to the public in ways that are accessible to those in lower socioeconomic groups, Dr. Johnson added. “Awareness needs to be raised continuously with each new generation,” she noted.

The UICC has relationships with Astellas, Daiichi Sankyo, Diaceutics, MSD Inventing for Life, Bristol-Myers Squibb, CUBEBIO, the Icon Group, Roche, and Sanofi.

This article first appeared on Medscape.com.

The first international public survey on cancer perceptions and attitudes in a decade shows that, in spite of progress, low socioeconomic status and lack of education continue to jeopardize the health of the world’s most vulnerable populations.

The survey was commissioned by the Union for International Cancer Control (UICC) to mark the 20th anniversary of World Cancer Day on Feb. 4, 2020.

The survey, which was conducted by Ipsos, was taken by more than 15,000 people in 20 countries. It shows that people of lower socioeconomic status are less likely than those in higher-income households to recognize the risk factors for cancer or to make lifestyle changes. With the exception of tobacco use, people with low educational attainment also showed less cancer awareness and were less likely to engage in preventive behaviors than those with a university degree.

It is “unacceptable that millions of people have a greater chance of developing cancer in their lifetime because they are simply not aware of the cancer risks to avoid and the healthy behaviors to adopt – information that many of us take for granted. And this is true around the world,” Cary Adams, MBA, CEO of the UICC, commented in a statement.

The survey was conducted from Oct. 25 to Nov., 2019, and included 15,427 participants from Australia, Bolivia, Brazil, Canada, China, France, Germany, Great Britain, India, Israel, Japan, Kenya, Mexico, the Philippines, Saudi Arabia, South Africa, Spain, Sweden, Turkey, and the United States.

The vast majority of those surveyed – 87% – said they were aware of the major risk factors for cancer, while only 6% said they were not.

The cancer risk factors that were most recognized were tobacco use (63%), ultraviolet light exposure (54%), and exposure to secondhand tobacco smoke (50%).

The cancer risks that were least recognized included being overweight (29%), a lack of exercise (28%), and exposure to certain viruses or bacteria (28%).

The difference in awareness across the social spectrum was striking. “Emerging from the survey are the apparent and glaring inequities faced by socioeconomically disadvantaged groups,” the authors said.

“Much more must be done to ensure that everyone has an equal chance to reduce their risk of preventable cancer,” commented Sonali Johnson, PhD, head of knowledge, advocacy, and policy at the UICC in Geneva, Switzerland.

“We’ve seen in the results that those surveyed with a lower education and those on lower incomes appear less aware of the main risk factors associated with cancer and thus are less likely to proactively take the steps needed to reduce their cancer risk as compared to those from a high income household or those with a university education,” Dr. Johnson said in an interview.

Does increased cancer awareness translate into behavioral change for the better? This question can only be answered by more research, the survey authors said. They reported that 7 of 10 survey respondents (69%) said they had made a behavioral change to reduce their cancer risk within the past 12 months. Most said they were eating more healthfully.

Slightly fewer than one-quarter reported that they had not taken any preventive measures in the past year.

When it comes to raising cancer awareness, World Cancer Day is “a powerful tool to remind every person that they can play a crucial role in reducing the impact of cancer,” said Dr. Johnson.
 

Health care providers are “crucial”

Reacting to the findings of the survey, the European Society for Medical Oncology (ESMO) emphasized the key role that physicians play in cancer prevention.

“Research speaks very clearly for prevention,” said ESMO President Solange Peters, MD, PhD. “With the number of cancer cases expected to rise to 29.5 million by 2040, we must act now. ESMO is committed to educating doctors on all aspects of cancer control, which should begin well before a cancer diagnosis.

“In the face of this emergency, which is rendered even more salient by the results of the report, we must work to enlarge the basis of doctors who are properly educated and trained in key prevention measures,” Dr. Peters added. “General practitioners and organ specialists are in the front line to guide and support patients on their quest for healthy lifestyles and reliable ways to detect cancer early.”

In a comment, Dr. Johnson acknowledged the role physicians play in health promotion and informing patients about noncommunicable disease risks, including those related to cancer. However, she emphasized that nurses, pharmacists, community health workers, midwives, and other health care providers who deliver primary care “are crucial around the world to imparting health information and offering services.”

Frontline health care workers can assess patients’ cancer knowledge and health literacy, determine the barriers to health care, and assess “how best to engage with people across the life course,” Dr. Johnson explained. “Rather than just focusing on physicians, we must work with all those involved in primary care, especially as primary care services are scaled up to achieve universal health coverage.”

Call on governments to do more

The authors noted that, although there is wide awareness of the cancer risks from tobacco use, adults younger than 35 years were less likely than those older than 50 to identify tobacco as a cancer risk factor. They described this finding as “most concerning” and said it “underscores the ongoing need to raise awareness about cancer risk factors in every new generation.”

Almost 60% of survey respondents, regardless of age, education, or income, expressed concern about being diagnosed with cancer in the future or having cancer recur.

In Kenya, where the death toll from cancer rose 30% from 2014 to 2018, people appeared to be the most worried about cancer, with four of five survey respondents (82%) expressing concern.

Survey respondents from Saudi Arabia appeared the least concerned, with one of three people saying they were worried.

Notably, 84% of survey respondents said that governments should be doing more to increase cancer prevention and awareness; 33% demanded that governments improve the affordability of cancer care.

“It is understandable that people turn to their governments for support,” Dr. Johnson commented. “Affordability is a big challenge for low-income settings.”

Data from the World Health Organization show that, for every U.S. $1 invested in low- and middle-income countries, the return is U.S. $3.20, Johnson pointed out. “We really need to convince decision makers ... and see the right investments being made. It is important to ensure that the health system strengthening takes place in tandem with prevention services.”

Governments have begun making commitments to tackle noncommunicable diseases and cancer, Dr. Johnson commented. He highlighted the WHO’s Global Action Plan for Healthy Lives and Well-being for All and the updated cancer resolution adopted at the 2017 World Health Assembly.

“Education, training, and awareness-raising efforts need to be backed by strong and progressive health policies that prioritize prevention and help reduce the consumption of known cancer-causing products such as tobacco, sugary food, and beverages,” she said. “Countries should also invest proactively in national cancer control planning and the establishment of population-based registries to ensure the most effective resource allocation that benefits all groups.”

Up-to-date information on cancer risks and cancer prevention must be delivered to the public in ways that are accessible to those in lower socioeconomic groups, Dr. Johnson added. “Awareness needs to be raised continuously with each new generation,” she noted.

The UICC has relationships with Astellas, Daiichi Sankyo, Diaceutics, MSD Inventing for Life, Bristol-Myers Squibb, CUBEBIO, the Icon Group, Roche, and Sanofi.

This article first appeared on Medscape.com.

The first international public survey on cancer perceptions and attitudes in a decade shows that, in spite of progress, low socioeconomic status and lack of education continue to jeopardize the health of the world’s most vulnerable populations.

The survey was commissioned by the Union for International Cancer Control (UICC) to mark the 20th anniversary of World Cancer Day on Feb. 4, 2020.

The survey, which was conducted by Ipsos, was taken by more than 15,000 people in 20 countries. It shows that people of lower socioeconomic status are less likely than those in higher-income households to recognize the risk factors for cancer or to make lifestyle changes. With the exception of tobacco use, people with low educational attainment also showed less cancer awareness and were less likely to engage in preventive behaviors than those with a university degree.

It is “unacceptable that millions of people have a greater chance of developing cancer in their lifetime because they are simply not aware of the cancer risks to avoid and the healthy behaviors to adopt – information that many of us take for granted. And this is true around the world,” Cary Adams, MBA, CEO of the UICC, commented in a statement.

The survey was conducted from Oct. 25 to Nov., 2019, and included 15,427 participants from Australia, Bolivia, Brazil, Canada, China, France, Germany, Great Britain, India, Israel, Japan, Kenya, Mexico, the Philippines, Saudi Arabia, South Africa, Spain, Sweden, Turkey, and the United States.

The vast majority of those surveyed – 87% – said they were aware of the major risk factors for cancer, while only 6% said they were not.

The cancer risk factors that were most recognized were tobacco use (63%), ultraviolet light exposure (54%), and exposure to secondhand tobacco smoke (50%).

The cancer risks that were least recognized included being overweight (29%), a lack of exercise (28%), and exposure to certain viruses or bacteria (28%).

The difference in awareness across the social spectrum was striking. “Emerging from the survey are the apparent and glaring inequities faced by socioeconomically disadvantaged groups,” the authors said.

“Much more must be done to ensure that everyone has an equal chance to reduce their risk of preventable cancer,” commented Sonali Johnson, PhD, head of knowledge, advocacy, and policy at the UICC in Geneva, Switzerland.

“We’ve seen in the results that those surveyed with a lower education and those on lower incomes appear less aware of the main risk factors associated with cancer and thus are less likely to proactively take the steps needed to reduce their cancer risk as compared to those from a high income household or those with a university education,” Dr. Johnson said in an interview.

Does increased cancer awareness translate into behavioral change for the better? This question can only be answered by more research, the survey authors said. They reported that 7 of 10 survey respondents (69%) said they had made a behavioral change to reduce their cancer risk within the past 12 months. Most said they were eating more healthfully.

Slightly fewer than one-quarter reported that they had not taken any preventive measures in the past year.

When it comes to raising cancer awareness, World Cancer Day is “a powerful tool to remind every person that they can play a crucial role in reducing the impact of cancer,” said Dr. Johnson.
 

Health care providers are “crucial”

Reacting to the findings of the survey, the European Society for Medical Oncology (ESMO) emphasized the key role that physicians play in cancer prevention.

“Research speaks very clearly for prevention,” said ESMO President Solange Peters, MD, PhD. “With the number of cancer cases expected to rise to 29.5 million by 2040, we must act now. ESMO is committed to educating doctors on all aspects of cancer control, which should begin well before a cancer diagnosis.

“In the face of this emergency, which is rendered even more salient by the results of the report, we must work to enlarge the basis of doctors who are properly educated and trained in key prevention measures,” Dr. Peters added. “General practitioners and organ specialists are in the front line to guide and support patients on their quest for healthy lifestyles and reliable ways to detect cancer early.”

In a comment, Dr. Johnson acknowledged the role physicians play in health promotion and informing patients about noncommunicable disease risks, including those related to cancer. However, she emphasized that nurses, pharmacists, community health workers, midwives, and other health care providers who deliver primary care “are crucial around the world to imparting health information and offering services.”

Frontline health care workers can assess patients’ cancer knowledge and health literacy, determine the barriers to health care, and assess “how best to engage with people across the life course,” Dr. Johnson explained. “Rather than just focusing on physicians, we must work with all those involved in primary care, especially as primary care services are scaled up to achieve universal health coverage.”

Call on governments to do more

The authors noted that, although there is wide awareness of the cancer risks from tobacco use, adults younger than 35 years were less likely than those older than 50 to identify tobacco as a cancer risk factor. They described this finding as “most concerning” and said it “underscores the ongoing need to raise awareness about cancer risk factors in every new generation.”

Almost 60% of survey respondents, regardless of age, education, or income, expressed concern about being diagnosed with cancer in the future or having cancer recur.

In Kenya, where the death toll from cancer rose 30% from 2014 to 2018, people appeared to be the most worried about cancer, with four of five survey respondents (82%) expressing concern.

Survey respondents from Saudi Arabia appeared the least concerned, with one of three people saying they were worried.

Notably, 84% of survey respondents said that governments should be doing more to increase cancer prevention and awareness; 33% demanded that governments improve the affordability of cancer care.

“It is understandable that people turn to their governments for support,” Dr. Johnson commented. “Affordability is a big challenge for low-income settings.”

Data from the World Health Organization show that, for every U.S. $1 invested in low- and middle-income countries, the return is U.S. $3.20, Johnson pointed out. “We really need to convince decision makers ... and see the right investments being made. It is important to ensure that the health system strengthening takes place in tandem with prevention services.”

Governments have begun making commitments to tackle noncommunicable diseases and cancer, Dr. Johnson commented. He highlighted the WHO’s Global Action Plan for Healthy Lives and Well-being for All and the updated cancer resolution adopted at the 2017 World Health Assembly.

“Education, training, and awareness-raising efforts need to be backed by strong and progressive health policies that prioritize prevention and help reduce the consumption of known cancer-causing products such as tobacco, sugary food, and beverages,” she said. “Countries should also invest proactively in national cancer control planning and the establishment of population-based registries to ensure the most effective resource allocation that benefits all groups.”

Up-to-date information on cancer risks and cancer prevention must be delivered to the public in ways that are accessible to those in lower socioeconomic groups, Dr. Johnson added. “Awareness needs to be raised continuously with each new generation,” she noted.

The UICC has relationships with Astellas, Daiichi Sankyo, Diaceutics, MSD Inventing for Life, Bristol-Myers Squibb, CUBEBIO, the Icon Group, Roche, and Sanofi.

