Declines in death rates for lung cancer and melanoma have gained momentum in recent years, fueling a record drop in cancer mortality, the American Cancer Society says.

Lung cancer death rates, which were falling by 3% in men and 2% in women annually in 2008 through 2013, dropped by 5% in men and nearly 4% per year in women annually from 2013 to 2017, according to the society’s 2020 statistical report.

Those accelerating reductions in death rates helped fuel the biggest-ever single year decline in overall cancer mortality, of 2.2%, from 2016 to 2017, their report shows.

According to the investigators, the decline in melanoma death rates escalated to 6.9% per year among 20- to 49-year-olds over 2013-2017, compared with a decline of just 2.9% per year during 2006-2010. Likewise, the melanoma death rate decline was 7.2% annually for the more recent time period, compared with just 1.3% annually in the earlier time period. The finding was even more remarkable for those 65 years of age and older, according to investigators, since the declines in melanoma death rates reached 6.2% annually, compared with a 0.9% annual increase in the years before immunotherapy.

Smoking cessation has been the main driver of progress in cutting lung cancer death rates, according to the report, while in melanoma, death rates have dropped after the introduction of immune checkpoint inhibitors and targeted therapies.

By contrast, reductions in death rates have slowed for colorectal cancers and female breast cancers, and have stabilized for prostate cancer, Ms. Siegel and coauthors stated, adding that racial and geographic disparities persist in preventable cancers, including those of the lung and cervix.

“Increased investment in both the equitable application of existing cancer control interventions and basic and clinical research to further advance treatment options would undoubtedly accelerate progress against cancer,” said the investigators. The report appears in CA: A Cancer Journal for Clinicians.

While the decline in lung cancer death rates is good news, the disease remains a major killer, responsible for more deaths than breast, colorectal, and ovarian cancer combined, said Jacques P. Fontaine, MD, a thoracic surgeon at Moffitt Cancer Center in Tampa, Fla.

“Five-year survival rates are still around the 18%-20% range, which is much lower than breast and prostate cancer,” Dr. Fontaine said in an interview. “Nonetheless, we’ve made a little dent in that, and we’re improving.”

Two other factors that have helped spur that improvement, according to Dr. Fontaine, are the reduced incidence of squamous cell carcinomas, which are linked to smoking, and the increased use of lung cancer screening with low-dose computed tomography.

Squamous cell carcinomas tend to be a central rather than peripheral, which makes the tumors harder to resect: “Surgery is sometimes not an option, and even to this day in 2020, the single most effective treatment for lung cancer remains surgical resection,” said Dr. Fontaine.

Likewise, centrally located tumors may preclude giving high-dose radiation and may result in more “collateral damage” to healthy tissue, he added.

Landmark studies show that low-dose CT scans reduce lung cancer deaths by 20% or more; however, screening can have false-positive results that lead to unnecessary biopsies and other harms, suggesting that the procedures should be done in centers of excellence that provide high-quality, responsible screening for early lung cancer, Dr. Fontaine said.

While the drop in melanoma death rates is encouraging and, not surprising in light of new cutting-edge therapies, an ongoing unmet treatment need still exists, according to Vishal Anil Patel, MD, director of cutaneous oncology at the George Washington Cancer Center in Washington.

“We still have a lot to learn, and a way to go, because we’ve really just made the first breakthrough,” Dr. Patel said in an interview.

SOURCE: Siegel RL et al. CA Cancer J Clin. 2020;70(1):7-30. doi: 10.3322/caac.21590.

Declines in death rates for lung cancer and melanoma have gained momentum in recent years, fueling a record drop in cancer mortality, the American Cancer Society says.

Lung cancer death rates, which were falling by 3% in men and 2% in women annually in 2008 through 2013, dropped by 5% in men and nearly 4% per year in women annually from 2013 to 2017, according to the society’s 2020 statistical report.

Those accelerating reductions in death rates helped fuel the biggest-ever single year decline in overall cancer mortality, of 2.2%, from 2016 to 2017, their report shows.

According to the investigators, the decline in melanoma death rates escalated to 6.9% per year among 20- to 49-year-olds over 2013-2017, compared with a decline of just 2.9% per year during 2006-2010. Likewise, the melanoma death rate decline was 7.2% annually for the more recent time period, compared with just 1.3% annually in the earlier time period. The finding was even more remarkable for those 65 years of age and older, according to investigators, since the declines in melanoma death rates reached 6.2% annually, compared with a 0.9% annual increase in the years before immunotherapy.

Smoking cessation has been the main driver of progress in cutting lung cancer death rates, according to the report, while in melanoma, death rates have dropped after the introduction of immune checkpoint inhibitors and targeted therapies.

By contrast, reductions in death rates have slowed for colorectal cancers and female breast cancers, and have stabilized for prostate cancer, Ms. Siegel and coauthors stated, adding that racial and geographic disparities persist in preventable cancers, including those of the lung and cervix.

“Increased investment in both the equitable application of existing cancer control interventions and basic and clinical research to further advance treatment options would undoubtedly accelerate progress against cancer,” said the investigators. The report appears in CA: A Cancer Journal for Clinicians.

While the decline in lung cancer death rates is good news, the disease remains a major killer, responsible for more deaths than breast, colorectal, and ovarian cancer combined, said Jacques P. Fontaine, MD, a thoracic surgeon at Moffitt Cancer Center in Tampa, Fla.

“Five-year survival rates are still around the 18%-20% range, which is much lower than breast and prostate cancer,” Dr. Fontaine said in an interview. “Nonetheless, we’ve made a little dent in that, and we’re improving.”

Two other factors that have helped spur that improvement, according to Dr. Fontaine, are the reduced incidence of squamous cell carcinomas, which are linked to smoking, and the increased use of lung cancer screening with low-dose computed tomography.

Squamous cell carcinomas tend to be a central rather than peripheral, which makes the tumors harder to resect: “Surgery is sometimes not an option, and even to this day in 2020, the single most effective treatment for lung cancer remains surgical resection,” said Dr. Fontaine.

Likewise, centrally located tumors may preclude giving high-dose radiation and may result in more “collateral damage” to healthy tissue, he added.

Landmark studies show that low-dose CT scans reduce lung cancer deaths by 20% or more; however, screening can have false-positive results that lead to unnecessary biopsies and other harms, suggesting that the procedures should be done in centers of excellence that provide high-quality, responsible screening for early lung cancer, Dr. Fontaine said.

While the drop in melanoma death rates is encouraging and, not surprising in light of new cutting-edge therapies, an ongoing unmet treatment need still exists, according to Vishal Anil Patel, MD, director of cutaneous oncology at the George Washington Cancer Center in Washington.

“We still have a lot to learn, and a way to go, because we’ve really just made the first breakthrough,” Dr. Patel said in an interview.

SOURCE: Siegel RL et al. CA Cancer J Clin. 2020;70(1):7-30. doi: 10.3322/caac.21590.

Declines in death rates for lung cancer and melanoma have gained momentum in recent years, fueling a record drop in cancer mortality, the American Cancer Society says.

Lung cancer death rates, which were falling by 3% in men and 2% in women annually in 2008 through 2013, dropped by 5% in men and nearly 4% per year in women annually from 2013 to 2017, according to the society’s 2020 statistical report.

Those accelerating reductions in death rates helped fuel the biggest-ever single year decline in overall cancer mortality, of 2.2%, from 2016 to 2017, their report shows.

According to the investigators, the decline in melanoma death rates escalated to 6.9% per year among 20- to 49-year-olds over 2013-2017, compared with a decline of just 2.9% per year during 2006-2010. Likewise, the melanoma death rate decline was 7.2% annually for the more recent time period, compared with just 1.3% annually in the earlier time period. The finding was even more remarkable for those 65 years of age and older, according to investigators, since the declines in melanoma death rates reached 6.2% annually, compared with a 0.9% annual increase in the years before immunotherapy.

Smoking cessation has been the main driver of progress in cutting lung cancer death rates, according to the report, while in melanoma, death rates have dropped after the introduction of immune checkpoint inhibitors and targeted therapies.

By contrast, reductions in death rates have slowed for colorectal cancers and female breast cancers, and have stabilized for prostate cancer, Ms. Siegel and coauthors stated, adding that racial and geographic disparities persist in preventable cancers, including those of the lung and cervix.

“Increased investment in both the equitable application of existing cancer control interventions and basic and clinical research to further advance treatment options would undoubtedly accelerate progress against cancer,” said the investigators. The report appears in CA: A Cancer Journal for Clinicians.

While the decline in lung cancer death rates is good news, the disease remains a major killer, responsible for more deaths than breast, colorectal, and ovarian cancer combined, said Jacques P. Fontaine, MD, a thoracic surgeon at Moffitt Cancer Center in Tampa, Fla.

“Five-year survival rates are still around the 18%-20% range, which is much lower than breast and prostate cancer,” Dr. Fontaine said in an interview. “Nonetheless, we’ve made a little dent in that, and we’re improving.”

Two other factors that have helped spur that improvement, according to Dr. Fontaine, are the reduced incidence of squamous cell carcinomas, which are linked to smoking, and the increased use of lung cancer screening with low-dose computed tomography.

Squamous cell carcinomas tend to be a central rather than peripheral, which makes the tumors harder to resect: “Surgery is sometimes not an option, and even to this day in 2020, the single most effective treatment for lung cancer remains surgical resection,” said Dr. Fontaine.

Likewise, centrally located tumors may preclude giving high-dose radiation and may result in more “collateral damage” to healthy tissue, he added.

Landmark studies show that low-dose CT scans reduce lung cancer deaths by 20% or more; however, screening can have false-positive results that lead to unnecessary biopsies and other harms, suggesting that the procedures should be done in centers of excellence that provide high-quality, responsible screening for early lung cancer, Dr. Fontaine said.

While the drop in melanoma death rates is encouraging and, not surprising in light of new cutting-edge therapies, an ongoing unmet treatment need still exists, according to Vishal Anil Patel, MD, director of cutaneous oncology at the George Washington Cancer Center in Washington.

“We still have a lot to learn, and a way to go, because we’ve really just made the first breakthrough,” Dr. Patel said in an interview.

SOURCE: Siegel RL et al. CA Cancer J Clin. 2020;70(1):7-30. doi: 10.3322/caac.21590.

Over the past 10 years, much has changed in the world of pediatric hospital medicine. The annual national PHM conference sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) is robust; textbooks and journal articles in the field abound; and networks and training in research, quality improvement, and education are successful and ongoing.

Much of this did not exist or was in its infancy back in 2010. Since then, it has grown and greatly evolved. In parallel, medicine and society have changed. These influences on health care, along with the growth of the field over time, prompted a review and revision of the 2010 PHM Core Competencies published by SHM. With support from the society, the Pediatric Hospital Medicine Special Interest Group launched the plan for revision of the PHM Core Competencies.

The selected editors included Sandra Gage, MD, PhD, SFHM, of Phoenix Children’s Hospital; Erin Stucky Fisher, MD, MHM, of UCSD/Rady Children’s Hospital in San Diego; Jennifer Maniscalco, MD, MPH, of Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.; and Sofia Teferi, MD, SFHM, a pediatric hospitalist based at Bon Secours St. Mary’s Hospital in Richmond, Va. They began their work in 2017 along with six associate editors, meeting every 2 weeks via conference call, dividing the work accordingly.

Dr. Teferi served in a new and critical role as contributing editor. She described her role as a “sweeper” of sorts, bringing her unique perspective to the process. “The other three members are from academic settings, and I’m from a community setting, which is very different,” Dr. Teferi said. “I went through all the chapters to ensure they were inclusive of the community setting.”

According to Dr. Gage, “the purpose of the original PHM Core Competencies was to define the roles and responsibilities of a PHM practitioner. In the intervening 10 years, the field has changed and matured, and we have solidified our role since then.”

Today’s pediatric hospitalists, for instance, may coordinate care in EDs, provide inpatient consultations, engage or lead quality improvement programs, and teach. The demands for pediatric hospital care today go beyond the training provided in a standard pediatric residency. The core competencies need to provide the information necessary, therefore, to ensure pediatric hospital medicine is practiced at its most informed level.
 

A profession transformed

At the time of the first set of core competencies, there were over 2,500 members in three core societies in which pediatric hospitalists were members: the AAP, the APA, and SHM. As of 2017, those numbers have swelled as the care for children in the hospital setting has shifted away from these patients’ primary care providers.

The original core competencies included 54 chapters, designed to be used independent of the others. They provided a foundation for the creation of pediatric hospital medicine and served to standardize and improve inpatient training practices.

For the new core competencies, every single chapter was reviewed line by line, Dr. Gage said. Many chapters had content modified, and new chapters were added to reflect the evolution of the field and of medicine. “We added about 14 new chapters, adjusted the titles of others, and significantly changed the content of over half,” Dr. Gage explained. “They are fairly broad changes, related to the breadth of the practice today.”

Dr. Teferi noted that practitioners can use the updated competencies with additions to the service lines that have arisen since the last version. “These include areas like step down and newborn nursery, things that weren’t part of our portfolio 10 years ago,” she said. “This reflects the fact that often you’ll see a hospital leader who might want to add to a hospitalist’s portfolio of services because there is no one else to do it. Or maybe community pediatrics no longer want to treat babies, so we add that. The settings vary widely today and we need the competencies to address that.”

Practices within these settings can also vary widely. Teaching, palliative care, airway management, critical care, and anesthesia may all come into play, among other factors. Research opportunities throughout the field also continue to expand.

Dr. Fisher said that the editors and associate editors kept in mind the fact that not every hospital would have all the resources necessary at its fingertips. “The competencies must reflect the realities of the variety of community settings,” she said. “Also, on a national level, the majority of pediatric patients are not seen in a children’s hospital. Community sites are where pediatric hospitalists are not only advocates for care, but can be working with limited resources – the ‘lone soldiers.’ We wanted to make sure the competencies reflect that reality and environment community site or not; academic site or not; tertiary care site or not; rural or not – these are overlapping but independent considerations for all who practice pediatric hospital medicine – a Venn diagram, and the PHM core competencies try to attend to all of those.”

This made Dr. Teferi’s perspective all the more important. “While many, including other editors and associate editors, work in community sites, Dr. Teferi has this as her unique and sole focus. She brought a unique viewpoint to the table,” Dr. Fisher said.

A goal of the core competencies is to make it possible for a pediatric hospitalist to move to a different practice environment and still provide the same level of high-quality care. “It’s difficult but important to grasp the concepts and competencies of various settings,” Dr. Fisher said. “In this way, our competencies are a parallel model to the adult hospitalist competencies.”

The editors surveyed practitioners across the country to gather their input on content, and brought on topic experts to write the new chapters. “If we didn’t have an author for a specific chapter or area from the last set of competencies, we came to a consensus on who the new one should be,” Dr. Gage explained. “We looked for known and accepted experts in the field by reviewing the literature and conference lecturers at all major PHM meetings.”

Once the editors and associate editors worked with authors to refine their chapter(s), the chapters were sent to multiple external reviewers including subgroups of SHM, AAP, and APA, as well as a variety of other associations. They provided input that the editors and associate editors collated, reviewed, and incorporated according to consensus and discussion with the authors.
 

A preview

As far as the actual changes go, some of new chapters include four common clinical, two core skills, three specialized services, and five health care systems, with many others undergoing content changes, according to Dr. Gage.

Major considerations in developing the new competencies include the national trend of rising mental health issues among young patients. According to the AAP, over the last decade the number of young people aged 6-17 years requiring mental health care has risen from 9% to more than 14%. In outpatient settings, many pediatricians report that half or more of their visits are dedicated to these issues, a number that may spill out into the hospital setting as well.

According to Dr. Fisher, pediatric hospitalists today see increasing numbers of chronic and acute diseases accompanied by mental and behavioral health issues. “We wanted to underscore this complexity in the competencies,” she explained. “We needed to focus new attention on how to identify and treat children with behavioral or psychiatric diagnoses or needs.”

Other new areas of focus include infection care and antimicrobial stewardship. “We see kids on antibiotics in hospital settings and we need to focus on narrowing choices, decreasing use, and shortening duration,” Dr. Gage said.

Dr. Maniscalco said that, overall, the changes represent the evolution of the field. “Pediatric hospitalists are taking on far more patients with acute and complex issues,” she explained. “Our skill set is coming into focus.”

Dr. Gage added that there is an increased need for pediatric hospitalists to be adept at “managing acute psychiatric care and navigating the mental health care arena.”

There’s also the growing need for an understanding of neonatal abstinence and opioid withdrawal syndrome. “This is definitely a hot topic and one that most hospitalists must address today,” Dr. Gage said. “That wasn’t the case a decade ago.”

Hospital care for pediatrics today often means a team effort, including pediatric hospitalists, surgeons, mental health professionals, and others. Often missing from the picture today are primary care physicians, who instead refer a growing percentage of their patients to hospitalists. The pediatric hospitalist’s role has evolved and grown from what it was 10 years ago, as reflected in the competencies.

“We are very much coordinating care and collaborating today in ways we weren’t 10 years ago,” said Dr. Gage. “There’s a lot more attention on creating partnerships. While we may not always be the ones performing procedures, we will most likely take part in patient care, especially as surgeons step farther away from care outside of the OR.”

The field has also become more family centered, said Dr. Gage. “All of health care today is more astute about the participation of families in care,” she said. “We kept that in mind in developing the competencies.”

Also important in this set of competencies was the concept of high-value care using evidence-based medicine.
 

Into the field

How exactly the core competencies will be utilized from one hospital or setting to the next will vary, said Dr. Fisher. “For some sites, they can aid existing teaching programs, and they will most likely adapt their curriculum to address the new competencies, informing how they teach.”

Even in centers where there isn’t a formal academic role, teaching still occurs. “Pediatric hospitalists have roles on committees and projects, and giving a talk to respiratory therapists, having group meetings – these all involve teaching in some form,” Dr. Fisher said. “Most physicians will determine how they wish to insert the competencies into their own education, as well as use them to educate others.”

Regardless of how they may be used locally, Dr. Fisher anticipates that the entire pediatric hospitalist community will appreciate the updates. “The competencies address our rapidly changing health care environment,” she said. “We believe the field will benefit from the additions and changes.”

Indeed, the core competencies will help standardize and improve consistency of care across the board. Improved efficiencies, economics, and practices are all desired and expected outcomes from the release of the revised competencies.

To ensure that the changes to the competencies are highlighted in settings nationwide, the editors and associate editors hope to present about them at upcoming conferences, including at the SHM 2020 Annual Conference, the Pediatric Hospital Medicine conference, the Pediatric Academic Societies conference, and the American Pediatric Association.

“We want to present to as many venues as possible to bring people up to speed and ensure they are aware of the changes,” Dr. Teferi said. “We’ll be including workshops with visual aids, along with our presentations.”

While this update represents a 10-year evolution, the editors and the SHM Pediatric Special Interest Group do not have an exact time frame for when the core competencies will need another revision. As quickly as the profession is developing, it may be as few as 5 years, but may also be another full decade.

“Like most fields, we will continue to evolve as our roles become better defined and we gain more knowledge,” Dr. Maniscalco said. “The core competencies represent the field whether a senior pediatric hospitalist, a fellow, or an educator. They bring the field together and provide education for everyone. That’s their role.”

Over the past 10 years, much has changed in the world of pediatric hospital medicine. The annual national PHM conference sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) is robust; textbooks and journal articles in the field abound; and networks and training in research, quality improvement, and education are successful and ongoing.

Much of this did not exist or was in its infancy back in 2010. Since then, it has grown and greatly evolved. In parallel, medicine and society have changed. These influences on health care, along with the growth of the field over time, prompted a review and revision of the 2010 PHM Core Competencies published by SHM. With support from the society, the Pediatric Hospital Medicine Special Interest Group launched the plan for revision of the PHM Core Competencies.

The selected editors included Sandra Gage, MD, PhD, SFHM, of Phoenix Children’s Hospital; Erin Stucky Fisher, MD, MHM, of UCSD/Rady Children’s Hospital in San Diego; Jennifer Maniscalco, MD, MPH, of Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.; and Sofia Teferi, MD, SFHM, a pediatric hospitalist based at Bon Secours St. Mary’s Hospital in Richmond, Va. They began their work in 2017 along with six associate editors, meeting every 2 weeks via conference call, dividing the work accordingly.

Dr. Teferi served in a new and critical role as contributing editor. She described her role as a “sweeper” of sorts, bringing her unique perspective to the process. “The other three members are from academic settings, and I’m from a community setting, which is very different,” Dr. Teferi said. “I went through all the chapters to ensure they were inclusive of the community setting.”

According to Dr. Gage, “the purpose of the original PHM Core Competencies was to define the roles and responsibilities of a PHM practitioner. In the intervening 10 years, the field has changed and matured, and we have solidified our role since then.”

Today’s pediatric hospitalists, for instance, may coordinate care in EDs, provide inpatient consultations, engage or lead quality improvement programs, and teach. The demands for pediatric hospital care today go beyond the training provided in a standard pediatric residency. The core competencies need to provide the information necessary, therefore, to ensure pediatric hospital medicine is practiced at its most informed level.
 

A profession transformed

At the time of the first set of core competencies, there were over 2,500 members in three core societies in which pediatric hospitalists were members: the AAP, the APA, and SHM. As of 2017, those numbers have swelled as the care for children in the hospital setting has shifted away from these patients’ primary care providers.

The original core competencies included 54 chapters, designed to be used independent of the others. They provided a foundation for the creation of pediatric hospital medicine and served to standardize and improve inpatient training practices.

For the new core competencies, every single chapter was reviewed line by line, Dr. Gage said. Many chapters had content modified, and new chapters were added to reflect the evolution of the field and of medicine. “We added about 14 new chapters, adjusted the titles of others, and significantly changed the content of over half,” Dr. Gage explained. “They are fairly broad changes, related to the breadth of the practice today.”

Dr. Teferi noted that practitioners can use the updated competencies with additions to the service lines that have arisen since the last version. “These include areas like step down and newborn nursery, things that weren’t part of our portfolio 10 years ago,” she said. “This reflects the fact that often you’ll see a hospital leader who might want to add to a hospitalist’s portfolio of services because there is no one else to do it. Or maybe community pediatrics no longer want to treat babies, so we add that. The settings vary widely today and we need the competencies to address that.”