This article first appeared on Medscape.com.

The personal statement is a narrative written by an applicant to residency programs to discuss his/her interests. It is one of the few places in the residency application process where applicants can express their personalities.¹ Applicants believe the personal statement is an important opportunity to distinguish themselves from others, thus increasing their chances of successful matching, particularly in competitive specialties.^1,2

Dermatology is a highly competitive specialty, with 614 medical students applying for 440 total dermatology positions in 2016.³ According to the results of the 2016 National Resident Matching program director survey, 82% (27/33) of dermatology program directors reported that the personal statement was a factor in selecting applicants to interview. Furthermore, dermatology program directors, on average, rated personal statements as more important than the Medical Student Performance Evaluation/Dean’s Letter, US Medical Licensing Examination (USMLE) Step 2 scores, and class ranking/quartile.⁴

Prior studies have sought to evaluate the impact of personal statements on the application process. A 2014 study of personal statements submitted by dermatology residency applicants found that the prevalence of certain themes differed according to match outcome.⁵ However, some of the conclusions drawn in this study were not supported by the reported results or were based on low numbers of participants. The purpose of our study was to examine personal statements from applications to a dermatology program at a major academic institution. This study identified common themes in personal statements, allowing for an analysis of their association with successful matching into dermatology.

Methods

All applications to the dermatology residency program at UNC School of Medicine (Chapel Hill, North Carolina) during the 2012 application cycle (N=422) were eligible. All submitted personal statements (N=422) were included with all personal identifiers removed prior to analysis. The investigator (D.S.M.) was blinded to other Electronic Residency Application Service data and match outcome.

The investigator initially reviewed a small, randomly selected subset of 20 personal statements to identify characteristics and common themes. The investigator then analyzed each of the personal statements to quantify the frequency of each theme. All personal statements submitted to the dermatology residency program at UNC School of Medicine were analyzed in this manner. Dermatology match outcomes for each applicant were confirmed later using dermatology program websites.

Differences in the prevalence of common themes between matched and unmatched applicants were calculated. Analysis of variance tests were used to determine if the differences in prevalence were statistically significant (P≤.05).

Results

All 422 submitted personal statements were evaluated, with 308 personal statements from applicants who matched and 114 personal statements from unmatched applicants. The screening of the initial subset of 20 personal statements resulted in a total of 9 content themes. The prevalence of each theme among matched and unmatched applicants is shown in the Table.

The most common themes among both matched and unmatched groups were personal accomplishments or attributes and positive qualities of dermatology. The prevalence of certain themes varied between matched and unmatched groups. Dermatologic cases were discussed significantly more frequently in the matched group compared to the unmatched group (60.06% vs 46.49%, P=.013). Name-dropping was more prevalent in the unmatched group (37.72%) compared to the matched group (26.95%). This difference in prevalence reached statistical significance (P=.014). Religious influences also were discussed more frequently in the unmatched group (5.26%) vs the matched group (0.65%) with statistical significance (P=.002).

Comment

This study of 422 personal statements submitted to a major academic institution showed that certain themes were common in personal statements among both matched and unmatched applicants. These themes included personal accomplishments/attributes and positive qualities of dermatology. This finding is consistent with prior studies that show common themes in the personal statements of applicants across a wide variety of specialties, including dermatology, anesthesiology, pediatrics, general surgery, internal medicine, and radiology.^5-10 Most commonly, applicants feel the need to justify why they chose their particular specialty, with Olazagasti et al⁵ (N=332) reporting that 70% of submitted dermatology personal statements explained why the applicant chose dermatology.

Certain themes, however, varied in prevalence between matched and unmatched groups in our study. Discussion of dermatologic cases was significantly more prevalent in the matched group compared to the unmatched group (P=.013), possibly because dermatology faculty enjoy hearing about cases and how the applicant responds and interacts with the cases. These data suggest that matched applicants focus more on characteristics specific to the clinical aspects of dermatology.

Conversely, name-dropping was significantly more prevalent in the unmatched group (P=.014). Dermatology is a highly competitive specialty. In 2016, applicants who matched into dermatology had a mean USMLE Step 1 score of 249 with a mean number of 4.7 research experiences and 11.7 abstracts, presentations, or publications, which is higher than the average USMLE Step 1 score of 239 with a mean number of 3.8 research experiences and 8.7 abstracts, presentations, or publications for unmatched applicants.³ It is possible that residency selection committees may view name-dropping negatively if applicants choose to name-drop to strengthen their applications in comparison to more competitive candidates. Religious influences also were significantly more prevalent in the unmatched group (P=.002), but the overall frequency of religious influences was low (approximately 2% of all applicants).

The 422 personal statements examined in our study represent 83.1% of the total pool of applicants to postgraduate year 2 dermatology positions in 2012 (N=508).¹¹ Our data differed somewhat from an analysis of same-year dermatology personal statements of 65% of the national applicant pool.⁵ Olazagasti et al⁵ found that themes of a family member in medicine (more in unmatched), a desire to contribute to decreasing literature gap (more in matched), and a desire to better understand dermatologic pathophysiology (more in matched) to be statistically significant (P≤.05 for all). Unfortunately, these themes were found in a small number of applicants, with each being reported in less than 7%.⁵ Our study included 23% more unmatched candidates and likely better estimated potential significant differences between matched and unmatched applicants.

In the Results section, Olazagasti et al⁵ reported that matched applicants emphasized the study of cutaneous manifestations of systemic disease significantly more frequently than unmatched applicants. However, the P value in their report did not support this statement (P=.054). In addition, their Conclusion section discussed matched candidates including themes of “why dermatology” and unmatched candidates including a “personal story” as differences between groups. Again, their results did not show any statistical significance to support these recommendations.⁵ When providing medical student mentorship in a field as competitive as dermatology, faculty must be careful in giving accurate advice that, if at all possible, is supported by objective data rather than personal preference or anecdotes.

Our study was limited in that only personal statements of applicants to a single program in a specific specialty were analyzed. Applicants may have submitted personalized versions of their personal statements to specific schools, which may have biased the themes present in this subset of personal statements. Given these limitations, we are unable to determine if these results are generalizable to all dermatology residency applicants. Further limitation is that the analysis of personal statements is in itself a subjective process.

This study included a larger number of personal statements representing a larger proportion of the total pool of applicants in 2012 than prior studies examining personal statements of dermatology residency applicants. In addition, this study examined the ultimate dermatology match outcome for each applicant during the 2012 application cycle. Future investigations could explore the role of other factors in the residency selection process such as USMLE Step scores, community service, research experiences, and Alpha Omega Alpha Honor Medical Society status.

Conclusion

There are common themes in the personal statements of dermatology residency applicants, including personal accomplishments/attributes and positive qualities of dermatology. In addition, discussion of dermatologic cases was statistically more prevalent in applicants who ultimately matched, whereas name-dropping and religious influences were more prevalent in applicants who did not match. This information may be useful to effectively mentor medical students about the writing process for the personal statement. Further investigation is needed to explore these associations and the role of other aspects of the application in the residency selection process.

The personal statement is a narrative written by an applicant to residency programs to discuss his/her interests. It is one of the few places in the residency application process where applicants can express their personalities.¹ Applicants believe the personal statement is an important opportunity to distinguish themselves from others, thus increasing their chances of successful matching, particularly in competitive specialties.^1,2

Dermatology is a highly competitive specialty, with 614 medical students applying for 440 total dermatology positions in 2016.³ According to the results of the 2016 National Resident Matching program director survey, 82% (27/33) of dermatology program directors reported that the personal statement was a factor in selecting applicants to interview. Furthermore, dermatology program directors, on average, rated personal statements as more important than the Medical Student Performance Evaluation/Dean’s Letter, US Medical Licensing Examination (USMLE) Step 2 scores, and class ranking/quartile.⁴

Prior studies have sought to evaluate the impact of personal statements on the application process. A 2014 study of personal statements submitted by dermatology residency applicants found that the prevalence of certain themes differed according to match outcome.⁵ However, some of the conclusions drawn in this study were not supported by the reported results or were based on low numbers of participants. The purpose of our study was to examine personal statements from applications to a dermatology program at a major academic institution. This study identified common themes in personal statements, allowing for an analysis of their association with successful matching into dermatology.

Methods

All applications to the dermatology residency program at UNC School of Medicine (Chapel Hill, North Carolina) during the 2012 application cycle (N=422) were eligible. All submitted personal statements (N=422) were included with all personal identifiers removed prior to analysis. The investigator (D.S.M.) was blinded to other Electronic Residency Application Service data and match outcome.

The investigator initially reviewed a small, randomly selected subset of 20 personal statements to identify characteristics and common themes. The investigator then analyzed each of the personal statements to quantify the frequency of each theme. All personal statements submitted to the dermatology residency program at UNC School of Medicine were analyzed in this manner. Dermatology match outcomes for each applicant were confirmed later using dermatology program websites.

Differences in the prevalence of common themes between matched and unmatched applicants were calculated. Analysis of variance tests were used to determine if the differences in prevalence were statistically significant (P≤.05).

Results

All 422 submitted personal statements were evaluated, with 308 personal statements from applicants who matched and 114 personal statements from unmatched applicants. The screening of the initial subset of 20 personal statements resulted in a total of 9 content themes. The prevalence of each theme among matched and unmatched applicants is shown in the Table.

The most common themes among both matched and unmatched groups were personal accomplishments or attributes and positive qualities of dermatology. The prevalence of certain themes varied between matched and unmatched groups. Dermatologic cases were discussed significantly more frequently in the matched group compared to the unmatched group (60.06% vs 46.49%, P=.013). Name-dropping was more prevalent in the unmatched group (37.72%) compared to the matched group (26.95%). This difference in prevalence reached statistical significance (P=.014). Religious influences also were discussed more frequently in the unmatched group (5.26%) vs the matched group (0.65%) with statistical significance (P=.002).

Comment

This study of 422 personal statements submitted to a major academic institution showed that certain themes were common in personal statements among both matched and unmatched applicants. These themes included personal accomplishments/attributes and positive qualities of dermatology. This finding is consistent with prior studies that show common themes in the personal statements of applicants across a wide variety of specialties, including dermatology, anesthesiology, pediatrics, general surgery, internal medicine, and radiology.^5-10 Most commonly, applicants feel the need to justify why they chose their particular specialty, with Olazagasti et al⁵ (N=332) reporting that 70% of submitted dermatology personal statements explained why the applicant chose dermatology.

Certain themes, however, varied in prevalence between matched and unmatched groups in our study. Discussion of dermatologic cases was significantly more prevalent in the matched group compared to the unmatched group (P=.013), possibly because dermatology faculty enjoy hearing about cases and how the applicant responds and interacts with the cases. These data suggest that matched applicants focus more on characteristics specific to the clinical aspects of dermatology.

Conversely, name-dropping was significantly more prevalent in the unmatched group (P=.014). Dermatology is a highly competitive specialty. In 2016, applicants who matched into dermatology had a mean USMLE Step 1 score of 249 with a mean number of 4.7 research experiences and 11.7 abstracts, presentations, or publications, which is higher than the average USMLE Step 1 score of 239 with a mean number of 3.8 research experiences and 8.7 abstracts, presentations, or publications for unmatched applicants.³ It is possible that residency selection committees may view name-dropping negatively if applicants choose to name-drop to strengthen their applications in comparison to more competitive candidates. Religious influences also were significantly more prevalent in the unmatched group (P=.002), but the overall frequency of religious influences was low (approximately 2% of all applicants).

The 422 personal statements examined in our study represent 83.1% of the total pool of applicants to postgraduate year 2 dermatology positions in 2012 (N=508).¹¹ Our data differed somewhat from an analysis of same-year dermatology personal statements of 65% of the national applicant pool.⁵ Olazagasti et al⁵ found that themes of a family member in medicine (more in unmatched), a desire to contribute to decreasing literature gap (more in matched), and a desire to better understand dermatologic pathophysiology (more in matched) to be statistically significant (P≤.05 for all). Unfortunately, these themes were found in a small number of applicants, with each being reported in less than 7%.⁵ Our study included 23% more unmatched candidates and likely better estimated potential significant differences between matched and unmatched applicants.

In the Results section, Olazagasti et al⁵ reported that matched applicants emphasized the study of cutaneous manifestations of systemic disease significantly more frequently than unmatched applicants. However, the P value in their report did not support this statement (P=.054). In addition, their Conclusion section discussed matched candidates including themes of “why dermatology” and unmatched candidates including a “personal story” as differences between groups. Again, their results did not show any statistical significance to support these recommendations.⁵ When providing medical student mentorship in a field as competitive as dermatology, faculty must be careful in giving accurate advice that, if at all possible, is supported by objective data rather than personal preference or anecdotes.

Our study was limited in that only personal statements of applicants to a single program in a specific specialty were analyzed. Applicants may have submitted personalized versions of their personal statements to specific schools, which may have biased the themes present in this subset of personal statements. Given these limitations, we are unable to determine if these results are generalizable to all dermatology residency applicants. Further limitation is that the analysis of personal statements is in itself a subjective process.

This study included a larger number of personal statements representing a larger proportion of the total pool of applicants in 2012 than prior studies examining personal statements of dermatology residency applicants. In addition, this study examined the ultimate dermatology match outcome for each applicant during the 2012 application cycle. Future investigations could explore the role of other factors in the residency selection process such as USMLE Step scores, community service, research experiences, and Alpha Omega Alpha Honor Medical Society status.

Conclusion

There are common themes in the personal statements of dermatology residency applicants, including personal accomplishments/attributes and positive qualities of dermatology. In addition, discussion of dermatologic cases was statistically more prevalent in applicants who ultimately matched, whereas name-dropping and religious influences were more prevalent in applicants who did not match. This information may be useful to effectively mentor medical students about the writing process for the personal statement. Further investigation is needed to explore these associations and the role of other aspects of the application in the residency selection process.

The personal statement is a narrative written by an applicant to residency programs to discuss his/her interests. It is one of the few places in the residency application process where applicants can express their personalities.¹ Applicants believe the personal statement is an important opportunity to distinguish themselves from others, thus increasing their chances of successful matching, particularly in competitive specialties.^1,2

Dermatology is a highly competitive specialty, with 614 medical students applying for 440 total dermatology positions in 2016.³ According to the results of the 2016 National Resident Matching program director survey, 82% (27/33) of dermatology program directors reported that the personal statement was a factor in selecting applicants to interview. Furthermore, dermatology program directors, on average, rated personal statements as more important than the Medical Student Performance Evaluation/Dean’s Letter, US Medical Licensing Examination (USMLE) Step 2 scores, and class ranking/quartile.⁴

Prior studies have sought to evaluate the impact of personal statements on the application process. A 2014 study of personal statements submitted by dermatology residency applicants found that the prevalence of certain themes differed according to match outcome.⁵ However, some of the conclusions drawn in this study were not supported by the reported results or were based on low numbers of participants. The purpose of our study was to examine personal statements from applications to a dermatology program at a major academic institution. This study identified common themes in personal statements, allowing for an analysis of their association with successful matching into dermatology.

Methods

All applications to the dermatology residency program at UNC School of Medicine (Chapel Hill, North Carolina) during the 2012 application cycle (N=422) were eligible. All submitted personal statements (N=422) were included with all personal identifiers removed prior to analysis. The investigator (D.S.M.) was blinded to other Electronic Residency Application Service data and match outcome.

The investigator initially reviewed a small, randomly selected subset of 20 personal statements to identify characteristics and common themes. The investigator then analyzed each of the personal statements to quantify the frequency of each theme. All personal statements submitted to the dermatology residency program at UNC School of Medicine were analyzed in this manner. Dermatology match outcomes for each applicant were confirmed later using dermatology program websites.

Differences in the prevalence of common themes between matched and unmatched applicants were calculated. Analysis of variance tests were used to determine if the differences in prevalence were statistically significant (P≤.05).

Results

All 422 submitted personal statements were evaluated, with 308 personal statements from applicants who matched and 114 personal statements from unmatched applicants. The screening of the initial subset of 20 personal statements resulted in a total of 9 content themes. The prevalence of each theme among matched and unmatched applicants is shown in the Table.

The most common themes among both matched and unmatched groups were personal accomplishments or attributes and positive qualities of dermatology. The prevalence of certain themes varied between matched and unmatched groups. Dermatologic cases were discussed significantly more frequently in the matched group compared to the unmatched group (60.06% vs 46.49%, P=.013). Name-dropping was more prevalent in the unmatched group (37.72%) compared to the matched group (26.95%). This difference in prevalence reached statistical significance (P=.014). Religious influences also were discussed more frequently in the unmatched group (5.26%) vs the matched group (0.65%) with statistical significance (P=.002).

Comment

This study of 422 personal statements submitted to a major academic institution showed that certain themes were common in personal statements among both matched and unmatched applicants. These themes included personal accomplishments/attributes and positive qualities of dermatology. This finding is consistent with prior studies that show common themes in the personal statements of applicants across a wide variety of specialties, including dermatology, anesthesiology, pediatrics, general surgery, internal medicine, and radiology.^5-10 Most commonly, applicants feel the need to justify why they chose their particular specialty, with Olazagasti et al⁵ (N=332) reporting that 70% of submitted dermatology personal statements explained why the applicant chose dermatology.

Certain themes, however, varied in prevalence between matched and unmatched groups in our study. Discussion of dermatologic cases was significantly more prevalent in the matched group compared to the unmatched group (P=.013), possibly because dermatology faculty enjoy hearing about cases and how the applicant responds and interacts with the cases. These data suggest that matched applicants focus more on characteristics specific to the clinical aspects of dermatology.

Conversely, name-dropping was significantly more prevalent in the unmatched group (P=.014). Dermatology is a highly competitive specialty. In 2016, applicants who matched into dermatology had a mean USMLE Step 1 score of 249 with a mean number of 4.7 research experiences and 11.7 abstracts, presentations, or publications, which is higher than the average USMLE Step 1 score of 239 with a mean number of 3.8 research experiences and 8.7 abstracts, presentations, or publications for unmatched applicants.³ It is possible that residency selection committees may view name-dropping negatively if applicants choose to name-drop to strengthen their applications in comparison to more competitive candidates. Religious influences also were significantly more prevalent in the unmatched group (P=.002), but the overall frequency of religious influences was low (approximately 2% of all applicants).

The 422 personal statements examined in our study represent 83.1% of the total pool of applicants to postgraduate year 2 dermatology positions in 2012 (N=508).¹¹ Our data differed somewhat from an analysis of same-year dermatology personal statements of 65% of the national applicant pool.⁵ Olazagasti et al⁵ found that themes of a family member in medicine (more in unmatched), a desire to contribute to decreasing literature gap (more in matched), and a desire to better understand dermatologic pathophysiology (more in matched) to be statistically significant (P≤.05 for all). Unfortunately, these themes were found in a small number of applicants, with each being reported in less than 7%.⁵ Our study included 23% more unmatched candidates and likely better estimated potential significant differences between matched and unmatched applicants.

In the Results section, Olazagasti et al⁵ reported that matched applicants emphasized the study of cutaneous manifestations of systemic disease significantly more frequently than unmatched applicants. However, the P value in their report did not support this statement (P=.054). In addition, their Conclusion section discussed matched candidates including themes of “why dermatology” and unmatched candidates including a “personal story” as differences between groups. Again, their results did not show any statistical significance to support these recommendations.⁵ When providing medical student mentorship in a field as competitive as dermatology, faculty must be careful in giving accurate advice that, if at all possible, is supported by objective data rather than personal preference or anecdotes.

Our study was limited in that only personal statements of applicants to a single program in a specific specialty were analyzed. Applicants may have submitted personalized versions of their personal statements to specific schools, which may have biased the themes present in this subset of personal statements. Given these limitations, we are unable to determine if these results are generalizable to all dermatology residency applicants. Further limitation is that the analysis of personal statements is in itself a subjective process.

This study included a larger number of personal statements representing a larger proportion of the total pool of applicants in 2012 than prior studies examining personal statements of dermatology residency applicants. In addition, this study examined the ultimate dermatology match outcome for each applicant during the 2012 application cycle. Future investigations could explore the role of other factors in the residency selection process such as USMLE Step scores, community service, research experiences, and Alpha Omega Alpha Honor Medical Society status.

Conclusion

There are common themes in the personal statements of dermatology residency applicants, including personal accomplishments/attributes and positive qualities of dermatology. In addition, discussion of dermatologic cases was statistically more prevalent in applicants who ultimately matched, whereas name-dropping and religious influences were more prevalent in applicants who did not match. This information may be useful to effectively mentor medical students about the writing process for the personal statement. Further investigation is needed to explore these associations and the role of other aspects of the application in the residency selection process.

Documentation has always been part of a physician’s job. Historically, in the days of paper records, physicians saw a patient on rounds and immediately following, while still on the unit, wrote a daily note detailing the events, test results, and plans since the last note. Addenda were written over the course of the day and night as needed.

The medical record was a chronological itemization of the encounter. The chart told the patient’s story, hopefully legibly and without excessive rehashing of previous material. The discharge summary then encapsulated the hospitalization in several coherent paragraphs.

In the current electronic records environment, we are inundated with excessive and repetitious information, data without interpretation, differentials without diagnoses. Prepopulation of templated notes, defaults without edit, and dictation without revision have degraded our documentation to the point of unintelligibility. The chronological storytelling and trustworthiness of the medical record has become suspect.

The Centers for Medicare & Medicaid Services is touting its “Patients over Paperwork” initiative. The solution is flawed (that is, future relaxation of documentation requirements for professional billing) because the premise is delusive. Documentation isn’t fundamentally the problem. Having clinicians jump through regulatory hoops which do not advance patients’ care, and providers misunderstanding the requirements for level-of-service billing are the essential issues. Getting no training on how to properly document in medical school/residency and receiving no formative feedback on documentation throughout one’s career compounds the problem. Having clinical documentation serve too many masters, including compliance, quality, medicolegal, utilization review, and reimbursement, is also to blame. The advent of the electronic medical record was just the straw that broke the camel’s back.

Many hospitals now have a clinical documentation integrity (CDI) team which is tasked with querying the provider when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent. They are charged with getting practitioners to associate clinical indicators with diagnoses and to consider removal of diagnoses which do not seem clinically valid from the existing documentation. From this explanation, you might well conclude that the CDI specialist could generate a query on every patient if they were so inclined, and you would be correct. But the goal isn’t to torture the physician – it is to ensure that the medical record is accurately depicting the encounter.

You are not being asked for more documentation by the CDI team; they are entreating you for higher-quality documentation. Let me give you some pointers to ward off queries.

• Tell the story. The most important goal of documentation is to clinically communicate to other caregivers. Think to yourself: “What would a fellow clinician need to know about this patient to understand why I drew those conclusions or to pick up where I left off?” At 2 a.m., that information, or lack thereof, could literally be a matter of life or death.
• Tell the truth. Embellishing the record or including invalid diagnoses with the intent to increase the severity of illness resulting in a more favorable diagnosis-related group – the inpatient risk-adjustment system – is considered fraud.
• You may like the convenience of copy forward, but do you relish reading other people’s copy and paste? Consider doing a documentation time-out. Before you copy and paste yesterday’s assessment and plan, stop and think: “Why is the patient still here? Why are we doing what we are doing?” If you choose to copy and paste, be certain to do mindful editing so the documentation represents the current situation and avoids redundancy. Appropriately editing copy and pasted documentation may prove more time consuming than generating a note de novo.
• Translate findings into diagnoses using your best medical judgment. One man’s hypotension may be another health care provider’s shock. Coders are not clinical and are not permitted to make inferences. A potassium of 6.7 may be hyperkalemia or it may be spurious – only a clinician may make that determination using their clinical expertise and experience. The coder is not allowed to read your mind. You must explicitly draw the conclusion that a febrile patient with bacteremia, encephalopathy, hypoxemia, and a blood pressure of 85/60 is in septic shock.
• Uncertain diagnoses (heralded by words such as: likely, possible, probable, suspected, rule out, etc.) which are not ruled out prior to discharge or demise are coded as if they were definitively present, for the inpatient technical side of hospital billing. This is distinctly different than the professional fee where you can only code definitive diagnoses. If you have a strong suspicion (not wild speculation) that a condition is present, best practice is to offer an uncertain diagnosis. Associate signs and symptoms with your most likely diagnosis: “Shortness of breath, pleuritic chest pain, and hypoxemia in the setting of cancer, probable pulmonary embolism.”
• Evolve, resolve, remove, and recap. If an uncertain diagnosis is ruled in, take away the uncertainty. If it is ruled out, don’t have 4 days of copy and pasted: “Possible eosinophilic pneumonia.” You do not have to maintain a resolved diagnosis ad infinitum. It can drop off the diagnosis list but be sure to have it reappear in the discharge summary.
• I know it can be a hASSLe to do excellent documentation, but it is critical for many reasons, most importantly for superlative patient care. More accurate coding and billing is an intended consequence. A: Acuity; S: Severity; S: Specificity (may affect the coding and the risk-adjustment implications. Acute systolic heart failure does not equal heart failure; type 2 diabetes mellitus with diabetic chronic kidney disease, stage 4 does not equal chronic kidney disease); and L: Linkage (of diagnosis with underlying cause or manifestation [e.g., because of, associated with, as a result of, secondary to, or from diabetic nephropathy, hypertensive encephalopathy]).
• If you have the capability to keep a running summary throughout the hospital stay, do so and keep it updated. A few moments of daily careful editing and composing can save time and effort at the back end creating the discharge summary. The follow-up care provider can reconstruct the hospital course and it is your last chance to spin the narrative for the lawyers.
• Read your documentation over. Ensure that it is clear, accurate, concise, and tells the story and the plans for the patient. Make sure that someone reading the note will know what you were thinking.
• Set up a program to self-audit documentation where monthly or quarterly, you and your partners mutually review a certain number of records and give each other feedback. Design an assessment tool which rates the quality of documentation elements which your hospital/network/service line values (clarity, copy and paste, complete and specific diagnoses, etc.). You know who the best documenters are. Why do you think their documentation is superior? How can you emulate them?