Practices within these settings can also vary widely. Teaching, palliative care, airway management, critical care, and anesthesia may all come into play, among other factors. Research opportunities throughout the field also continue to expand.

Dr. Fisher said that the editors and associate editors kept in mind the fact that not every hospital would have all the resources necessary at its fingertips. “The competencies must reflect the realities of the variety of community settings,” she said. “Also, on a national level, the majority of pediatric patients are not seen in a children’s hospital. Community sites are where pediatric hospitalists are not only advocates for care, but can be working with limited resources – the ‘lone soldiers.’ We wanted to make sure the competencies reflect that reality and environment community site or not; academic site or not; tertiary care site or not; rural or not – these are overlapping but independent considerations for all who practice pediatric hospital medicine – a Venn diagram, and the PHM core competencies try to attend to all of those.”

This made Dr. Teferi’s perspective all the more important. “While many, including other editors and associate editors, work in community sites, Dr. Teferi has this as her unique and sole focus. She brought a unique viewpoint to the table,” Dr. Fisher said.

A goal of the core competencies is to make it possible for a pediatric hospitalist to move to a different practice environment and still provide the same level of high-quality care. “It’s difficult but important to grasp the concepts and competencies of various settings,” Dr. Fisher said. “In this way, our competencies are a parallel model to the adult hospitalist competencies.”

The editors surveyed practitioners across the country to gather their input on content, and brought on topic experts to write the new chapters. “If we didn’t have an author for a specific chapter or area from the last set of competencies, we came to a consensus on who the new one should be,” Dr. Gage explained. “We looked for known and accepted experts in the field by reviewing the literature and conference lecturers at all major PHM meetings.”

Once the editors and associate editors worked with authors to refine their chapter(s), the chapters were sent to multiple external reviewers including subgroups of SHM, AAP, and APA, as well as a variety of other associations. They provided input that the editors and associate editors collated, reviewed, and incorporated according to consensus and discussion with the authors.
 

A preview

As far as the actual changes go, some of new chapters include four common clinical, two core skills, three specialized services, and five health care systems, with many others undergoing content changes, according to Dr. Gage.

Major considerations in developing the new competencies include the national trend of rising mental health issues among young patients. According to the AAP, over the last decade the number of young people aged 6-17 years requiring mental health care has risen from 9% to more than 14%. In outpatient settings, many pediatricians report that half or more of their visits are dedicated to these issues, a number that may spill out into the hospital setting as well.

According to Dr. Fisher, pediatric hospitalists today see increasing numbers of chronic and acute diseases accompanied by mental and behavioral health issues. “We wanted to underscore this complexity in the competencies,” she explained. “We needed to focus new attention on how to identify and treat children with behavioral or psychiatric diagnoses or needs.”

Other new areas of focus include infection care and antimicrobial stewardship. “We see kids on antibiotics in hospital settings and we need to focus on narrowing choices, decreasing use, and shortening duration,” Dr. Gage said.

Dr. Maniscalco said that, overall, the changes represent the evolution of the field. “Pediatric hospitalists are taking on far more patients with acute and complex issues,” she explained. “Our skill set is coming into focus.”

Dr. Gage added that there is an increased need for pediatric hospitalists to be adept at “managing acute psychiatric care and navigating the mental health care arena.”

There’s also the growing need for an understanding of neonatal abstinence and opioid withdrawal syndrome. “This is definitely a hot topic and one that most hospitalists must address today,” Dr. Gage said. “That wasn’t the case a decade ago.”

Hospital care for pediatrics today often means a team effort, including pediatric hospitalists, surgeons, mental health professionals, and others. Often missing from the picture today are primary care physicians, who instead refer a growing percentage of their patients to hospitalists. The pediatric hospitalist’s role has evolved and grown from what it was 10 years ago, as reflected in the competencies.

“We are very much coordinating care and collaborating today in ways we weren’t 10 years ago,” said Dr. Gage. “There’s a lot more attention on creating partnerships. While we may not always be the ones performing procedures, we will most likely take part in patient care, especially as surgeons step farther away from care outside of the OR.”

The field has also become more family centered, said Dr. Gage. “All of health care today is more astute about the participation of families in care,” she said. “We kept that in mind in developing the competencies.”

Also important in this set of competencies was the concept of high-value care using evidence-based medicine.
 

Into the field

How exactly the core competencies will be utilized from one hospital or setting to the next will vary, said Dr. Fisher. “For some sites, they can aid existing teaching programs, and they will most likely adapt their curriculum to address the new competencies, informing how they teach.”

Even in centers where there isn’t a formal academic role, teaching still occurs. “Pediatric hospitalists have roles on committees and projects, and giving a talk to respiratory therapists, having group meetings – these all involve teaching in some form,” Dr. Fisher said. “Most physicians will determine how they wish to insert the competencies into their own education, as well as use them to educate others.”

Regardless of how they may be used locally, Dr. Fisher anticipates that the entire pediatric hospitalist community will appreciate the updates. “The competencies address our rapidly changing health care environment,” she said. “We believe the field will benefit from the additions and changes.”

Indeed, the core competencies will help standardize and improve consistency of care across the board. Improved efficiencies, economics, and practices are all desired and expected outcomes from the release of the revised competencies.

To ensure that the changes to the competencies are highlighted in settings nationwide, the editors and associate editors hope to present about them at upcoming conferences, including at the SHM 2020 Annual Conference, the Pediatric Hospital Medicine conference, the Pediatric Academic Societies conference, and the American Pediatric Association.

“We want to present to as many venues as possible to bring people up to speed and ensure they are aware of the changes,” Dr. Teferi said. “We’ll be including workshops with visual aids, along with our presentations.”

While this update represents a 10-year evolution, the editors and the SHM Pediatric Special Interest Group do not have an exact time frame for when the core competencies will need another revision. As quickly as the profession is developing, it may be as few as 5 years, but may also be another full decade.

“Like most fields, we will continue to evolve as our roles become better defined and we gain more knowledge,” Dr. Maniscalco said. “The core competencies represent the field whether a senior pediatric hospitalist, a fellow, or an educator. They bring the field together and provide education for everyone. That’s their role.”

Over the past 10 years, much has changed in the world of pediatric hospital medicine. The annual national PHM conference sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) is robust; textbooks and journal articles in the field abound; and networks and training in research, quality improvement, and education are successful and ongoing.

Much of this did not exist or was in its infancy back in 2010. Since then, it has grown and greatly evolved. In parallel, medicine and society have changed. These influences on health care, along with the growth of the field over time, prompted a review and revision of the 2010 PHM Core Competencies published by SHM. With support from the society, the Pediatric Hospital Medicine Special Interest Group launched the plan for revision of the PHM Core Competencies.

The selected editors included Sandra Gage, MD, PhD, SFHM, of Phoenix Children’s Hospital; Erin Stucky Fisher, MD, MHM, of UCSD/Rady Children’s Hospital in San Diego; Jennifer Maniscalco, MD, MPH, of Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.; and Sofia Teferi, MD, SFHM, a pediatric hospitalist based at Bon Secours St. Mary’s Hospital in Richmond, Va. They began their work in 2017 along with six associate editors, meeting every 2 weeks via conference call, dividing the work accordingly.

Dr. Teferi served in a new and critical role as contributing editor. She described her role as a “sweeper” of sorts, bringing her unique perspective to the process. “The other three members are from academic settings, and I’m from a community setting, which is very different,” Dr. Teferi said. “I went through all the chapters to ensure they were inclusive of the community setting.”

According to Dr. Gage, “the purpose of the original PHM Core Competencies was to define the roles and responsibilities of a PHM practitioner. In the intervening 10 years, the field has changed and matured, and we have solidified our role since then.”

Today’s pediatric hospitalists, for instance, may coordinate care in EDs, provide inpatient consultations, engage or lead quality improvement programs, and teach. The demands for pediatric hospital care today go beyond the training provided in a standard pediatric residency. The core competencies need to provide the information necessary, therefore, to ensure pediatric hospital medicine is practiced at its most informed level.
 

A profession transformed

At the time of the first set of core competencies, there were over 2,500 members in three core societies in which pediatric hospitalists were members: the AAP, the APA, and SHM. As of 2017, those numbers have swelled as the care for children in the hospital setting has shifted away from these patients’ primary care providers.

The original core competencies included 54 chapters, designed to be used independent of the others. They provided a foundation for the creation of pediatric hospital medicine and served to standardize and improve inpatient training practices.

For the new core competencies, every single chapter was reviewed line by line, Dr. Gage said. Many chapters had content modified, and new chapters were added to reflect the evolution of the field and of medicine. “We added about 14 new chapters, adjusted the titles of others, and significantly changed the content of over half,” Dr. Gage explained. “They are fairly broad changes, related to the breadth of the practice today.”

Dr. Teferi noted that practitioners can use the updated competencies with additions to the service lines that have arisen since the last version. “These include areas like step down and newborn nursery, things that weren’t part of our portfolio 10 years ago,” she said. “This reflects the fact that often you’ll see a hospital leader who might want to add to a hospitalist’s portfolio of services because there is no one else to do it. Or maybe community pediatrics no longer want to treat babies, so we add that. The settings vary widely today and we need the competencies to address that.”

Practices within these settings can also vary widely. Teaching, palliative care, airway management, critical care, and anesthesia may all come into play, among other factors. Research opportunities throughout the field also continue to expand.

Dr. Fisher said that the editors and associate editors kept in mind the fact that not every hospital would have all the resources necessary at its fingertips. “The competencies must reflect the realities of the variety of community settings,” she said. “Also, on a national level, the majority of pediatric patients are not seen in a children’s hospital. Community sites are where pediatric hospitalists are not only advocates for care, but can be working with limited resources – the ‘lone soldiers.’ We wanted to make sure the competencies reflect that reality and environment community site or not; academic site or not; tertiary care site or not; rural or not – these are overlapping but independent considerations for all who practice pediatric hospital medicine – a Venn diagram, and the PHM core competencies try to attend to all of those.”

This made Dr. Teferi’s perspective all the more important. “While many, including other editors and associate editors, work in community sites, Dr. Teferi has this as her unique and sole focus. She brought a unique viewpoint to the table,” Dr. Fisher said.

A goal of the core competencies is to make it possible for a pediatric hospitalist to move to a different practice environment and still provide the same level of high-quality care. “It’s difficult but important to grasp the concepts and competencies of various settings,” Dr. Fisher said. “In this way, our competencies are a parallel model to the adult hospitalist competencies.”

The editors surveyed practitioners across the country to gather their input on content, and brought on topic experts to write the new chapters. “If we didn’t have an author for a specific chapter or area from the last set of competencies, we came to a consensus on who the new one should be,” Dr. Gage explained. “We looked for known and accepted experts in the field by reviewing the literature and conference lecturers at all major PHM meetings.”

Once the editors and associate editors worked with authors to refine their chapter(s), the chapters were sent to multiple external reviewers including subgroups of SHM, AAP, and APA, as well as a variety of other associations. They provided input that the editors and associate editors collated, reviewed, and incorporated according to consensus and discussion with the authors.
 

A preview

As far as the actual changes go, some of new chapters include four common clinical, two core skills, three specialized services, and five health care systems, with many others undergoing content changes, according to Dr. Gage.