Finally, answer CDI queries. The CDI specialist is your ally, not your enemy. They want you to get credit for taking care of sick and complex patients. They are not permitted to lead the provider, so don’t ask them what they want you to write. But, if you don’t understand the query or issue, have a conversation and get it clarified. It is in everyone’s best interest to get this right.

Documentation improves patient care and demonstrates that you provided excellent patient care. Put mentation back into documentation.

Dr. Remer was a practicing emergency physician for 25 years and a physician advisor for 4 years. She is on the board of directors of the American College of Physician Advisors and the advisory board of the Association of Clinical Documentation Improvement Specialists. She currently provides consulting services for provider education on documentation, CDI, and ICD-10 coding. Dr. Remer can be reached at [email protected]

Documentation has always been part of a physician’s job. Historically, in the days of paper records, physicians saw a patient on rounds and immediately following, while still on the unit, wrote a daily note detailing the events, test results, and plans since the last note. Addenda were written over the course of the day and night as needed.

The medical record was a chronological itemization of the encounter. The chart told the patient’s story, hopefully legibly and without excessive rehashing of previous material. The discharge summary then encapsulated the hospitalization in several coherent paragraphs.

In the current electronic records environment, we are inundated with excessive and repetitious information, data without interpretation, differentials without diagnoses. Prepopulation of templated notes, defaults without edit, and dictation without revision have degraded our documentation to the point of unintelligibility. The chronological storytelling and trustworthiness of the medical record has become suspect.

The Centers for Medicare & Medicaid Services is touting its “Patients over Paperwork” initiative. The solution is flawed (that is, future relaxation of documentation requirements for professional billing) because the premise is delusive. Documentation isn’t fundamentally the problem. Having clinicians jump through regulatory hoops which do not advance patients’ care, and providers misunderstanding the requirements for level-of-service billing are the essential issues. Getting no training on how to properly document in medical school/residency and receiving no formative feedback on documentation throughout one’s career compounds the problem. Having clinical documentation serve too many masters, including compliance, quality, medicolegal, utilization review, and reimbursement, is also to blame. The advent of the electronic medical record was just the straw that broke the camel’s back.

Many hospitals now have a clinical documentation integrity (CDI) team which is tasked with querying the provider when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent. They are charged with getting practitioners to associate clinical indicators with diagnoses and to consider removal of diagnoses which do not seem clinically valid from the existing documentation. From this explanation, you might well conclude that the CDI specialist could generate a query on every patient if they were so inclined, and you would be correct. But the goal isn’t to torture the physician – it is to ensure that the medical record is accurately depicting the encounter.

You are not being asked for more documentation by the CDI team; they are entreating you for higher-quality documentation. Let me give you some pointers to ward off queries.

• Tell the story. The most important goal of documentation is to clinically communicate to other caregivers. Think to yourself: “What would a fellow clinician need to know about this patient to understand why I drew those conclusions or to pick up where I left off?” At 2 a.m., that information, or lack thereof, could literally be a matter of life or death.
• Tell the truth. Embellishing the record or including invalid diagnoses with the intent to increase the severity of illness resulting in a more favorable diagnosis-related group – the inpatient risk-adjustment system – is considered fraud.
• You may like the convenience of copy forward, but do you relish reading other people’s copy and paste? Consider doing a documentation time-out. Before you copy and paste yesterday’s assessment and plan, stop and think: “Why is the patient still here? Why are we doing what we are doing?” If you choose to copy and paste, be certain to do mindful editing so the documentation represents the current situation and avoids redundancy. Appropriately editing copy and pasted documentation may prove more time consuming than generating a note de novo.
• Translate findings into diagnoses using your best medical judgment. One man’s hypotension may be another health care provider’s shock. Coders are not clinical and are not permitted to make inferences. A potassium of 6.7 may be hyperkalemia or it may be spurious – only a clinician may make that determination using their clinical expertise and experience. The coder is not allowed to read your mind. You must explicitly draw the conclusion that a febrile patient with bacteremia, encephalopathy, hypoxemia, and a blood pressure of 85/60 is in septic shock.
• Uncertain diagnoses (heralded by words such as: likely, possible, probable, suspected, rule out, etc.) which are not ruled out prior to discharge or demise are coded as if they were definitively present, for the inpatient technical side of hospital billing. This is distinctly different than the professional fee where you can only code definitive diagnoses. If you have a strong suspicion (not wild speculation) that a condition is present, best practice is to offer an uncertain diagnosis. Associate signs and symptoms with your most likely diagnosis: “Shortness of breath, pleuritic chest pain, and hypoxemia in the setting of cancer, probable pulmonary embolism.”
• Evolve, resolve, remove, and recap. If an uncertain diagnosis is ruled in, take away the uncertainty. If it is ruled out, don’t have 4 days of copy and pasted: “Possible eosinophilic pneumonia.” You do not have to maintain a resolved diagnosis ad infinitum. It can drop off the diagnosis list but be sure to have it reappear in the discharge summary.
• I know it can be a hASSLe to do excellent documentation, but it is critical for many reasons, most importantly for superlative patient care. More accurate coding and billing is an intended consequence. A: Acuity; S: Severity; S: Specificity (may affect the coding and the risk-adjustment implications. Acute systolic heart failure does not equal heart failure; type 2 diabetes mellitus with diabetic chronic kidney disease, stage 4 does not equal chronic kidney disease); and L: Linkage (of diagnosis with underlying cause or manifestation [e.g., because of, associated with, as a result of, secondary to, or from diabetic nephropathy, hypertensive encephalopathy]).
• If you have the capability to keep a running summary throughout the hospital stay, do so and keep it updated. A few moments of daily careful editing and composing can save time and effort at the back end creating the discharge summary. The follow-up care provider can reconstruct the hospital course and it is your last chance to spin the narrative for the lawyers.
• Read your documentation over. Ensure that it is clear, accurate, concise, and tells the story and the plans for the patient. Make sure that someone reading the note will know what you were thinking.
• Set up a program to self-audit documentation where monthly or quarterly, you and your partners mutually review a certain number of records and give each other feedback. Design an assessment tool which rates the quality of documentation elements which your hospital/network/service line values (clarity, copy and paste, complete and specific diagnoses, etc.). You know who the best documenters are. Why do you think their documentation is superior? How can you emulate them?

Finally, answer CDI queries. The CDI specialist is your ally, not your enemy. They want you to get credit for taking care of sick and complex patients. They are not permitted to lead the provider, so don’t ask them what they want you to write. But, if you don’t understand the query or issue, have a conversation and get it clarified. It is in everyone’s best interest to get this right.

Documentation improves patient care and demonstrates that you provided excellent patient care. Put mentation back into documentation.

Dr. Remer was a practicing emergency physician for 25 years and a physician advisor for 4 years. She is on the board of directors of the American College of Physician Advisors and the advisory board of the Association of Clinical Documentation Improvement Specialists. She currently provides consulting services for provider education on documentation, CDI, and ICD-10 coding. Dr. Remer can be reached at [email protected]

Documentation has always been part of a physician’s job. Historically, in the days of paper records, physicians saw a patient on rounds and immediately following, while still on the unit, wrote a daily note detailing the events, test results, and plans since the last note. Addenda were written over the course of the day and night as needed.

The medical record was a chronological itemization of the encounter. The chart told the patient’s story, hopefully legibly and without excessive rehashing of previous material. The discharge summary then encapsulated the hospitalization in several coherent paragraphs.

In the current electronic records environment, we are inundated with excessive and repetitious information, data without interpretation, differentials without diagnoses. Prepopulation of templated notes, defaults without edit, and dictation without revision have degraded our documentation to the point of unintelligibility. The chronological storytelling and trustworthiness of the medical record has become suspect.

The Centers for Medicare & Medicaid Services is touting its “Patients over Paperwork” initiative. The solution is flawed (that is, future relaxation of documentation requirements for professional billing) because the premise is delusive. Documentation isn’t fundamentally the problem. Having clinicians jump through regulatory hoops which do not advance patients’ care, and providers misunderstanding the requirements for level-of-service billing are the essential issues. Getting no training on how to properly document in medical school/residency and receiving no formative feedback on documentation throughout one’s career compounds the problem. Having clinical documentation serve too many masters, including compliance, quality, medicolegal, utilization review, and reimbursement, is also to blame. The advent of the electronic medical record was just the straw that broke the camel’s back.

Many hospitals now have a clinical documentation integrity (CDI) team which is tasked with querying the provider when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent. They are charged with getting practitioners to associate clinical indicators with diagnoses and to consider removal of diagnoses which do not seem clinically valid from the existing documentation. From this explanation, you might well conclude that the CDI specialist could generate a query on every patient if they were so inclined, and you would be correct. But the goal isn’t to torture the physician – it is to ensure that the medical record is accurately depicting the encounter.

You are not being asked for more documentation by the CDI team; they are entreating you for higher-quality documentation. Let me give you some pointers to ward off queries.

• Tell the story. The most important goal of documentation is to clinically communicate to other caregivers. Think to yourself: “What would a fellow clinician need to know about this patient to understand why I drew those conclusions or to pick up where I left off?” At 2 a.m., that information, or lack thereof, could literally be a matter of life or death.
• Tell the truth. Embellishing the record or including invalid diagnoses with the intent to increase the severity of illness resulting in a more favorable diagnosis-related group – the inpatient risk-adjustment system – is considered fraud.
• You may like the convenience of copy forward, but do you relish reading other people’s copy and paste? Consider doing a documentation time-out. Before you copy and paste yesterday’s assessment and plan, stop and think: “Why is the patient still here? Why are we doing what we are doing?” If you choose to copy and paste, be certain to do mindful editing so the documentation represents the current situation and avoids redundancy. Appropriately editing copy and pasted documentation may prove more time consuming than generating a note de novo.
• Translate findings into diagnoses using your best medical judgment. One man’s hypotension may be another health care provider’s shock. Coders are not clinical and are not permitted to make inferences. A potassium of 6.7 may be hyperkalemia or it may be spurious – only a clinician may make that determination using their clinical expertise and experience. The coder is not allowed to read your mind. You must explicitly draw the conclusion that a febrile patient with bacteremia, encephalopathy, hypoxemia, and a blood pressure of 85/60 is in septic shock.
• Uncertain diagnoses (heralded by words such as: likely, possible, probable, suspected, rule out, etc.) which are not ruled out prior to discharge or demise are coded as if they were definitively present, for the inpatient technical side of hospital billing. This is distinctly different than the professional fee where you can only code definitive diagnoses. If you have a strong suspicion (not wild speculation) that a condition is present, best practice is to offer an uncertain diagnosis. Associate signs and symptoms with your most likely diagnosis: “Shortness of breath, pleuritic chest pain, and hypoxemia in the setting of cancer, probable pulmonary embolism.”
• Evolve, resolve, remove, and recap. If an uncertain diagnosis is ruled in, take away the uncertainty. If it is ruled out, don’t have 4 days of copy and pasted: “Possible eosinophilic pneumonia.” You do not have to maintain a resolved diagnosis ad infinitum. It can drop off the diagnosis list but be sure to have it reappear in the discharge summary.
• I know it can be a hASSLe to do excellent documentation, but it is critical for many reasons, most importantly for superlative patient care. More accurate coding and billing is an intended consequence. A: Acuity; S: Severity; S: Specificity (may affect the coding and the risk-adjustment implications. Acute systolic heart failure does not equal heart failure; type 2 diabetes mellitus with diabetic chronic kidney disease, stage 4 does not equal chronic kidney disease); and L: Linkage (of diagnosis with underlying cause or manifestation [e.g., because of, associated with, as a result of, secondary to, or from diabetic nephropathy, hypertensive encephalopathy]).
• If you have the capability to keep a running summary throughout the hospital stay, do so and keep it updated. A few moments of daily careful editing and composing can save time and effort at the back end creating the discharge summary. The follow-up care provider can reconstruct the hospital course and it is your last chance to spin the narrative for the lawyers.
• Read your documentation over. Ensure that it is clear, accurate, concise, and tells the story and the plans for the patient. Make sure that someone reading the note will know what you were thinking.
• Set up a program to self-audit documentation where monthly or quarterly, you and your partners mutually review a certain number of records and give each other feedback. Design an assessment tool which rates the quality of documentation elements which your hospital/network/service line values (clarity, copy and paste, complete and specific diagnoses, etc.). You know who the best documenters are. Why do you think their documentation is superior? How can you emulate them?

Finally, answer CDI queries. The CDI specialist is your ally, not your enemy. They want you to get credit for taking care of sick and complex patients. They are not permitted to lead the provider, so don’t ask them what they want you to write. But, if you don’t understand the query or issue, have a conversation and get it clarified. It is in everyone’s best interest to get this right.

Documentation improves patient care and demonstrates that you provided excellent patient care. Put mentation back into documentation.

Dr. Remer was a practicing emergency physician for 25 years and a physician advisor for 4 years. She is on the board of directors of the American College of Physician Advisors and the advisory board of the Association of Clinical Documentation Improvement Specialists. She currently provides consulting services for provider education on documentation, CDI, and ICD-10 coding. Dr. Remer can be reached at [email protected]

People with neurologic disorders have a higher rate of suicide, compared with people without neurologic conditions, according to a population-based study in Denmark.

The absolute risk difference is small, but statistically significant. “These findings do not necessarily warrant changing the management of treatment for individual patients,” wrote Annette Erlangsen, PhD, a researcher at the Danish Research Institute for Suicide Prevention in Hellerup, and colleagues. “As with all patients, physicians should be aware of the potential for depression, demoralization, and suicide.”

In addition, dementia, Alzheimer’s disease, and intellectual disabilities may be associated with lower suicide rates, according to the study, which was published in JAMA.

“Plausible mechanisms” could underlie the association between neurologic disease and suicide, the authors wrote. A neurologic diagnosis “may constitute a distressing life event,” and the diseases may have psychological, physical, and psychiatric effects. Patients may see themselves as a burden or have less financial security. In addition, the diseases may entail “communication difficulties, poor sleep, and pain.” Neurologic diseases may alter brain circuitry and functioning and influence aggression and impulsivity. “People with neurologic disorders may also have easier access to toxic medication,” they added.
 

More than a dozen conditions examined

Prior studies have found associations between neurologic conditions and rates of suicide, but data have been inconclusive or inconsistent for some of the disorders. To examine whether people with neurologic disorders have higher suicide rates, relative to people without these disorders, the researchers conducted a retrospective study. They analyzed data from more than 7.3 million people aged 15 years or older who lived in Denmark between 1980 and 2016. The cohort included more than 1.2 million people with neurologic disorders. The investigators identified neurologic disorders using ICD codes for head injury, stroke, epilepsy, polyneuropathy, diseases of the myoneural junction, Parkinson’s disease, multiple sclerosis, CNS infections, meningitis, encephalitis, amyotrophic lateral sclerosis, Huntington’s disease, dementia, intellectual disability, and other brain disorders. They compared incidence rates using a Poisson regression model and adjusted for time period, sex, age, region, socioeconomic status, comorbidity, self-harm or psychiatric hospitalization prior to a neurologic diagnosis, and whether a person lived alone.

In all, 35,483 people in the cohort died by suicide at an average age of about 52 years; 77.4% were male. About 15% of those who died by suicide had a neurologic disorder. The suicide incidence rate among people with a neurologic disorder was 44.0 per 100,000 person-years, whereas the rate among people without a neurologic disorder was 20.1 per 100,000 person-years.

The adjusted incidence rate ratio for people with a neurologic disorder was 1.8. The rate ratio was highest during the 3 months after diagnosis, at 3.1. Huntington’s disease and amyotrophic lateral sclerosis were associated with “the largest excess adjusted [incidence rate ratios] of suicide mortality,” with a rate ratio of 4.9 for each condition, the researchers reported. The adjusted incidence rate ratio was 1.7 for head injury, 1.3 for stroke, 1.7 for epilepsy, 1.4 for intracerebral hemorrhage, 1.3 for cerebral infarction, 1.3 for subarachnoid hemorrhage, 1.7 for polyneuropathy and peripheral neuropathy, 2.2 for Guillain-Barré syndrome, 1.9 for diseases of myoneural junction and muscle, 1.8 for other brain disorders, 1.7 for Parkinson’s disease, 2.2 for multiple sclerosis, and 1.6 for CNS infection.

Compared with people without a neurologic condition, people with dementia, Alzheimer’s disease, and intellectual disabilities had lower suicide rates, with adjusted incidence rate ratios of 0.8, 0.2, and 0.6, respectively. “However, the adjusted [incidence rate ratio] for people with dementia during the first month after diagnosis was 3.0,” the researchers wrote.

In addition, the suicide rate increased with an increasing cumulative number of hospital contacts for neurologic conditions.

Overall incidence rates declined

“Over the study period, the suicide incidence rate for people with neurological disorders decreased from 78.6 per 100,000 person-years during the 1980-1999 years to 27.3 per 100,000 person-years during the 2000-2016 years,” wrote Dr. Erlangsen and colleagues. “The suicide incidence rate for those without a disorder decreased from 26.3 to 12.7 during the same time spans. ... The decline in the overall suicide rate over time did not affect the relative risk pattern.”

The decline in the general suicide rate in Denmark “has largely been attributed to means restriction, such as efforts to limit availability of firearms and particularly toxic medication,” the authors added.

In those time spans, the adjusted incidence rate ratio for suicide among those with dementia decreased from 2.4 to 1.0, and among those with multiple sclerosis from 2.0 to 1.0. “It is possible that the improvements observed for dementia and multiple sclerosis may be related to improvements in treatment and intensified community-based support,” Dr. Erlangsen and coauthors wrote.

When the researchers used people with rheumatoid arthritis as a reference group, those with a neurologic disorder had a higher suicide rate per 100,000 person-years, 30.2 versus 18.4. The adjusted incidence rate ratio for that comparison was 1.4.

In patients with Huntington’s disease, depression mediated by hyperactivity in the hypothalamic-pituitary-adrenal axis may contribute to the risk of suicide. “Witnessing the course of the disease in one’s parent” also may contribute the risk, the researchers wrote.

The analysis may have missed people with neurologic disorders diagnosed before 1977 if they did not have subsequent contact with a hospital, the investigators noted. In addition, diagnoses given in primary care were not included, suicide deaths may be underrecorded, and “adjusting for preexisting mental disorders could be viewed as overadjusting,” they wrote.

The study was supported by a grant from the Psychiatric Research Foundation in Denmark. The authors reported that they had no disclosures.

[email protected]

SOURCE: Erlangsen A et al. JAMA. 2020 Feb 4. doi: 10.1001/jama.2019.21834.

People with neurologic disorders have a higher rate of suicide, compared with people without neurologic conditions, according to a population-based study in Denmark.

The absolute risk difference is small, but statistically significant. “These findings do not necessarily warrant changing the management of treatment for individual patients,” wrote Annette Erlangsen, PhD, a researcher at the Danish Research Institute for Suicide Prevention in Hellerup, and colleagues. “As with all patients, physicians should be aware of the potential for depression, demoralization, and suicide.”

In addition, dementia, Alzheimer’s disease, and intellectual disabilities may be associated with lower suicide rates, according to the study, which was published in JAMA.

“Plausible mechanisms” could underlie the association between neurologic disease and suicide, the authors wrote. A neurologic diagnosis “may constitute a distressing life event,” and the diseases may have psychological, physical, and psychiatric effects. Patients may see themselves as a burden or have less financial security. In addition, the diseases may entail “communication difficulties, poor sleep, and pain.” Neurologic diseases may alter brain circuitry and functioning and influence aggression and impulsivity. “People with neurologic disorders may also have easier access to toxic medication,” they added.
 

More than a dozen conditions examined

Prior studies have found associations between neurologic conditions and rates of suicide, but data have been inconclusive or inconsistent for some of the disorders. To examine whether people with neurologic disorders have higher suicide rates, relative to people without these disorders, the researchers conducted a retrospective study. They analyzed data from more than 7.3 million people aged 15 years or older who lived in Denmark between 1980 and 2016. The cohort included more than 1.2 million people with neurologic disorders. The investigators identified neurologic disorders using ICD codes for head injury, stroke, epilepsy, polyneuropathy, diseases of the myoneural junction, Parkinson’s disease, multiple sclerosis, CNS infections, meningitis, encephalitis, amyotrophic lateral sclerosis, Huntington’s disease, dementia, intellectual disability, and other brain disorders. They compared incidence rates using a Poisson regression model and adjusted for time period, sex, age, region, socioeconomic status, comorbidity, self-harm or psychiatric hospitalization prior to a neurologic diagnosis, and whether a person lived alone.

In all, 35,483 people in the cohort died by suicide at an average age of about 52 years; 77.4% were male. About 15% of those who died by suicide had a neurologic disorder. The suicide incidence rate among people with a neurologic disorder was 44.0 per 100,000 person-years, whereas the rate among people without a neurologic disorder was 20.1 per 100,000 person-years.

The adjusted incidence rate ratio for people with a neurologic disorder was 1.8. The rate ratio was highest during the 3 months after diagnosis, at 3.1. Huntington’s disease and amyotrophic lateral sclerosis were associated with “the largest excess adjusted [incidence rate ratios] of suicide mortality,” with a rate ratio of 4.9 for each condition, the researchers reported. The adjusted incidence rate ratio was 1.7 for head injury, 1.3 for stroke, 1.7 for epilepsy, 1.4 for intracerebral hemorrhage, 1.3 for cerebral infarction, 1.3 for subarachnoid hemorrhage, 1.7 for polyneuropathy and peripheral neuropathy, 2.2 for Guillain-Barré syndrome, 1.9 for diseases of myoneural junction and muscle, 1.8 for other brain disorders, 1.7 for Parkinson’s disease, 2.2 for multiple sclerosis, and 1.6 for CNS infection.

Compared with people without a neurologic condition, people with dementia, Alzheimer’s disease, and intellectual disabilities had lower suicide rates, with adjusted incidence rate ratios of 0.8, 0.2, and 0.6, respectively. “However, the adjusted [incidence rate ratio] for people with dementia during the first month after diagnosis was 3.0,” the researchers wrote.

In addition, the suicide rate increased with an increasing cumulative number of hospital contacts for neurologic conditions.

Overall incidence rates declined

“Over the study period, the suicide incidence rate for people with neurological disorders decreased from 78.6 per 100,000 person-years during the 1980-1999 years to 27.3 per 100,000 person-years during the 2000-2016 years,” wrote Dr. Erlangsen and colleagues. “The suicide incidence rate for those without a disorder decreased from 26.3 to 12.7 during the same time spans. ... The decline in the overall suicide rate over time did not affect the relative risk pattern.”

The decline in the general suicide rate in Denmark “has largely been attributed to means restriction, such as efforts to limit availability of firearms and particularly toxic medication,” the authors added.

In those time spans, the adjusted incidence rate ratio for suicide among those with dementia decreased from 2.4 to 1.0, and among those with multiple sclerosis from 2.0 to 1.0. “It is possible that the improvements observed for dementia and multiple sclerosis may be related to improvements in treatment and intensified community-based support,” Dr. Erlangsen and coauthors wrote.

When the researchers used people with rheumatoid arthritis as a reference group, those with a neurologic disorder had a higher suicide rate per 100,000 person-years, 30.2 versus 18.4. The adjusted incidence rate ratio for that comparison was 1.4.

In patients with Huntington’s disease, depression mediated by hyperactivity in the hypothalamic-pituitary-adrenal axis may contribute to the risk of suicide. “Witnessing the course of the disease in one’s parent” also may contribute the risk, the researchers wrote.

The analysis may have missed people with neurologic disorders diagnosed before 1977 if they did not have subsequent contact with a hospital, the investigators noted. In addition, diagnoses given in primary care were not included, suicide deaths may be underrecorded, and “adjusting for preexisting mental disorders could be viewed as overadjusting,” they wrote.

The study was supported by a grant from the Psychiatric Research Foundation in Denmark. The authors reported that they had no disclosures.

[email protected]

SOURCE: Erlangsen A et al. JAMA. 2020 Feb 4. doi: 10.1001/jama.2019.21834.

People with neurologic disorders have a higher rate of suicide, compared with people without neurologic conditions, according to a population-based study in Denmark.

The absolute risk difference is small, but statistically significant. “These findings do not necessarily warrant changing the management of treatment for individual patients,” wrote Annette Erlangsen, PhD, a researcher at the Danish Research Institute for Suicide Prevention in Hellerup, and colleagues. “As with all patients, physicians should be aware of the potential for depression, demoralization, and suicide.”

In addition, dementia, Alzheimer’s disease, and intellectual disabilities may be associated with lower suicide rates, according to the study, which was published in JAMA.