Major considerations in developing the new competencies include the national trend of rising mental health issues among young patients. According to the AAP, over the last decade the number of young people aged 6-17 years requiring mental health care has risen from 9% to more than 14%. In outpatient settings, many pediatricians report that half or more of their visits are dedicated to these issues, a number that may spill out into the hospital setting as well.

According to Dr. Fisher, pediatric hospitalists today see increasing numbers of chronic and acute diseases accompanied by mental and behavioral health issues. “We wanted to underscore this complexity in the competencies,” she explained. “We needed to focus new attention on how to identify and treat children with behavioral or psychiatric diagnoses or needs.”

Other new areas of focus include infection care and antimicrobial stewardship. “We see kids on antibiotics in hospital settings and we need to focus on narrowing choices, decreasing use, and shortening duration,” Dr. Gage said.

Dr. Maniscalco said that, overall, the changes represent the evolution of the field. “Pediatric hospitalists are taking on far more patients with acute and complex issues,” she explained. “Our skill set is coming into focus.”

Dr. Gage added that there is an increased need for pediatric hospitalists to be adept at “managing acute psychiatric care and navigating the mental health care arena.”

There’s also the growing need for an understanding of neonatal abstinence and opioid withdrawal syndrome. “This is definitely a hot topic and one that most hospitalists must address today,” Dr. Gage said. “That wasn’t the case a decade ago.”

Hospital care for pediatrics today often means a team effort, including pediatric hospitalists, surgeons, mental health professionals, and others. Often missing from the picture today are primary care physicians, who instead refer a growing percentage of their patients to hospitalists. The pediatric hospitalist’s role has evolved and grown from what it was 10 years ago, as reflected in the competencies.

“We are very much coordinating care and collaborating today in ways we weren’t 10 years ago,” said Dr. Gage. “There’s a lot more attention on creating partnerships. While we may not always be the ones performing procedures, we will most likely take part in patient care, especially as surgeons step farther away from care outside of the OR.”

The field has also become more family centered, said Dr. Gage. “All of health care today is more astute about the participation of families in care,” she said. “We kept that in mind in developing the competencies.”

Also important in this set of competencies was the concept of high-value care using evidence-based medicine.
 

Into the field

How exactly the core competencies will be utilized from one hospital or setting to the next will vary, said Dr. Fisher. “For some sites, they can aid existing teaching programs, and they will most likely adapt their curriculum to address the new competencies, informing how they teach.”

Even in centers where there isn’t a formal academic role, teaching still occurs. “Pediatric hospitalists have roles on committees and projects, and giving a talk to respiratory therapists, having group meetings – these all involve teaching in some form,” Dr. Fisher said. “Most physicians will determine how they wish to insert the competencies into their own education, as well as use them to educate others.”

Regardless of how they may be used locally, Dr. Fisher anticipates that the entire pediatric hospitalist community will appreciate the updates. “The competencies address our rapidly changing health care environment,” she said. “We believe the field will benefit from the additions and changes.”

Indeed, the core competencies will help standardize and improve consistency of care across the board. Improved efficiencies, economics, and practices are all desired and expected outcomes from the release of the revised competencies.

To ensure that the changes to the competencies are highlighted in settings nationwide, the editors and associate editors hope to present about them at upcoming conferences, including at the SHM 2020 Annual Conference, the Pediatric Hospital Medicine conference, the Pediatric Academic Societies conference, and the American Pediatric Association.

“We want to present to as many venues as possible to bring people up to speed and ensure they are aware of the changes,” Dr. Teferi said. “We’ll be including workshops with visual aids, along with our presentations.”

While this update represents a 10-year evolution, the editors and the SHM Pediatric Special Interest Group do not have an exact time frame for when the core competencies will need another revision. As quickly as the profession is developing, it may be as few as 5 years, but may also be another full decade.

“Like most fields, we will continue to evolve as our roles become better defined and we gain more knowledge,” Dr. Maniscalco said. “The core competencies represent the field whether a senior pediatric hospitalist, a fellow, or an educator. They bring the field together and provide education for everyone. That’s their role.”

ORLANDO – A small study suggests health care providers may fail to ask patients about heavy menstrual bleeding before or during treatment with oral anticoagulants.

Jennifer Smith/MDedge News

Researchers performed a chart review at a single center, which indicated that 60% of women were not asked about heavy menstrual bleeding before they were prescribed an oral anticoagulant.

Six months after the women started anticoagulant therapy, 29% required treatment for heavy menstrual bleeding. Charts for the remaining 71% of women contained no information about heavy menstrual bleeding.

“We were unable to distinguish between true absence of heavy menstrual bleeding and absence of reporting,” said Bethany T. Samuelson Bannow, MD, of Oregon Health & Science University, Portland.

Dr. Samuelson Bannow presented these findings at the annual meeting of the American Society of Hematology.

She explained that heavy menstrual bleeding is defined as more than 80 mL of blood loss per cycle. It affects 10%-15% of women in their lifetime, and anticoagulants increase the risk of heavy menstrual bleeding.

Studies have shown that heavy menstrual bleeding occurs in 22%-65% of women treated with vitamin K agonists and 20%-27% of women treated with rivaroxaban (Blood. 2017;130[24]:2603-9). However, many anticoagulant studies don’t include heavy menstrual bleeding as an outcome.

To gain more insight, Dr. Samuelson Bannow and colleagues conducted a chart review. Their study included 236 women of reproductive age treated at Oregon Health & Science University between Jan. 1, 2012, and Dec. 31, 2018.

The patients’ median age was 37 years (range, 18-50 years). Most patients (67%) were receiving an oral anticoagulant for venous thromboembolism. The rest were on anticoagulant therapy for arterial thrombosis (6%), atrial fibrillation (6%), a mechanical valve (1%), or “other” reasons (20%).

Dr. Samuelson Bannow said the other group was “almost exclusively women who were receiving prophylaxis” postoperatively or for travel. Most women in this group were receiving rivaroxaban.

Rivaroxaban was the most commonly prescribed anticoagulant in the entire cohort (41%), followed by warfarin (34%) and apixaban (25%).

At the time of anticoagulant prescription, 12% of women reported a history of heavy menstrual bleeding, and 28% did not. For most patients – 60% – there was no discussion of menstrual history documented.

Six months after starting oral anticoagulant therapy, 29% of patients required treatment for heavy menstrual bleeding. For 71% of patients, there was no documentation on the treatment of heavy menstrual bleeding.

Treatment for heavy menstrual bleeding was required in 33% of patients on rivaroxaban, 24% of those on apixaban, and 29% of those on warfarin, a significant difference (P less than .001).

“Rates of heavy menstrual bleeding … are higher in rivaroxaban users,” Dr. Samuelson Bannow said. “This is not the first study to demonstrate this. However, [the rate of heavy menstrual bleeding in this study] is still a lot lower than we would expect based on past levels with warfarin. This tells us we’re probably missing a lot of heavy menstrual bleeding. That’s not too surprising considering how few providers are actually asking about the menses.”

Dr. Samuelson Bannow and colleagues disclosed no conflicts of interest.

jensmith@mdedge.com

SOURCE: Samuelson Bannow BT et al. ASH 2019, Abstract 60.

ORLANDO – A small study suggests health care providers may fail to ask patients about heavy menstrual bleeding before or during treatment with oral anticoagulants.

Jennifer Smith/MDedge News

Researchers performed a chart review at a single center, which indicated that 60% of women were not asked about heavy menstrual bleeding before they were prescribed an oral anticoagulant.

Six months after the women started anticoagulant therapy, 29% required treatment for heavy menstrual bleeding. Charts for the remaining 71% of women contained no information about heavy menstrual bleeding.

“We were unable to distinguish between true absence of heavy menstrual bleeding and absence of reporting,” said Bethany T. Samuelson Bannow, MD, of Oregon Health & Science University, Portland.

Dr. Samuelson Bannow presented these findings at the annual meeting of the American Society of Hematology.

She explained that heavy menstrual bleeding is defined as more than 80 mL of blood loss per cycle. It affects 10%-15% of women in their lifetime, and anticoagulants increase the risk of heavy menstrual bleeding.

Studies have shown that heavy menstrual bleeding occurs in 22%-65% of women treated with vitamin K agonists and 20%-27% of women treated with rivaroxaban (Blood. 2017;130[24]:2603-9). However, many anticoagulant studies don’t include heavy menstrual bleeding as an outcome.

To gain more insight, Dr. Samuelson Bannow and colleagues conducted a chart review. Their study included 236 women of reproductive age treated at Oregon Health & Science University between Jan. 1, 2012, and Dec. 31, 2018.

The patients’ median age was 37 years (range, 18-50 years). Most patients (67%) were receiving an oral anticoagulant for venous thromboembolism. The rest were on anticoagulant therapy for arterial thrombosis (6%), atrial fibrillation (6%), a mechanical valve (1%), or “other” reasons (20%).

Dr. Samuelson Bannow said the other group was “almost exclusively women who were receiving prophylaxis” postoperatively or for travel. Most women in this group were receiving rivaroxaban.

Rivaroxaban was the most commonly prescribed anticoagulant in the entire cohort (41%), followed by warfarin (34%) and apixaban (25%).

At the time of anticoagulant prescription, 12% of women reported a history of heavy menstrual bleeding, and 28% did not. For most patients – 60% – there was no discussion of menstrual history documented.

Six months after starting oral anticoagulant therapy, 29% of patients required treatment for heavy menstrual bleeding. For 71% of patients, there was no documentation on the treatment of heavy menstrual bleeding.

Treatment for heavy menstrual bleeding was required in 33% of patients on rivaroxaban, 24% of those on apixaban, and 29% of those on warfarin, a significant difference (P less than .001).

“Rates of heavy menstrual bleeding … are higher in rivaroxaban users,” Dr. Samuelson Bannow said. “This is not the first study to demonstrate this. However, [the rate of heavy menstrual bleeding in this study] is still a lot lower than we would expect based on past levels with warfarin. This tells us we’re probably missing a lot of heavy menstrual bleeding. That’s not too surprising considering how few providers are actually asking about the menses.”

Dr. Samuelson Bannow and colleagues disclosed no conflicts of interest.

jensmith@mdedge.com

SOURCE: Samuelson Bannow BT et al. ASH 2019, Abstract 60.

ORLANDO – A small study suggests health care providers may fail to ask patients about heavy menstrual bleeding before or during treatment with oral anticoagulants.

Jennifer Smith/MDedge News

Researchers performed a chart review at a single center, which indicated that 60% of women were not asked about heavy menstrual bleeding before they were prescribed an oral anticoagulant.

Six months after the women started anticoagulant therapy, 29% required treatment for heavy menstrual bleeding. Charts for the remaining 71% of women contained no information about heavy menstrual bleeding.

“We were unable to distinguish between true absence of heavy menstrual bleeding and absence of reporting,” said Bethany T. Samuelson Bannow, MD, of Oregon Health & Science University, Portland.

Dr. Samuelson Bannow presented these findings at the annual meeting of the American Society of Hematology.

She explained that heavy menstrual bleeding is defined as more than 80 mL of blood loss per cycle. It affects 10%-15% of women in their lifetime, and anticoagulants increase the risk of heavy menstrual bleeding.