“Plausible mechanisms” could underlie the association between neurologic disease and suicide, the authors wrote. A neurologic diagnosis “may constitute a distressing life event,” and the diseases may have psychological, physical, and psychiatric effects. Patients may see themselves as a burden or have less financial security. In addition, the diseases may entail “communication difficulties, poor sleep, and pain.” Neurologic diseases may alter brain circuitry and functioning and influence aggression and impulsivity. “People with neurologic disorders may also have easier access to toxic medication,” they added.
 

More than a dozen conditions examined

Prior studies have found associations between neurologic conditions and rates of suicide, but data have been inconclusive or inconsistent for some of the disorders. To examine whether people with neurologic disorders have higher suicide rates, relative to people without these disorders, the researchers conducted a retrospective study. They analyzed data from more than 7.3 million people aged 15 years or older who lived in Denmark between 1980 and 2016. The cohort included more than 1.2 million people with neurologic disorders. The investigators identified neurologic disorders using ICD codes for head injury, stroke, epilepsy, polyneuropathy, diseases of the myoneural junction, Parkinson’s disease, multiple sclerosis, CNS infections, meningitis, encephalitis, amyotrophic lateral sclerosis, Huntington’s disease, dementia, intellectual disability, and other brain disorders. They compared incidence rates using a Poisson regression model and adjusted for time period, sex, age, region, socioeconomic status, comorbidity, self-harm or psychiatric hospitalization prior to a neurologic diagnosis, and whether a person lived alone.

In all, 35,483 people in the cohort died by suicide at an average age of about 52 years; 77.4% were male. About 15% of those who died by suicide had a neurologic disorder. The suicide incidence rate among people with a neurologic disorder was 44.0 per 100,000 person-years, whereas the rate among people without a neurologic disorder was 20.1 per 100,000 person-years.

The adjusted incidence rate ratio for people with a neurologic disorder was 1.8. The rate ratio was highest during the 3 months after diagnosis, at 3.1. Huntington’s disease and amyotrophic lateral sclerosis were associated with “the largest excess adjusted [incidence rate ratios] of suicide mortality,” with a rate ratio of 4.9 for each condition, the researchers reported. The adjusted incidence rate ratio was 1.7 for head injury, 1.3 for stroke, 1.7 for epilepsy, 1.4 for intracerebral hemorrhage, 1.3 for cerebral infarction, 1.3 for subarachnoid hemorrhage, 1.7 for polyneuropathy and peripheral neuropathy, 2.2 for Guillain-Barré syndrome, 1.9 for diseases of myoneural junction and muscle, 1.8 for other brain disorders, 1.7 for Parkinson’s disease, 2.2 for multiple sclerosis, and 1.6 for CNS infection.

Compared with people without a neurologic condition, people with dementia, Alzheimer’s disease, and intellectual disabilities had lower suicide rates, with adjusted incidence rate ratios of 0.8, 0.2, and 0.6, respectively. “However, the adjusted [incidence rate ratio] for people with dementia during the first month after diagnosis was 3.0,” the researchers wrote.

In addition, the suicide rate increased with an increasing cumulative number of hospital contacts for neurologic conditions.

Overall incidence rates declined

“Over the study period, the suicide incidence rate for people with neurological disorders decreased from 78.6 per 100,000 person-years during the 1980-1999 years to 27.3 per 100,000 person-years during the 2000-2016 years,” wrote Dr. Erlangsen and colleagues. “The suicide incidence rate for those without a disorder decreased from 26.3 to 12.7 during the same time spans. ... The decline in the overall suicide rate over time did not affect the relative risk pattern.”

The decline in the general suicide rate in Denmark “has largely been attributed to means restriction, such as efforts to limit availability of firearms and particularly toxic medication,” the authors added.

In those time spans, the adjusted incidence rate ratio for suicide among those with dementia decreased from 2.4 to 1.0, and among those with multiple sclerosis from 2.0 to 1.0. “It is possible that the improvements observed for dementia and multiple sclerosis may be related to improvements in treatment and intensified community-based support,” Dr. Erlangsen and coauthors wrote.

When the researchers used people with rheumatoid arthritis as a reference group, those with a neurologic disorder had a higher suicide rate per 100,000 person-years, 30.2 versus 18.4. The adjusted incidence rate ratio for that comparison was 1.4.

In patients with Huntington’s disease, depression mediated by hyperactivity in the hypothalamic-pituitary-adrenal axis may contribute to the risk of suicide. “Witnessing the course of the disease in one’s parent” also may contribute the risk, the researchers wrote.

The analysis may have missed people with neurologic disorders diagnosed before 1977 if they did not have subsequent contact with a hospital, the investigators noted. In addition, diagnoses given in primary care were not included, suicide deaths may be underrecorded, and “adjusting for preexisting mental disorders could be viewed as overadjusting,” they wrote.

The study was supported by a grant from the Psychiatric Research Foundation in Denmark. The authors reported that they had no disclosures.

[email protected]

SOURCE: Erlangsen A et al. JAMA. 2020 Feb 4. doi: 10.1001/jama.2019.21834.

The Centers for Disease Control and Prevention has released an updated schedule for adult vaccines. The update includes changes regarding the administration of several vaccines, including those for influenza, human papillomavirus (HPV), hepatitis A and B, and meningitis B, as well as the pneumococcal 13-valent conjugate (PCV13) vaccine.

The schedule, revised annually by the Advisory Committee on Immunization Practices (ACIP) of the CDC, was simultaneously published online February 3, 2020, in the Annals of Internal Medicine and on the CDC website.

Perhaps the change most likely to raise questions is that concerning the PCV13 vaccine. “Owing to a decline in prevalence of the types covered by the PCV13 vaccine, this is no longer routinely recommended for all persons age 65 and older,” senior author Mark Freedman, DVM, MPH, of the immunization services division at the National Center for Immunization and Respiratory Disease, said in an interview.

For purposes of shared clinical decision, however, it should be discussed with previously unvaccinated seniors who do not have risk factors, such as an immunocompromising condition, a cerebrospinal fluid leak, or a cochlear implant.

“But the circumstances for use of the vaccine are not always clear even based on the detailed list of considerations provided, because it’s impossible to think of every conceivable combination of risk factors,” Mr. Freedman added.

Possible beneficiaries of this vaccine are vulnerable elderly people living in nursing homes and long-term care facilities and those living in or traveling to settings in which the rate of pediatric PCV13 uptake is low or zero.

All adults in this age group should continue to receive a single dose of the pneumococcal 23-valent polysaccharide vaccine.*

HPV

The advisory committee now recommends catch-up immunization for women and men through age 26 years (the previous cutoff for men was 21). And in another new recommendation, the ACIP advises considering vaccination for some patients aged 27-45 years who have not been adequately vaccinated.

“Most people ages 27-45 do not need vaccination, but some may benefit,” Mr. Freedman said. “For example, somebody who’s been in a prior long-term monogamous relationship and suddenly finds himself with a new sexual partner.”

“That makes very good sense for older people who haven’t been vaccinated and might continue to be exposed to HPV,” Daniel M. Musher, MD, a professor of medicine at Baylor College of Medicine and an infectious diseases physician at the Michael E. DeBakey Veterans Affairs Medical Center, both in Houston, said in an interview.

Here again, the ACIP advises taking a shared decision-making approach, with clinicians discussing the merits of vaccination in this and other scenarios with patients according to the talking points outlined in the HPV section.

Influenza, hepatitis A and B

For the 2019-2020 influenza season, routine influenza vaccination is recommended for all persons aged 6 months or older who have no contraindications. Where more than one appropriate option is available, the ACIP does not recommend any product over another.

Routine hepatitis A vaccination is recommended for all persons aged 1 year or older who have HIV infection regardless of their level of immune suppression.

For hepatitis B, a new addition to the list of vulnerable patients who may possibly benefit from vaccination is pregnant women at risk for infection or an adverse infection-related pregnancy outcome. Whereas older formulations are safe, the ACIP does not recommend the HepB-CpG (Heplisav-B) vaccine during pregnancy, owing to the fact that safety data are lacking.

Meningitis B

Individuals aged 10 years or older who have complement deficiency, who use a complement inhibitor, who have asplenia, or who are microbiologists should receive a meningitis B booster dose 1 year following completion of a primary series. After that, they should receive booster doses every 2-3 years for as long they are at elevated risk.

Vaccination should be discussed with individuals aged 16-23 years even if they are not at increased risk for meningococcal disease. Persons aged 10 years or older whom public health authorities deem to be at increased risk during an outbreak should have a one-time booster dose if at least 1 year has elapsed since completion of a meningitis B primary series.

Td/Tdap, varicella

The ACIP now recommends that either the Td or Tdap vaccine be given in cases in which currently just the Td vaccine is recommended; that is, for the 10-year booster shot as well as for tetanus prophylaxis in wound management and the catch-up immunization schedule, including that for pregnant women.

Vaccination against varicella should be considered for HIV-infected individuals who are without evidence of varicella immunity and whose CD4 counts are at least 200 cells/mL.

Dr. Musher, who was not involved in drafting the recommendations, takes issue generally with the addition of shared clinical decision making on vaccination. “Shared decision making is a problem for anyone practicing medicine. It places a terrible burden [on] the doctors to discuss these options with patients at great length. Most patients want the doctor to make the decision.”

In his view, this approach makes little sense in the case of the PCV13 vaccine because the strains it covers have disappeared from the population through the widespread vaccination of children. “But discussions are important for some vaccines, such as the herpes zoster vaccine, since patients can have a terrible reaction to the first dose and refuse to have the second,” he said.

Some of these new recommendations were released in 2019 after ACIP members met to vote on them in February, June, and October.

As in previous years, the schedule has been streamlined for easier reference. Physicians are reminded to closely read the details in the vaccine notes, as these specify who needs what vaccine, when, and at what dose.

The ACIP develops its recommendations after reviewing vaccine-related data, including the data regarding the epidemiology and burden of the vaccine-preventable disease, vaccine effectiveness and safety, the quality of evidence, implementability, and the economics of immunization policy.

The authors have received grants and expense payments from public and not-for-profit institutions. One coauthor has received fees from ACI Clinical for data and safety monitoring in an immunization trial. Dr. Musher has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Correction, 3/31/20: An earlier version of this article misstated the recommendation for administration of the pneumococcal 23-valent polysaccharide vaccine. All adults in this age group should continue to receive a single dose of this vaccine. 

The Centers for Disease Control and Prevention has released an updated schedule for adult vaccines. The update includes changes regarding the administration of several vaccines, including those for influenza, human papillomavirus (HPV), hepatitis A and B, and meningitis B, as well as the pneumococcal 13-valent conjugate (PCV13) vaccine.

The schedule, revised annually by the Advisory Committee on Immunization Practices (ACIP) of the CDC, was simultaneously published online February 3, 2020, in the Annals of Internal Medicine and on the CDC website.

Perhaps the change most likely to raise questions is that concerning the PCV13 vaccine. “Owing to a decline in prevalence of the types covered by the PCV13 vaccine, this is no longer routinely recommended for all persons age 65 and older,” senior author Mark Freedman, DVM, MPH, of the immunization services division at the National Center for Immunization and Respiratory Disease, said in an interview.

For purposes of shared clinical decision, however, it should be discussed with previously unvaccinated seniors who do not have risk factors, such as an immunocompromising condition, a cerebrospinal fluid leak, or a cochlear implant.

“But the circumstances for use of the vaccine are not always clear even based on the detailed list of considerations provided, because it’s impossible to think of every conceivable combination of risk factors,” Mr. Freedman added.

Possible beneficiaries of this vaccine are vulnerable elderly people living in nursing homes and long-term care facilities and those living in or traveling to settings in which the rate of pediatric PCV13 uptake is low or zero.

All adults in this age group should continue to receive a single dose of the pneumococcal 23-valent polysaccharide vaccine.*

HPV

The advisory committee now recommends catch-up immunization for women and men through age 26 years (the previous cutoff for men was 21). And in another new recommendation, the ACIP advises considering vaccination for some patients aged 27-45 years who have not been adequately vaccinated.

“Most people ages 27-45 do not need vaccination, but some may benefit,” Mr. Freedman said. “For example, somebody who’s been in a prior long-term monogamous relationship and suddenly finds himself with a new sexual partner.”

“That makes very good sense for older people who haven’t been vaccinated and might continue to be exposed to HPV,” Daniel M. Musher, MD, a professor of medicine at Baylor College of Medicine and an infectious diseases physician at the Michael E. DeBakey Veterans Affairs Medical Center, both in Houston, said in an interview.

Here again, the ACIP advises taking a shared decision-making approach, with clinicians discussing the merits of vaccination in this and other scenarios with patients according to the talking points outlined in the HPV section.

Influenza, hepatitis A and B

For the 2019-2020 influenza season, routine influenza vaccination is recommended for all persons aged 6 months or older who have no contraindications. Where more than one appropriate option is available, the ACIP does not recommend any product over another.