Studies have shown that heavy menstrual bleeding occurs in 22%-65% of women treated with vitamin K agonists and 20%-27% of women treated with rivaroxaban (Blood. 2017;130[24]:2603-9). However, many anticoagulant studies don’t include heavy menstrual bleeding as an outcome.

To gain more insight, Dr. Samuelson Bannow and colleagues conducted a chart review. Their study included 236 women of reproductive age treated at Oregon Health & Science University between Jan. 1, 2012, and Dec. 31, 2018.

The patients’ median age was 37 years (range, 18-50 years). Most patients (67%) were receiving an oral anticoagulant for venous thromboembolism. The rest were on anticoagulant therapy for arterial thrombosis (6%), atrial fibrillation (6%), a mechanical valve (1%), or “other” reasons (20%).

Dr. Samuelson Bannow said the other group was “almost exclusively women who were receiving prophylaxis” postoperatively or for travel. Most women in this group were receiving rivaroxaban.

Rivaroxaban was the most commonly prescribed anticoagulant in the entire cohort (41%), followed by warfarin (34%) and apixaban (25%).

At the time of anticoagulant prescription, 12% of women reported a history of heavy menstrual bleeding, and 28% did not. For most patients – 60% – there was no discussion of menstrual history documented.

Six months after starting oral anticoagulant therapy, 29% of patients required treatment for heavy menstrual bleeding. For 71% of patients, there was no documentation on the treatment of heavy menstrual bleeding.

Treatment for heavy menstrual bleeding was required in 33% of patients on rivaroxaban, 24% of those on apixaban, and 29% of those on warfarin, a significant difference (P less than .001).

“Rates of heavy menstrual bleeding … are higher in rivaroxaban users,” Dr. Samuelson Bannow said. “This is not the first study to demonstrate this. However, [the rate of heavy menstrual bleeding in this study] is still a lot lower than we would expect based on past levels with warfarin. This tells us we’re probably missing a lot of heavy menstrual bleeding. That’s not too surprising considering how few providers are actually asking about the menses.”

Dr. Samuelson Bannow and colleagues disclosed no conflicts of interest.

jensmith@mdedge.com

SOURCE: Samuelson Bannow BT et al. ASH 2019, Abstract 60.

Patients with nonalcoholic fatty liver disease (NAFLD) in a prospective observational study had a twofold increase in cardiovascular events, NAFLD patients with liver fibrosis had a fourfold increase in risk, and liver fibrosis scores predicted risk.

At median follow-up of 41.4 months representing 3,044.4 person-years of observation in the Progression of Liver Damage and Cardiometabolic Disorders in NAFLD (PLINIO) study, 58 cardiovascular events (CVEs) were reported in 898 consecutive outpatients who were screened for liver steatosis by ultrasound. The annual rate of CVEs among 643 patients with NAFLD was 2.1%, compared with 1.0% among 255 patients without NAFLD, according to Francesco Baratta, MD, of Clinica Medica, Sapienza University of Rome, and colleagues. Their report is in Clinical Gastroenterology and Hepatology.

The difference did not meet a priori thresholds for statistical significance (P = .066), but became significant after exclusion of new-onset atrial fibrillation events (annual CVE rates of 1.9% vs. 0.7%; P = .034), and on multivariate analysis, age, male sex, and NAFLD were found to be independently associated with CVE occurrence (hazard ratios, 1.07, 3.20, and 2.73, respectively), the investigators found.

In NAFLD patients, a NAFLD fibrosis score (NFS) greater than 0.676 was significantly associated with CVEs after adjustment for comorbidities (HR, 2.29), and a Fibrosis-4 (FIB-4) score greater than 2.67, a history of cardiovascular disease, and metabolic syndrome predicted incident CVEs (HRs, 4.57, 2.95, and 2.30, respectively). The findings were similar after exclusion of new-onset atrial fibrillation from the composite endpoint (HRs, 2.42 and 4.00, respectively).

“Furthermore, when we analyzed only patients without CVEs at baseline, we found a similar association between liver fibrosis and CVEs,” the researchers wrote, noting that the adjusted HRs for NFS were 2.50 and 4.28, respectively.

In addition to liver-related complications, patients with NAFLD are known to have an increased CVE risk, and while liver fibrosis severity is used to determine prognosis, not all patients can undergo a liver biopsy to assess fibrosis. Therefore, there is a need to identify and validate noninvasive markers of liver fibrosis, but few data exist with respect to the predictive role of noninvasive scoring on CVEs, they said.

The findings of this study suggest the use of the NFS and FIB-4 score may reduce the need for liver biopsy by identifying NAFLD patients at higher risk of having advanced liver fibrosis. They further suggest that liver fibrosis development in patients with NAFLD “may be the result of a long-term exposure to cardiometabolic risk factors such as diabetes,” and that “the concomitant presence of multiple cardiometabolic conditions may induce a chronic low-grade proinflammatory and pro-oxidant status leading to liver inflammation (i.e., macrophage activation) and collagen deposition.”

The findings may also have clinical implications: “The association between liver fibrosis and cardiovascular risk supports a potential role for statin treatment in patients with NAFLD,” they explained.

The authors reported having no disclosures.
 

sworcester@mdedge.com

SOURCE: Baratta F et al. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2019.12.026.

Patients with nonalcoholic fatty liver disease (NAFLD) in a prospective observational study had a twofold increase in cardiovascular events, NAFLD patients with liver fibrosis had a fourfold increase in risk, and liver fibrosis scores predicted risk.

At median follow-up of 41.4 months representing 3,044.4 person-years of observation in the Progression of Liver Damage and Cardiometabolic Disorders in NAFLD (PLINIO) study, 58 cardiovascular events (CVEs) were reported in 898 consecutive outpatients who were screened for liver steatosis by ultrasound. The annual rate of CVEs among 643 patients with NAFLD was 2.1%, compared with 1.0% among 255 patients without NAFLD, according to Francesco Baratta, MD, of Clinica Medica, Sapienza University of Rome, and colleagues. Their report is in Clinical Gastroenterology and Hepatology.

The difference did not meet a priori thresholds for statistical significance (P = .066), but became significant after exclusion of new-onset atrial fibrillation events (annual CVE rates of 1.9% vs. 0.7%; P = .034), and on multivariate analysis, age, male sex, and NAFLD were found to be independently associated with CVE occurrence (hazard ratios, 1.07, 3.20, and 2.73, respectively), the investigators found.

In NAFLD patients, a NAFLD fibrosis score (NFS) greater than 0.676 was significantly associated with CVEs after adjustment for comorbidities (HR, 2.29), and a Fibrosis-4 (FIB-4) score greater than 2.67, a history of cardiovascular disease, and metabolic syndrome predicted incident CVEs (HRs, 4.57, 2.95, and 2.30, respectively). The findings were similar after exclusion of new-onset atrial fibrillation from the composite endpoint (HRs, 2.42 and 4.00, respectively).

“Furthermore, when we analyzed only patients without CVEs at baseline, we found a similar association between liver fibrosis and CVEs,” the researchers wrote, noting that the adjusted HRs for NFS were 2.50 and 4.28, respectively.

In addition to liver-related complications, patients with NAFLD are known to have an increased CVE risk, and while liver fibrosis severity is used to determine prognosis, not all patients can undergo a liver biopsy to assess fibrosis. Therefore, there is a need to identify and validate noninvasive markers of liver fibrosis, but few data exist with respect to the predictive role of noninvasive scoring on CVEs, they said.

The findings of this study suggest the use of the NFS and FIB-4 score may reduce the need for liver biopsy by identifying NAFLD patients at higher risk of having advanced liver fibrosis. They further suggest that liver fibrosis development in patients with NAFLD “may be the result of a long-term exposure to cardiometabolic risk factors such as diabetes,” and that “the concomitant presence of multiple cardiometabolic conditions may induce a chronic low-grade proinflammatory and pro-oxidant status leading to liver inflammation (i.e., macrophage activation) and collagen deposition.”

The findings may also have clinical implications: “The association between liver fibrosis and cardiovascular risk supports a potential role for statin treatment in patients with NAFLD,” they explained.

The authors reported having no disclosures.
 

sworcester@mdedge.com

SOURCE: Baratta F et al. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2019.12.026.

Patients with nonalcoholic fatty liver disease (NAFLD) in a prospective observational study had a twofold increase in cardiovascular events, NAFLD patients with liver fibrosis had a fourfold increase in risk, and liver fibrosis scores predicted risk.

At median follow-up of 41.4 months representing 3,044.4 person-years of observation in the Progression of Liver Damage and Cardiometabolic Disorders in NAFLD (PLINIO) study, 58 cardiovascular events (CVEs) were reported in 898 consecutive outpatients who were screened for liver steatosis by ultrasound. The annual rate of CVEs among 643 patients with NAFLD was 2.1%, compared with 1.0% among 255 patients without NAFLD, according to Francesco Baratta, MD, of Clinica Medica, Sapienza University of Rome, and colleagues. Their report is in Clinical Gastroenterology and Hepatology.

The difference did not meet a priori thresholds for statistical significance (P = .066), but became significant after exclusion of new-onset atrial fibrillation events (annual CVE rates of 1.9% vs. 0.7%; P = .034), and on multivariate analysis, age, male sex, and NAFLD were found to be independently associated with CVE occurrence (hazard ratios, 1.07, 3.20, and 2.73, respectively), the investigators found.

In NAFLD patients, a NAFLD fibrosis score (NFS) greater than 0.676 was significantly associated with CVEs after adjustment for comorbidities (HR, 2.29), and a Fibrosis-4 (FIB-4) score greater than 2.67, a history of cardiovascular disease, and metabolic syndrome predicted incident CVEs (HRs, 4.57, 2.95, and 2.30, respectively). The findings were similar after exclusion of new-onset atrial fibrillation from the composite endpoint (HRs, 2.42 and 4.00, respectively).

“Furthermore, when we analyzed only patients without CVEs at baseline, we found a similar association between liver fibrosis and CVEs,” the researchers wrote, noting that the adjusted HRs for NFS were 2.50 and 4.28, respectively.

In addition to liver-related complications, patients with NAFLD are known to have an increased CVE risk, and while liver fibrosis severity is used to determine prognosis, not all patients can undergo a liver biopsy to assess fibrosis. Therefore, there is a need to identify and validate noninvasive markers of liver fibrosis, but few data exist with respect to the predictive role of noninvasive scoring on CVEs, they said.

The findings of this study suggest the use of the NFS and FIB-4 score may reduce the need for liver biopsy by identifying NAFLD patients at higher risk of having advanced liver fibrosis. They further suggest that liver fibrosis development in patients with NAFLD “may be the result of a long-term exposure to cardiometabolic risk factors such as diabetes,” and that “the concomitant presence of multiple cardiometabolic conditions may induce a chronic low-grade proinflammatory and pro-oxidant status leading to liver inflammation (i.e., macrophage activation) and collagen deposition.”

The findings may also have clinical implications: “The association between liver fibrosis and cardiovascular risk supports a potential role for statin treatment in patients with NAFLD,” they explained.

The authors reported having no disclosures.
 

sworcester@mdedge.com

SOURCE: Baratta F et al. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2019.12.026.

Lichenoid dermatoses are a heterogeneous group of diseases with varying clinical presentations. The term “lichenoid” refers to the popular lesions of certain skin disorders of which lichen planus (LP) is the prototype. The papules are shiny, flat topped, polygonal, of different sizes, and occur in clusters creating a pattern that resembles lichen growing on a rock. Lichenoid eruptions are quite common in children and can result from many different origins. In most instances the precise mechanism of disease is not known, although it is usually believed to be immunologic in nature. Certain disorders are common in children, whereas others more often affect the adult population.

Lichen striatus, lichen nitidus (LN), and lichen spinulosus are lichenoid lesions that are more common in children than adults.

LN – as seen in the patient described here – is an uncommon benign inflammatory skin disease, primarily of children. Individual lesions are sharply demarcated, pinpoint to pinhead sized, round or polygonal, and strikingly monomorphous in nature. The papules are usually flesh colored, however, the color varies from yellow and brown to violet hues depending on the background color of the patient’s skin. This variation in color is in contrast with LP which is characteristically violaceous. The surfaces of the papules are flat, shiny, and slightly elevated. They may have a fine scale or a hyperkeratotic plug. The lesions tend to occur in groups, primarily on the abdomen, chest, glans penis, and upper extremities. The Koebner phenomenon is observed and is a hallmark for the disorder. LN is generally asymptomatic, unlike LP, which is exceedingly pruritic.

The cause of LN is unknown; however, it has been proposed that LN, in particular generalized LN, may be associated with immune alterations in the patient. The course of LN is slowly progressive with a tendency toward remission. The lesions can remain stationary for years; however, they sometimes disappear spontaneously and completely.

The differential diagnosis of LN beyond the entities discussed above includes frictional lichenoid eruption, lichenoid drug eruption, LP, and keratosis pilaris.

LP is the classic lichenoid eruption. It is rare in children and occurs most frequently in individuals aged 30-60 years. LP usually manifests as an extremely pruritic eruption of flat-topped polygonal and violaceous papules that often have fine linear white scales known as Wickham striae. The distribution is usually bilateral and symmetric with most of the papules and plaques located on the legs, flexor wrists, neck, and genitalia. The lesions may exhibit the Koebner phenomenon, appearing in a linear pattern along the site of a scratch. Generally, in childhood cases there is reported itching, and oral and nail lesions are less common.

Frictional lichenoid eruption occurs in childhood. The lesions consist of lichenoid papules with regular borders 1-2 mm in diameter that generally are asymptomatic, although they may be mildly pruritic. The papules are found in a very characteristic distribution with almost exclusive involvement of the backs of the hands, fingers, elbows, and knees with occasional involvement of the extensor forearms and cheeks. This disorder occurs in predisposed children who have been exposed to significant frictional force during play, and typically resolves spontaneously after removal of the stimulus.

Keratosis pilaris is a rash that usually is found on the outer areas of the upper arms, upper thighs, buttocks, and cheeks. It consists of small bumps that are flesh colored to red. The bumps generally don’t hurt or itch.

The lack of symptoms and spontaneous healing have rendered treatment unnecessary in most cases. LN generally is self-limiting, thus treatment may not be necessary. However, topical treatment with mid- to high-potency corticosteroids has hastened resolution of lesions in some children, as have topical dinitrochlorobenzene and systemic treatment with psoralens, astemizole, etretinate, and psoralen-UVA.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Bhatti is a research fellow in pediatric dermatology at Rady Children’s Hospital and the University of California, San Diego. Neither Dr. Eichenfield nor Dr. Bhatti has any relevant financial disclosures. Email them at pdnews@mdedge.com.

References

Pickert A. Cutis. 2012 Sep;90(3):E1-3. https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0900300E1.pdf Tziotzios C et al. J Am Acad Dermatol. 2018 Nov;79(5):789-804. Tilly JJ et al. J Am Acad Dermatol. 2004 Oct;51(4):606-24.

Lichenoid dermatoses are a heterogeneous group of diseases with varying clinical presentations. The term “lichenoid” refers to the popular lesions of certain skin disorders of which lichen planus (LP) is the prototype. The papules are shiny, flat topped, polygonal, of different sizes, and occur in clusters creating a pattern that resembles lichen growing on a rock. Lichenoid eruptions are quite common in children and can result from many different origins. In most instances the precise mechanism of disease is not known, although it is usually believed to be immunologic in nature. Certain disorders are common in children, whereas others more often affect the adult population.

Lichen striatus, lichen nitidus (LN), and lichen spinulosus are lichenoid lesions that are more common in children than adults.

LN – as seen in the patient described here – is an uncommon benign inflammatory skin disease, primarily of children. Individual lesions are sharply demarcated, pinpoint to pinhead sized, round or polygonal, and strikingly monomorphous in nature. The papules are usually flesh colored, however, the color varies from yellow and brown to violet hues depending on the background color of the patient’s skin. This variation in color is in contrast with LP which is characteristically violaceous. The surfaces of the papules are flat, shiny, and slightly elevated. They may have a fine scale or a hyperkeratotic plug. The lesions tend to occur in groups, primarily on the abdomen, chest, glans penis, and upper extremities. The Koebner phenomenon is observed and is a hallmark for the disorder. LN is generally asymptomatic, unlike LP, which is exceedingly pruritic.

The cause of LN is unknown; however, it has been proposed that LN, in particular generalized LN, may be associated with immune alterations in the patient. The course of LN is slowly progressive with a tendency toward remission. The lesions can remain stationary for years; however, they sometimes disappear spontaneously and completely.

The differential diagnosis of LN beyond the entities discussed above includes frictional lichenoid eruption, lichenoid drug eruption, LP, and keratosis pilaris.

LP is the classic lichenoid eruption. It is rare in children and occurs most frequently in individuals aged 30-60 years. LP usually manifests as an extremely pruritic eruption of flat-topped polygonal and violaceous papules that often have fine linear white scales known as Wickham striae. The distribution is usually bilateral and symmetric with most of the papules and plaques located on the legs, flexor wrists, neck, and genitalia. The lesions may exhibit the Koebner phenomenon, appearing in a linear pattern along the site of a scratch. Generally, in childhood cases there is reported itching, and oral and nail lesions are less common.

Frictional lichenoid eruption occurs in childhood. The lesions consist of lichenoid papules with regular borders 1-2 mm in diameter that generally are asymptomatic, although they may be mildly pruritic. The papules are found in a very characteristic distribution with almost exclusive involvement of the backs of the hands, fingers, elbows, and knees with occasional involvement of the extensor forearms and cheeks. This disorder occurs in predisposed children who have been exposed to significant frictional force during play, and typically resolves spontaneously after removal of the stimulus.

Keratosis pilaris is a rash that usually is found on the outer areas of the upper arms, upper thighs, buttocks, and cheeks. It consists of small bumps that are flesh colored to red. The bumps generally don’t hurt or itch.

The lack of symptoms and spontaneous healing have rendered treatment unnecessary in most cases. LN generally is self-limiting, thus treatment may not be necessary. However, topical treatment with mid- to high-potency corticosteroids has hastened resolution of lesions in some children, as have topical dinitrochlorobenzene and systemic treatment with psoralens, astemizole, etretinate, and psoralen-UVA.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Bhatti is a research fellow in pediatric dermatology at Rady Children’s Hospital and the University of California, San Diego. Neither Dr. Eichenfield nor Dr. Bhatti has any relevant financial disclosures. Email them at pdnews@mdedge.com.

References

Pickert A. Cutis. 2012 Sep;90(3):E1-3. https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0900300E1.pdf Tziotzios C et al. J Am Acad Dermatol. 2018 Nov;79(5):789-804. Tilly JJ et al. J Am Acad Dermatol. 2004 Oct;51(4):606-24.

Lichenoid dermatoses are a heterogeneous group of diseases with varying clinical presentations. The term “lichenoid” refers to the popular lesions of certain skin disorders of which lichen planus (LP) is the prototype. The papules are shiny, flat topped, polygonal, of different sizes, and occur in clusters creating a pattern that resembles lichen growing on a rock. Lichenoid eruptions are quite common in children and can result from many different origins. In most instances the precise mechanism of disease is not known, although it is usually believed to be immunologic in nature. Certain disorders are common in children, whereas others more often affect the adult population.

Lichen striatus, lichen nitidus (LN), and lichen spinulosus are lichenoid lesions that are more common in children than adults.

LN – as seen in the patient described here – is an uncommon benign inflammatory skin disease, primarily of children. Individual lesions are sharply demarcated, pinpoint to pinhead sized, round or polygonal, and strikingly monomorphous in nature. The papules are usually flesh colored, however, the color varies from yellow and brown to violet hues depending on the background color of the patient’s skin. This variation in color is in contrast with LP which is characteristically violaceous. The surfaces of the papules are flat, shiny, and slightly elevated. They may have a fine scale or a hyperkeratotic plug. The lesions tend to occur in groups, primarily on the abdomen, chest, glans penis, and upper extremities. The Koebner phenomenon is observed and is a hallmark for the disorder. LN is generally asymptomatic, unlike LP, which is exceedingly pruritic.

The cause of LN is unknown; however, it has been proposed that LN, in particular generalized LN, may be associated with immune alterations in the patient. The course of LN is slowly progressive with a tendency toward remission. The lesions can remain stationary for years; however, they sometimes disappear spontaneously and completely.

The differential diagnosis of LN beyond the entities discussed above includes frictional lichenoid eruption, lichenoid drug eruption, LP, and keratosis pilaris.

LP is the classic lichenoid eruption. It is rare in children and occurs most frequently in individuals aged 30-60 years. LP usually manifests as an extremely pruritic eruption of flat-topped polygonal and violaceous papules that often have fine linear white scales known as Wickham striae. The distribution is usually bilateral and symmetric with most of the papules and plaques located on the legs, flexor wrists, neck, and genitalia. The lesions may exhibit the Koebner phenomenon, appearing in a linear pattern along the site of a scratch. Generally, in childhood cases there is reported itching, and oral and nail lesions are less common.

Frictional lichenoid eruption occurs in childhood. The lesions consist of lichenoid papules with regular borders 1-2 mm in diameter that generally are asymptomatic, although they may be mildly pruritic. The papules are found in a very characteristic distribution with almost exclusive involvement of the backs of the hands, fingers, elbows, and knees with occasional involvement of the extensor forearms and cheeks. This disorder occurs in predisposed children who have been exposed to significant frictional force during play, and typically resolves spontaneously after removal of the stimulus.

Keratosis pilaris is a rash that usually is found on the outer areas of the upper arms, upper thighs, buttocks, and cheeks. It consists of small bumps that are flesh colored to red. The bumps generally don’t hurt or itch.

The lack of symptoms and spontaneous healing have rendered treatment unnecessary in most cases. LN generally is self-limiting, thus treatment may not be necessary. However, topical treatment with mid- to high-potency corticosteroids has hastened resolution of lesions in some children, as have topical dinitrochlorobenzene and systemic treatment with psoralens, astemizole, etretinate, and psoralen-UVA.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Bhatti is a research fellow in pediatric dermatology at Rady Children’s Hospital and the University of California, San Diego. Neither Dr. Eichenfield nor Dr. Bhatti has any relevant financial disclosures. Email them at pdnews@mdedge.com.