Routine hepatitis A vaccination is recommended for all persons aged 1 year or older who have HIV infection regardless of their level of immune suppression.

For hepatitis B, a new addition to the list of vulnerable patients who may possibly benefit from vaccination is pregnant women at risk for infection or an adverse infection-related pregnancy outcome. Whereas older formulations are safe, the ACIP does not recommend the HepB-CpG (Heplisav-B) vaccine during pregnancy, owing to the fact that safety data are lacking.

Meningitis B

Individuals aged 10 years or older who have complement deficiency, who use a complement inhibitor, who have asplenia, or who are microbiologists should receive a meningitis B booster dose 1 year following completion of a primary series. After that, they should receive booster doses every 2-3 years for as long they are at elevated risk.

Vaccination should be discussed with individuals aged 16-23 years even if they are not at increased risk for meningococcal disease. Persons aged 10 years or older whom public health authorities deem to be at increased risk during an outbreak should have a one-time booster dose if at least 1 year has elapsed since completion of a meningitis B primary series.

Td/Tdap, varicella

The ACIP now recommends that either the Td or Tdap vaccine be given in cases in which currently just the Td vaccine is recommended; that is, for the 10-year booster shot as well as for tetanus prophylaxis in wound management and the catch-up immunization schedule, including that for pregnant women.

Vaccination against varicella should be considered for HIV-infected individuals who are without evidence of varicella immunity and whose CD4 counts are at least 200 cells/mL.

Dr. Musher, who was not involved in drafting the recommendations, takes issue generally with the addition of shared clinical decision making on vaccination. “Shared decision making is a problem for anyone practicing medicine. It places a terrible burden [on] the doctors to discuss these options with patients at great length. Most patients want the doctor to make the decision.”

In his view, this approach makes little sense in the case of the PCV13 vaccine because the strains it covers have disappeared from the population through the widespread vaccination of children. “But discussions are important for some vaccines, such as the herpes zoster vaccine, since patients can have a terrible reaction to the first dose and refuse to have the second,” he said.

Some of these new recommendations were released in 2019 after ACIP members met to vote on them in February, June, and October.

As in previous years, the schedule has been streamlined for easier reference. Physicians are reminded to closely read the details in the vaccine notes, as these specify who needs what vaccine, when, and at what dose.

The ACIP develops its recommendations after reviewing vaccine-related data, including the data regarding the epidemiology and burden of the vaccine-preventable disease, vaccine effectiveness and safety, the quality of evidence, implementability, and the economics of immunization policy.

The authors have received grants and expense payments from public and not-for-profit institutions. One coauthor has received fees from ACI Clinical for data and safety monitoring in an immunization trial. Dr. Musher has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Correction, 3/31/20: An earlier version of this article misstated the recommendation for administration of the pneumococcal 23-valent polysaccharide vaccine. All adults in this age group should continue to receive a single dose of this vaccine. 

The Centers for Disease Control and Prevention has released an updated schedule for adult vaccines. The update includes changes regarding the administration of several vaccines, including those for influenza, human papillomavirus (HPV), hepatitis A and B, and meningitis B, as well as the pneumococcal 13-valent conjugate (PCV13) vaccine.

The schedule, revised annually by the Advisory Committee on Immunization Practices (ACIP) of the CDC, was simultaneously published online February 3, 2020, in the Annals of Internal Medicine and on the CDC website.

Perhaps the change most likely to raise questions is that concerning the PCV13 vaccine. “Owing to a decline in prevalence of the types covered by the PCV13 vaccine, this is no longer routinely recommended for all persons age 65 and older,” senior author Mark Freedman, DVM, MPH, of the immunization services division at the National Center for Immunization and Respiratory Disease, said in an interview.

For purposes of shared clinical decision, however, it should be discussed with previously unvaccinated seniors who do not have risk factors, such as an immunocompromising condition, a cerebrospinal fluid leak, or a cochlear implant.

“But the circumstances for use of the vaccine are not always clear even based on the detailed list of considerations provided, because it’s impossible to think of every conceivable combination of risk factors,” Mr. Freedman added.

Possible beneficiaries of this vaccine are vulnerable elderly people living in nursing homes and long-term care facilities and those living in or traveling to settings in which the rate of pediatric PCV13 uptake is low or zero.

All adults in this age group should continue to receive a single dose of the pneumococcal 23-valent polysaccharide vaccine.*

HPV

The advisory committee now recommends catch-up immunization for women and men through age 26 years (the previous cutoff for men was 21). And in another new recommendation, the ACIP advises considering vaccination for some patients aged 27-45 years who have not been adequately vaccinated.

“Most people ages 27-45 do not need vaccination, but some may benefit,” Mr. Freedman said. “For example, somebody who’s been in a prior long-term monogamous relationship and suddenly finds himself with a new sexual partner.”

“That makes very good sense for older people who haven’t been vaccinated and might continue to be exposed to HPV,” Daniel M. Musher, MD, a professor of medicine at Baylor College of Medicine and an infectious diseases physician at the Michael E. DeBakey Veterans Affairs Medical Center, both in Houston, said in an interview.

Here again, the ACIP advises taking a shared decision-making approach, with clinicians discussing the merits of vaccination in this and other scenarios with patients according to the talking points outlined in the HPV section.

Influenza, hepatitis A and B

For the 2019-2020 influenza season, routine influenza vaccination is recommended for all persons aged 6 months or older who have no contraindications. Where more than one appropriate option is available, the ACIP does not recommend any product over another.

Routine hepatitis A vaccination is recommended for all persons aged 1 year or older who have HIV infection regardless of their level of immune suppression.

For hepatitis B, a new addition to the list of vulnerable patients who may possibly benefit from vaccination is pregnant women at risk for infection or an adverse infection-related pregnancy outcome. Whereas older formulations are safe, the ACIP does not recommend the HepB-CpG (Heplisav-B) vaccine during pregnancy, owing to the fact that safety data are lacking.

Meningitis B

Individuals aged 10 years or older who have complement deficiency, who use a complement inhibitor, who have asplenia, or who are microbiologists should receive a meningitis B booster dose 1 year following completion of a primary series. After that, they should receive booster doses every 2-3 years for as long they are at elevated risk.

Vaccination should be discussed with individuals aged 16-23 years even if they are not at increased risk for meningococcal disease. Persons aged 10 years or older whom public health authorities deem to be at increased risk during an outbreak should have a one-time booster dose if at least 1 year has elapsed since completion of a meningitis B primary series.

Td/Tdap, varicella

The ACIP now recommends that either the Td or Tdap vaccine be given in cases in which currently just the Td vaccine is recommended; that is, for the 10-year booster shot as well as for tetanus prophylaxis in wound management and the catch-up immunization schedule, including that for pregnant women.

Vaccination against varicella should be considered for HIV-infected individuals who are without evidence of varicella immunity and whose CD4 counts are at least 200 cells/mL.

Dr. Musher, who was not involved in drafting the recommendations, takes issue generally with the addition of shared clinical decision making on vaccination. “Shared decision making is a problem for anyone practicing medicine. It places a terrible burden [on] the doctors to discuss these options with patients at great length. Most patients want the doctor to make the decision.”

In his view, this approach makes little sense in the case of the PCV13 vaccine because the strains it covers have disappeared from the population through the widespread vaccination of children. “But discussions are important for some vaccines, such as the herpes zoster vaccine, since patients can have a terrible reaction to the first dose and refuse to have the second,” he said.

Some of these new recommendations were released in 2019 after ACIP members met to vote on them in February, June, and October.

As in previous years, the schedule has been streamlined for easier reference. Physicians are reminded to closely read the details in the vaccine notes, as these specify who needs what vaccine, when, and at what dose.

The ACIP develops its recommendations after reviewing vaccine-related data, including the data regarding the epidemiology and burden of the vaccine-preventable disease, vaccine effectiveness and safety, the quality of evidence, implementability, and the economics of immunization policy.

The authors have received grants and expense payments from public and not-for-profit institutions. One coauthor has received fees from ACI Clinical for data and safety monitoring in an immunization trial. Dr. Musher has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Correction, 3/31/20: An earlier version of this article misstated the recommendation for administration of the pneumococcal 23-valent polysaccharide vaccine. All adults in this age group should continue to receive a single dose of this vaccine. 

Dear colleagues,

The first issue of The New Gastroenterologist in 2020 consists of a particularly interesting array of articles and the introduction of a new medical ethics series!

This month’s “In Focus” article, brought to you by Jennifer Maratt (Indiana University) and Elena Stoffel (University of Michigan), provides a high yield overview of hereditary colorectal cancer and polyposis syndromes, with guidance on when a referral to a high risk cancer specialist and geneticist is warranted.

Daniel Mills (Cunningham, Meyer & Vedrine P.C.) gives us a valuable legal perspective of the role of electronic patient portals in the dissemination of information and medical advice to patients – such an important topic for everyone to be aware of as the nature of patient communication now strongly relies on electronic messaging.

R. Thomas Finn III (Palo Alto Medical Foundation) and David Leiman (Duke) nicely broach the issue of patient satisfaction. This is a timely topic as many institutions are not only publishing patient reviews online so that they are readily available to the public, but are also making financial incentives contingent on high patient ratings. The article discusses the evolution of the emphasis placed on patient satisfaction throughout the years with tips on how to navigate some of the distinct challenges within gastroenterology.

As part of our DHPA Private Practice Perspectives series, David Stokesberry (Digestive Disease Specialists Inc, Oklahoma City) discusses the nuts and bolts of ambulatory endoscopy centers and some of the challenges and benefits that accompany ownership of such centers.

An often overlooked aspect of gastroenterology training is nutrition. In our postfellowship pathways section, Dejan Micic (University of Chicago) outlines his decision to pursue a career in nutrition support, small bowel disorders, and the practice of deep enteroscopy.

Finally, this quarter’s newsletter features the start of a new section, which I am very excited to introduce – a case based series which will address issues in clinical medical ethics specific to gastroenterology. Lauren Feld (University of Washington) writes the inaugural piece for the section, providing a systematic approach to the patient with an existing do-not-resuscitate (DNR) order that is about to undergo endoscopy.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
 

Sincerely,

Vijaya L. Rao, MD
Editor in Chief

Dear colleagues,

The first issue of The New Gastroenterologist in 2020 consists of a particularly interesting array of articles and the introduction of a new medical ethics series!

This month’s “In Focus” article, brought to you by Jennifer Maratt (Indiana University) and Elena Stoffel (University of Michigan), provides a high yield overview of hereditary colorectal cancer and polyposis syndromes, with guidance on when a referral to a high risk cancer specialist and geneticist is warranted.

Daniel Mills (Cunningham, Meyer & Vedrine P.C.) gives us a valuable legal perspective of the role of electronic patient portals in the dissemination of information and medical advice to patients – such an important topic for everyone to be aware of as the nature of patient communication now strongly relies on electronic messaging.

R. Thomas Finn III (Palo Alto Medical Foundation) and David Leiman (Duke) nicely broach the issue of patient satisfaction. This is a timely topic as many institutions are not only publishing patient reviews online so that they are readily available to the public, but are also making financial incentives contingent on high patient ratings. The article discusses the evolution of the emphasis placed on patient satisfaction throughout the years with tips on how to navigate some of the distinct challenges within gastroenterology.

As part of our DHPA Private Practice Perspectives series, David Stokesberry (Digestive Disease Specialists Inc, Oklahoma City) discusses the nuts and bolts of ambulatory endoscopy centers and some of the challenges and benefits that accompany ownership of such centers.

An often overlooked aspect of gastroenterology training is nutrition. In our postfellowship pathways section, Dejan Micic (University of Chicago) outlines his decision to pursue a career in nutrition support, small bowel disorders, and the practice of deep enteroscopy.

Finally, this quarter’s newsletter features the start of a new section, which I am very excited to introduce – a case based series which will address issues in clinical medical ethics specific to gastroenterology. Lauren Feld (University of Washington) writes the inaugural piece for the section, providing a systematic approach to the patient with an existing do-not-resuscitate (DNR) order that is about to undergo endoscopy.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
 

Sincerely,

Vijaya L. Rao, MD
Editor in Chief

Dear colleagues,

The first issue of The New Gastroenterologist in 2020 consists of a particularly interesting array of articles and the introduction of a new medical ethics series!

This month’s “In Focus” article, brought to you by Jennifer Maratt (Indiana University) and Elena Stoffel (University of Michigan), provides a high yield overview of hereditary colorectal cancer and polyposis syndromes, with guidance on when a referral to a high risk cancer specialist and geneticist is warranted.

Daniel Mills (Cunningham, Meyer & Vedrine P.C.) gives us a valuable legal perspective of the role of electronic patient portals in the dissemination of information and medical advice to patients – such an important topic for everyone to be aware of as the nature of patient communication now strongly relies on electronic messaging.