References

Pickert A. Cutis. 2012 Sep;90(3):E1-3. https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0900300E1.pdf Tziotzios C et al. J Am Acad Dermatol. 2018 Nov;79(5):789-804. Tilly JJ et al. J Am Acad Dermatol. 2004 Oct;51(4):606-24.

ANSWER

The correct answer is to perform a 3-mm punch biopsy (choice “a”).

DISCUSSION

When the history and physical exam fail to point to a clear diagnosis, skin biopsy can answer a very basic question: What is the pathophysiologic process associated with the lesions? The information thus obtained doesn’t always produce a blinking neon sign of a diagnosis, but at a minimum, it can rule out a great number of things, such as cancer or infection.

More often, the types of cells seen, and the patterns in which they are arranged, tell us a great deal. In this case, accumulations of monocytes, macrophages, and activated T-lymphocytes were arranged in circular patterns, but there was no evidence of necrosis (caseation), which can be seen in tubercular granulomas. Stains performed to identify mycobacterial organisms were negative. These findings established the diagnosis of cutaneous sarcoidosis, a granulomatous disease thought to represent a reaction to an unknown antigen (eg, a microorganism) or environmental substance. It is far more common in those with darker skin types.

Although this patient’s disease was confined to the skin, sarcoidosis can affect virtually any other organ in the body—in particular, the lungs, kidneys, liver, nervous system, or even the eyes. For this reason, patients with sarcoidosis are usually referred to pulmonology for a workup intended to rule out systemic involvement and to other specialists as symptoms dictate.

Many cases of sarcoidosis remit on their own, without treatment. When treatment is initiated, the 2 most commonly used medications are systemic glucocorticoids and/or methotrexate. Both drugs have been associated with serious adverse effects and should only be prescribed by experienced providers.

This combination was prescribed for the case patient, who obtained rapid relief. Blood work (complete blood count, comprehensive metabolic panel) was within normal limits prior to and during treatment, and the pulmonologist pronounced her free of lung involvement.

ANSWER

The correct answer is to perform a 3-mm punch biopsy (choice “a”).

DISCUSSION

When the history and physical exam fail to point to a clear diagnosis, skin biopsy can answer a very basic question: What is the pathophysiologic process associated with the lesions? The information thus obtained doesn’t always produce a blinking neon sign of a diagnosis, but at a minimum, it can rule out a great number of things, such as cancer or infection.

More often, the types of cells seen, and the patterns in which they are arranged, tell us a great deal. In this case, accumulations of monocytes, macrophages, and activated T-lymphocytes were arranged in circular patterns, but there was no evidence of necrosis (caseation), which can be seen in tubercular granulomas. Stains performed to identify mycobacterial organisms were negative. These findings established the diagnosis of cutaneous sarcoidosis, a granulomatous disease thought to represent a reaction to an unknown antigen (eg, a microorganism) or environmental substance. It is far more common in those with darker skin types.

Although this patient’s disease was confined to the skin, sarcoidosis can affect virtually any other organ in the body—in particular, the lungs, kidneys, liver, nervous system, or even the eyes. For this reason, patients with sarcoidosis are usually referred to pulmonology for a workup intended to rule out systemic involvement and to other specialists as symptoms dictate.

Many cases of sarcoidosis remit on their own, without treatment. When treatment is initiated, the 2 most commonly used medications are systemic glucocorticoids and/or methotrexate. Both drugs have been associated with serious adverse effects and should only be prescribed by experienced providers.

This combination was prescribed for the case patient, who obtained rapid relief. Blood work (complete blood count, comprehensive metabolic panel) was within normal limits prior to and during treatment, and the pulmonologist pronounced her free of lung involvement.

ANSWER

The correct answer is to perform a 3-mm punch biopsy (choice “a”).

DISCUSSION

When the history and physical exam fail to point to a clear diagnosis, skin biopsy can answer a very basic question: What is the pathophysiologic process associated with the lesions? The information thus obtained doesn’t always produce a blinking neon sign of a diagnosis, but at a minimum, it can rule out a great number of things, such as cancer or infection.

More often, the types of cells seen, and the patterns in which they are arranged, tell us a great deal. In this case, accumulations of monocytes, macrophages, and activated T-lymphocytes were arranged in circular patterns, but there was no evidence of necrosis (caseation), which can be seen in tubercular granulomas. Stains performed to identify mycobacterial organisms were negative. These findings established the diagnosis of cutaneous sarcoidosis, a granulomatous disease thought to represent a reaction to an unknown antigen (eg, a microorganism) or environmental substance. It is far more common in those with darker skin types.

Although this patient’s disease was confined to the skin, sarcoidosis can affect virtually any other organ in the body—in particular, the lungs, kidneys, liver, nervous system, or even the eyes. For this reason, patients with sarcoidosis are usually referred to pulmonology for a workup intended to rule out systemic involvement and to other specialists as symptoms dictate.

Many cases of sarcoidosis remit on their own, without treatment. When treatment is initiated, the 2 most commonly used medications are systemic glucocorticoids and/or methotrexate. Both drugs have been associated with serious adverse effects and should only be prescribed by experienced providers.

This combination was prescribed for the case patient, who obtained rapid relief. Blood work (complete blood count, comprehensive metabolic panel) was within normal limits prior to and during treatment, and the pulmonologist pronounced her free of lung involvement.

PHILADELPHIA – Engaging in at least 150 minutes of moderate to vigorous physical activity per week as recommended in national guidelines appears to mitigate the cardiometabolic risks associated with poor diet quality in middle-aged and older adults, according to an analysis of Framingham Heart Study data.

Bruce Jancin/MDedge News

“Our findings suggest adherence to physical activity guidelines may have a protective effect on cardiometabolic health regardless of diet quality,” Joowon Lee, PhD, declared at the American Heart Association scientific sessions.

He presented separate cross-sectional analyses of the risks of metabolic syndrome in 2,379 middle-aged participants in the National Heart, Lung, and Blood Institute–sponsored Framingham (Mass.) Third Generation Study and 1,180 older participants in the Framingham Offspring Study.

The two analyses showed the same thing across a broad age spectrum: The highest prevalence of metabolic syndrome as defined by Adult Treatment Panel III criteria was present among those individuals who got less than 150 minutes of physical activity per week and were also in the lowest tertile in terms of diet quality, while the lowest prevalence of metabolic syndrome occurred in participants in the top tertile for diet quality who engaged in at least 150 minutes per week of moderate to vigorous physical activity in accord with the Department of Health & Human Services 2018 Physical Activity Guidelines for Americans.

In both the middle-aged and older populations, optimal physical activity – that is, at least 150 minutes per week – appeared to override the adverse impact of suboptimal diet quality. Physically active individuals with moderate or even poor diet quality had a significantly lower prevalence of metabolic syndrome than did the reference group constituted by participants with poor diet quality who didn’t exercise for 150 minutes per week.

But the converse didn’t hold true: Individuals with optimal diet quality who didn’t reach the physical activity threshold had no reduction in metabolic syndrome, compared with the reference group, according to Dr. Lee of Boston University.

For example, among the Framingham Offspring Study participants, whose mean age was 69 years at the time of their ninth formal examination in 2014, the prevalence of metabolic syndrome was 59% in those who got less than 150 minutes of moderate to vigorous physical activity weekly as assessed by accelerometer and who were also in the lowest tertile for diet quality as self-reported on the DGAI-2010 (Dietary Guidelines Adherence Index) semiquantitative food frequency questionnaire. The relative risk of metabolic syndrome was reduced by 61% in participants with both optimal physical activity and diet quality, by 49% in those with at least 150 minutes of physical activity but only moderate diet quality, and by 39% in those with optimal exercise and poor diet quality. In contrast, individuals in the top or middle tertiles for diet quality who didn’t meet the physical activity standard had a metabolic syndrome rate that wasn’t significantly lower than the reference group.

Dr. Lee observed that his analyses are best viewed as hypothesis generating. Their cross-sectional format precludes firm conclusions as to causality.

His findings prompted session comoderator Satyam Sarma, MD, of the University of Texas, Dallas, to make one of the most memorable comments heard at AHA 2019: that the Framingham findings suggest it may be possible to outrun a bad diet.

Dr. Lee reported having no financial conflicts regarding his study, supported by Boston University.

bjancin@mdedge.com

SOURCE: Lee J. AHA 2019, Abstract RF244.

PHILADELPHIA – Engaging in at least 150 minutes of moderate to vigorous physical activity per week as recommended in national guidelines appears to mitigate the cardiometabolic risks associated with poor diet quality in middle-aged and older adults, according to an analysis of Framingham Heart Study data.

Bruce Jancin/MDedge News

“Our findings suggest adherence to physical activity guidelines may have a protective effect on cardiometabolic health regardless of diet quality,” Joowon Lee, PhD, declared at the American Heart Association scientific sessions.

He presented separate cross-sectional analyses of the risks of metabolic syndrome in 2,379 middle-aged participants in the National Heart, Lung, and Blood Institute–sponsored Framingham (Mass.) Third Generation Study and 1,180 older participants in the Framingham Offspring Study.

The two analyses showed the same thing across a broad age spectrum: The highest prevalence of metabolic syndrome as defined by Adult Treatment Panel III criteria was present among those individuals who got less than 150 minutes of physical activity per week and were also in the lowest tertile in terms of diet quality, while the lowest prevalence of metabolic syndrome occurred in participants in the top tertile for diet quality who engaged in at least 150 minutes per week of moderate to vigorous physical activity in accord with the Department of Health & Human Services 2018 Physical Activity Guidelines for Americans.

In both the middle-aged and older populations, optimal physical activity – that is, at least 150 minutes per week – appeared to override the adverse impact of suboptimal diet quality. Physically active individuals with moderate or even poor diet quality had a significantly lower prevalence of metabolic syndrome than did the reference group constituted by participants with poor diet quality who didn’t exercise for 150 minutes per week.

But the converse didn’t hold true: Individuals with optimal diet quality who didn’t reach the physical activity threshold had no reduction in metabolic syndrome, compared with the reference group, according to Dr. Lee of Boston University.

For example, among the Framingham Offspring Study participants, whose mean age was 69 years at the time of their ninth formal examination in 2014, the prevalence of metabolic syndrome was 59% in those who got less than 150 minutes of moderate to vigorous physical activity weekly as assessed by accelerometer and who were also in the lowest tertile for diet quality as self-reported on the DGAI-2010 (Dietary Guidelines Adherence Index) semiquantitative food frequency questionnaire. The relative risk of metabolic syndrome was reduced by 61% in participants with both optimal physical activity and diet quality, by 49% in those with at least 150 minutes of physical activity but only moderate diet quality, and by 39% in those with optimal exercise and poor diet quality. In contrast, individuals in the top or middle tertiles for diet quality who didn’t meet the physical activity standard had a metabolic syndrome rate that wasn’t significantly lower than the reference group.

Dr. Lee observed that his analyses are best viewed as hypothesis generating. Their cross-sectional format precludes firm conclusions as to causality.

His findings prompted session comoderator Satyam Sarma, MD, of the University of Texas, Dallas, to make one of the most memorable comments heard at AHA 2019: that the Framingham findings suggest it may be possible to outrun a bad diet.