R. Thomas Finn III (Palo Alto Medical Foundation) and David Leiman (Duke) nicely broach the issue of patient satisfaction. This is a timely topic as many institutions are not only publishing patient reviews online so that they are readily available to the public, but are also making financial incentives contingent on high patient ratings. The article discusses the evolution of the emphasis placed on patient satisfaction throughout the years with tips on how to navigate some of the distinct challenges within gastroenterology.

As part of our DHPA Private Practice Perspectives series, David Stokesberry (Digestive Disease Specialists Inc, Oklahoma City) discusses the nuts and bolts of ambulatory endoscopy centers and some of the challenges and benefits that accompany ownership of such centers.

An often overlooked aspect of gastroenterology training is nutrition. In our postfellowship pathways section, Dejan Micic (University of Chicago) outlines his decision to pursue a career in nutrition support, small bowel disorders, and the practice of deep enteroscopy.

Finally, this quarter’s newsletter features the start of a new section, which I am very excited to introduce – a case based series which will address issues in clinical medical ethics specific to gastroenterology. Lauren Feld (University of Washington) writes the inaugural piece for the section, providing a systematic approach to the patient with an existing do-not-resuscitate (DNR) order that is about to undergo endoscopy.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
 

Sincerely,

Vijaya L. Rao, MD
Editor in Chief

As practicing clinicians, we all want to do what is best for patients. We hope our treatments will improve actual health outcomes (and not intermediate process metrics), so we make decisions based on “evidence” that lies on a continuum from “I hope” on one end to “I’m sure” on the other. This month, our three lead articles represent differing points along that continuum.

First, we consider H. pylori and gastric cancer. We know H. pylori eradication reduces ulcer risk and that H. pylori is a risk for gastric cancer. We did not know whether eradication reduces cancer risk. In a large retrospective study from the VA, Kumar et al demonstrated that eradication (not just treatment) substantially reduced subsequent gastric cancers. These data are not definitive, but they nudge us towards the “I’m sure” end of the continuum.

A second group of studies (both retrospective and prospective) suggests that successful weight loss after bariatric surgery was associated with a substantial reduction of risk for 13 cancer types related to obesity. Moderate evidence but again nudging us away from “I hope.”

A third article highlights the recent Clinical Practice Update on Barrett’s esophagus published by the AGA Clinical Practice Update Committee in Gastroenterology’s February 2020 issue. This practice update helps us understand the impact we will make on cancer reduction with surveillance and treatment of Barrett’s. Despite this publication, Barrett’s management remains closer to “hope” than “sure.”

The difficulty we face, as clinician or patient, is what to do when outcomes are really serious but evidence remains close to the “I hope” end. Take a reasonably healthy 68-year-old man with asymptomatic coronary disease, but a very high (and increasing) coronary artery calcium score, despite maximum statins and appropriate lifestyle practices. Should he initiate a PCSK9 inhibitor ($14,000 per year) absent evidence that it would alter cardiac risk? Recently, a retrospective study nudged us along the continuum (Peng et al. JACC Cardiovascular Imaging. 2020 Jan;13[1 Pt 1]:83-93). A serious outcome, suggestive but not definitive evidence, and no time for an RCT. Will such aggressive therapy help? I sure hope so.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

As practicing clinicians, we all want to do what is best for patients. We hope our treatments will improve actual health outcomes (and not intermediate process metrics), so we make decisions based on “evidence” that lies on a continuum from “I hope” on one end to “I’m sure” on the other. This month, our three lead articles represent differing points along that continuum.

First, we consider H. pylori and gastric cancer. We know H. pylori eradication reduces ulcer risk and that H. pylori is a risk for gastric cancer. We did not know whether eradication reduces cancer risk. In a large retrospective study from the VA, Kumar et al demonstrated that eradication (not just treatment) substantially reduced subsequent gastric cancers. These data are not definitive, but they nudge us towards the “I’m sure” end of the continuum.

A second group of studies (both retrospective and prospective) suggests that successful weight loss after bariatric surgery was associated with a substantial reduction of risk for 13 cancer types related to obesity. Moderate evidence but again nudging us away from “I hope.”

A third article highlights the recent Clinical Practice Update on Barrett’s esophagus published by the AGA Clinical Practice Update Committee in Gastroenterology’s February 2020 issue. This practice update helps us understand the impact we will make on cancer reduction with surveillance and treatment of Barrett’s. Despite this publication, Barrett’s management remains closer to “hope” than “sure.”

The difficulty we face, as clinician or patient, is what to do when outcomes are really serious but evidence remains close to the “I hope” end. Take a reasonably healthy 68-year-old man with asymptomatic coronary disease, but a very high (and increasing) coronary artery calcium score, despite maximum statins and appropriate lifestyle practices. Should he initiate a PCSK9 inhibitor ($14,000 per year) absent evidence that it would alter cardiac risk? Recently, a retrospective study nudged us along the continuum (Peng et al. JACC Cardiovascular Imaging. 2020 Jan;13[1 Pt 1]:83-93). A serious outcome, suggestive but not definitive evidence, and no time for an RCT. Will such aggressive therapy help? I sure hope so.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

As practicing clinicians, we all want to do what is best for patients. We hope our treatments will improve actual health outcomes (and not intermediate process metrics), so we make decisions based on “evidence” that lies on a continuum from “I hope” on one end to “I’m sure” on the other. This month, our three lead articles represent differing points along that continuum.

First, we consider H. pylori and gastric cancer. We know H. pylori eradication reduces ulcer risk and that H. pylori is a risk for gastric cancer. We did not know whether eradication reduces cancer risk. In a large retrospective study from the VA, Kumar et al demonstrated that eradication (not just treatment) substantially reduced subsequent gastric cancers. These data are not definitive, but they nudge us towards the “I’m sure” end of the continuum.

A second group of studies (both retrospective and prospective) suggests that successful weight loss after bariatric surgery was associated with a substantial reduction of risk for 13 cancer types related to obesity. Moderate evidence but again nudging us away from “I hope.”

A third article highlights the recent Clinical Practice Update on Barrett’s esophagus published by the AGA Clinical Practice Update Committee in Gastroenterology’s February 2020 issue. This practice update helps us understand the impact we will make on cancer reduction with surveillance and treatment of Barrett’s. Despite this publication, Barrett’s management remains closer to “hope” than “sure.”

The difficulty we face, as clinician or patient, is what to do when outcomes are really serious but evidence remains close to the “I hope” end. Take a reasonably healthy 68-year-old man with asymptomatic coronary disease, but a very high (and increasing) coronary artery calcium score, despite maximum statins and appropriate lifestyle practices. Should he initiate a PCSK9 inhibitor ($14,000 per year) absent evidence that it would alter cardiac risk? Recently, a retrospective study nudged us along the continuum (Peng et al. JACC Cardiovascular Imaging. 2020 Jan;13[1 Pt 1]:83-93). A serious outcome, suggestive but not definitive evidence, and no time for an RCT. Will such aggressive therapy help? I sure hope so.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

In hospital medicine, inpatients often request more freedom to move within the hospital complex for a wide range of both benign and potentially concerning reasons, says Sara Stream, MD.

thinkstockphotos.com

“Hospitalists are often confronted with a dilemma when considering these patient requests: how to promote patient-centered care and autonomy while balancing patient safety, concerns for hospital liability, and the delivery of timely, efficient medical care,” said Dr. Stream, a hospitalist at the VA New York Harbor Healthcare System. Guidance from medical literature and institutional policies on inpatient movement are lacking, so Dr. Stream coauthored an article seeking to develop a framework with which hospitalists can approach patient requests for liberalized movement.

The authors concluded that for a small subset of patients, liberalized movement within the hospital may be clinically feasible: those who are medically, physically, and psychiatrically stable enough to move off their assigned floors without inordinate risk. “For the rest of inpatients, movement outside their monitored inpatient settings may interfere with appropriate medical care and undermine the indications for acute hospitalization,” Dr. Stream said.

Creating institutional policy that identifies relevant clinical, legal and ethical considerations, while incorporating the varied perspectives of physicians, patients, nurses, and hospital administration/risk management will allow requests for increased movement to be evaluated systematically and transparently.

“When patients request liberalized movement, hospitalists should consider the requests systematically: first to identify the intent behind requests, and then to follow a framework to determine whether increased movement would be safe and allow appropriate medical care without creating additional risks,” Dr. Stream said.

Hospitalists should assess and compile individual patient requests for liberalized movement and work with other physicians, nurses, hospital administration, and risk management to devise pertinent policy on this issue that is specific to their institutions. “By eventually creating clear guidelines in policy, health care providers will spend less time managing each individual request to leave the floor because they have a systematic strategy for making consistent decisions about patient movement,” the authors concluded.

Reference

1. Stream S, Alfandre D. “Just Getting a Cup of Coffee” – Considering Best Practices for Patients’ Movement off the Hospital Floor. J Hosp Med. 2019 Nov. doi: 10.12788/jhm.3227.

In hospital medicine, inpatients often request more freedom to move within the hospital complex for a wide range of both benign and potentially concerning reasons, says Sara Stream, MD.

thinkstockphotos.com

“Hospitalists are often confronted with a dilemma when considering these patient requests: how to promote patient-centered care and autonomy while balancing patient safety, concerns for hospital liability, and the delivery of timely, efficient medical care,” said Dr. Stream, a hospitalist at the VA New York Harbor Healthcare System. Guidance from medical literature and institutional policies on inpatient movement are lacking, so Dr. Stream coauthored an article seeking to develop a framework with which hospitalists can approach patient requests for liberalized movement.

The authors concluded that for a small subset of patients, liberalized movement within the hospital may be clinically feasible: those who are medically, physically, and psychiatrically stable enough to move off their assigned floors without inordinate risk. “For the rest of inpatients, movement outside their monitored inpatient settings may interfere with appropriate medical care and undermine the indications for acute hospitalization,” Dr. Stream said.

Creating institutional policy that identifies relevant clinical, legal and ethical considerations, while incorporating the varied perspectives of physicians, patients, nurses, and hospital administration/risk management will allow requests for increased movement to be evaluated systematically and transparently.

“When patients request liberalized movement, hospitalists should consider the requests systematically: first to identify the intent behind requests, and then to follow a framework to determine whether increased movement would be safe and allow appropriate medical care without creating additional risks,” Dr. Stream said.

Hospitalists should assess and compile individual patient requests for liberalized movement and work with other physicians, nurses, hospital administration, and risk management to devise pertinent policy on this issue that is specific to their institutions. “By eventually creating clear guidelines in policy, health care providers will spend less time managing each individual request to leave the floor because they have a systematic strategy for making consistent decisions about patient movement,” the authors concluded.

Reference

1. Stream S, Alfandre D. “Just Getting a Cup of Coffee” – Considering Best Practices for Patients’ Movement off the Hospital Floor. J Hosp Med. 2019 Nov. doi: 10.12788/jhm.3227.

In hospital medicine, inpatients often request more freedom to move within the hospital complex for a wide range of both benign and potentially concerning reasons, says Sara Stream, MD.

thinkstockphotos.com

“Hospitalists are often confronted with a dilemma when considering these patient requests: how to promote patient-centered care and autonomy while balancing patient safety, concerns for hospital liability, and the delivery of timely, efficient medical care,” said Dr. Stream, a hospitalist at the VA New York Harbor Healthcare System. Guidance from medical literature and institutional policies on inpatient movement are lacking, so Dr. Stream coauthored an article seeking to develop a framework with which hospitalists can approach patient requests for liberalized movement.

The authors concluded that for a small subset of patients, liberalized movement within the hospital may be clinically feasible: those who are medically, physically, and psychiatrically stable enough to move off their assigned floors without inordinate risk. “For the rest of inpatients, movement outside their monitored inpatient settings may interfere with appropriate medical care and undermine the indications for acute hospitalization,” Dr. Stream said.

Creating institutional policy that identifies relevant clinical, legal and ethical considerations, while incorporating the varied perspectives of physicians, patients, nurses, and hospital administration/risk management will allow requests for increased movement to be evaluated systematically and transparently.

“When patients request liberalized movement, hospitalists should consider the requests systematically: first to identify the intent behind requests, and then to follow a framework to determine whether increased movement would be safe and allow appropriate medical care without creating additional risks,” Dr. Stream said.

Hospitalists should assess and compile individual patient requests for liberalized movement and work with other physicians, nurses, hospital administration, and risk management to devise pertinent policy on this issue that is specific to their institutions. “By eventually creating clear guidelines in policy, health care providers will spend less time managing each individual request to leave the floor because they have a systematic strategy for making consistent decisions about patient movement,” the authors concluded.

Reference

1. Stream S, Alfandre D. “Just Getting a Cup of Coffee” – Considering Best Practices for Patients’ Movement off the Hospital Floor. J Hosp Med. 2019 Nov. doi: 10.12788/jhm.3227.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.