Dr. Lee reported having no financial conflicts regarding his study, supported by Boston University.

bjancin@mdedge.com

SOURCE: Lee J. AHA 2019, Abstract RF244.

PHILADELPHIA – Engaging in at least 150 minutes of moderate to vigorous physical activity per week as recommended in national guidelines appears to mitigate the cardiometabolic risks associated with poor diet quality in middle-aged and older adults, according to an analysis of Framingham Heart Study data.

Bruce Jancin/MDedge News

“Our findings suggest adherence to physical activity guidelines may have a protective effect on cardiometabolic health regardless of diet quality,” Joowon Lee, PhD, declared at the American Heart Association scientific sessions.

He presented separate cross-sectional analyses of the risks of metabolic syndrome in 2,379 middle-aged participants in the National Heart, Lung, and Blood Institute–sponsored Framingham (Mass.) Third Generation Study and 1,180 older participants in the Framingham Offspring Study.

The two analyses showed the same thing across a broad age spectrum: The highest prevalence of metabolic syndrome as defined by Adult Treatment Panel III criteria was present among those individuals who got less than 150 minutes of physical activity per week and were also in the lowest tertile in terms of diet quality, while the lowest prevalence of metabolic syndrome occurred in participants in the top tertile for diet quality who engaged in at least 150 minutes per week of moderate to vigorous physical activity in accord with the Department of Health & Human Services 2018 Physical Activity Guidelines for Americans.

In both the middle-aged and older populations, optimal physical activity – that is, at least 150 minutes per week – appeared to override the adverse impact of suboptimal diet quality. Physically active individuals with moderate or even poor diet quality had a significantly lower prevalence of metabolic syndrome than did the reference group constituted by participants with poor diet quality who didn’t exercise for 150 minutes per week.

But the converse didn’t hold true: Individuals with optimal diet quality who didn’t reach the physical activity threshold had no reduction in metabolic syndrome, compared with the reference group, according to Dr. Lee of Boston University.

For example, among the Framingham Offspring Study participants, whose mean age was 69 years at the time of their ninth formal examination in 2014, the prevalence of metabolic syndrome was 59% in those who got less than 150 minutes of moderate to vigorous physical activity weekly as assessed by accelerometer and who were also in the lowest tertile for diet quality as self-reported on the DGAI-2010 (Dietary Guidelines Adherence Index) semiquantitative food frequency questionnaire. The relative risk of metabolic syndrome was reduced by 61% in participants with both optimal physical activity and diet quality, by 49% in those with at least 150 minutes of physical activity but only moderate diet quality, and by 39% in those with optimal exercise and poor diet quality. In contrast, individuals in the top or middle tertiles for diet quality who didn’t meet the physical activity standard had a metabolic syndrome rate that wasn’t significantly lower than the reference group.

Dr. Lee observed that his analyses are best viewed as hypothesis generating. Their cross-sectional format precludes firm conclusions as to causality.

His findings prompted session comoderator Satyam Sarma, MD, of the University of Texas, Dallas, to make one of the most memorable comments heard at AHA 2019: that the Framingham findings suggest it may be possible to outrun a bad diet.

Dr. Lee reported having no financial conflicts regarding his study, supported by Boston University.

bjancin@mdedge.com

SOURCE: Lee J. AHA 2019, Abstract RF244.

Abnormalities in lipids, liver enzymes, and blood counts were rare, and serious abnormalities virtually nonexistent among individuals taking isotretinoin for moderate to severe acne who received laboratory testing.

In a review of 1,863 patients receiving isotretinoin, there were no cases of grade 4 abnormalities of lipids, liver enzymes, or complete blood count (CBC). Further, fewer than 1% of patients had grade 2-3 laboratory abnormalities, and no patients had cholesterol or CBC abnormalities of grade 3 or higher.

The retrospective cohort study used an electronic database to identify patients who were prescribed isotretinoin for acne from 2007 to 2017, with inclusion criteria structured to “increase the likelihood of capturing a complete course of isotretinoin therapy,” wrote John Barbieri, MD, and coauthors. The database allowed the investigators to group lab values into baseline testing, and testing by month of therapy for individual deidentified patient records.

Dr. Barbieri, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, and coinvestigators found that over half of all patients had baseline triglyceride, total cholesterol, AST, ALT, and platelet and white blood cell count levels.

Though the number of patients who had any of these levels checked in a given month of treatment declined over time, as did the total number of patients still on isotretinoin therapy, monthly AST and ALT monitoring occurred in 37.6%-58.5% of patients. Monthly triglyceride monitoring was conducted in between 39.6% and 61.4% of participants, and CBCs were obtained in 26.8%-37.4% of participants.

In terms of the abnormalities that were seen, grade 1 triglyceride elevations of 150-300 mg/dL were present in about 13% of patients at baseline, rising to 39% of participants who were still receiving isotretinoin at month 6. However, grade 2 elevations of up to 500 mg/dL were seen in 1.4% of patients at baseline and 2.4%-5.6% of patients during subsequent months.

Grade 1 liver enzyme abnormalities of less than three times the upper limit of normal values were seen at baseline in under 4% of patients, and in no more than 6.7% of patients through the course of treatment.

Leukopenia of between 3 x 10³/mcL and the lower limit of normal occurred in 4.1% of baseline tests and in 6.6%-10.1% of tests in subsequent months. Grade 1 thrombocytopenia (values between 75 x 10³/mcL and the lower limit of normal) occurred in 1.9% of baseline tests and no more than 2.9% of tests in the following months.

The results, wrote Dr. Barbieri and coauthors, affirm that most patients fare well on isotretinoin, and frequent laboratory testing is likely to be low-yield. Even using relatively low Medicare reimbursement rates for these tests yielded an estimated $134 in per-patient charges for the studied population. If baseline lipid and liver functions were followed only by repeat testing when peak isotretinoin dose was reached, charges would drop to about $87 per patient. Using the iPLEDGE database figures, this would save $17.4 million in monitoring costs annually, they wrote.

They also calculated that the monitoring regimen they observed puts the cost of detecting one single grade 3 hepatic enzyme elevation at $6,000; one grade 3 triglyceride elevation would cost $7,750.

Of the patients, 49% were female, the median age was 18.2 years, and the median duration of isotretinoin therapy was under 5 months (148 days). Nearly 90% of patients were white and non-Hispanic; 2.5% were black.

The data used for the analysis did not give the investigators access to clinician notes, but they did observe that, even when abnormal test values were seen, isotretinoin prescribing continued. This, they added, pointed toward reassuring clinical scenarios, even in cases of abnormal lab values.

“These findings are consistent with prior studies and suggest that extensive laboratory monitoring observed in this population may be of low value,” concluded Dr. Barbieri and colleagues. “In addition, changes to lipid levels observed in this study typically occurred during the first 2-3 months of therapy before stabilizing, which is consistent with findings in prior studies.”

The investigators noted that, despite mounting evidence of isotretinoin’s safety, there was no trend toward decreased CBC testing over the decade-long period of the study, and there were only “modest” decreases in hepatic enzyme and lipid monitoring. They called for an awareness campaign on the part of professional societies, and consideration for “more specific guideline recommendations” that may ease the testing burden on the adolescent and young adult population receiving isotretinoin.

The study was funded in part by the National Institutes of Health, and Dr. Barbieri receives partial salary support from Pfizer through a grant to the University of Pennsylvania. He has received support for unrelated work from Eli Lilly and Novartis. The other authors reported no conflicts of interest.

koakes@mdedge.com

SOURCE: Barbieri J et al. J Am Acad Dermatol. 2020 Jan;82(1):72-9.

Abnormalities in lipids, liver enzymes, and blood counts were rare, and serious abnormalities virtually nonexistent among individuals taking isotretinoin for moderate to severe acne who received laboratory testing.

In a review of 1,863 patients receiving isotretinoin, there were no cases of grade 4 abnormalities of lipids, liver enzymes, or complete blood count (CBC). Further, fewer than 1% of patients had grade 2-3 laboratory abnormalities, and no patients had cholesterol or CBC abnormalities of grade 3 or higher.

The retrospective cohort study used an electronic database to identify patients who were prescribed isotretinoin for acne from 2007 to 2017, with inclusion criteria structured to “increase the likelihood of capturing a complete course of isotretinoin therapy,” wrote John Barbieri, MD, and coauthors. The database allowed the investigators to group lab values into baseline testing, and testing by month of therapy for individual deidentified patient records.

Dr. Barbieri, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, and coinvestigators found that over half of all patients had baseline triglyceride, total cholesterol, AST, ALT, and platelet and white blood cell count levels.

Though the number of patients who had any of these levels checked in a given month of treatment declined over time, as did the total number of patients still on isotretinoin therapy, monthly AST and ALT monitoring occurred in 37.6%-58.5% of patients. Monthly triglyceride monitoring was conducted in between 39.6% and 61.4% of participants, and CBCs were obtained in 26.8%-37.4% of participants.

In terms of the abnormalities that were seen, grade 1 triglyceride elevations of 150-300 mg/dL were present in about 13% of patients at baseline, rising to 39% of participants who were still receiving isotretinoin at month 6. However, grade 2 elevations of up to 500 mg/dL were seen in 1.4% of patients at baseline and 2.4%-5.6% of patients during subsequent months.

Grade 1 liver enzyme abnormalities of less than three times the upper limit of normal values were seen at baseline in under 4% of patients, and in no more than 6.7% of patients through the course of treatment.

Leukopenia of between 3 x 10³/mcL and the lower limit of normal occurred in 4.1% of baseline tests and in 6.6%-10.1% of tests in subsequent months. Grade 1 thrombocytopenia (values between 75 x 10³/mcL and the lower limit of normal) occurred in 1.9% of baseline tests and no more than 2.9% of tests in the following months.

The results, wrote Dr. Barbieri and coauthors, affirm that most patients fare well on isotretinoin, and frequent laboratory testing is likely to be low-yield. Even using relatively low Medicare reimbursement rates for these tests yielded an estimated $134 in per-patient charges for the studied population. If baseline lipid and liver functions were followed only by repeat testing when peak isotretinoin dose was reached, charges would drop to about $87 per patient. Using the iPLEDGE database figures, this would save $17.4 million in monitoring costs annually, they wrote.

They also calculated that the monitoring regimen they observed puts the cost of detecting one single grade 3 hepatic enzyme elevation at $6,000; one grade 3 triglyceride elevation would cost $7,750.

Of the patients, 49% were female, the median age was 18.2 years, and the median duration of isotretinoin therapy was under 5 months (148 days). Nearly 90% of patients were white and non-Hispanic; 2.5% were black.

The data used for the analysis did not give the investigators access to clinician notes, but they did observe that, even when abnormal test values were seen, isotretinoin prescribing continued. This, they added, pointed toward reassuring clinical scenarios, even in cases of abnormal lab values.

“These findings are consistent with prior studies and suggest that extensive laboratory monitoring observed in this population may be of low value,” concluded Dr. Barbieri and colleagues. “In addition, changes to lipid levels observed in this study typically occurred during the first 2-3 months of therapy before stabilizing, which is consistent with findings in prior studies.”

The investigators noted that, despite mounting evidence of isotretinoin’s safety, there was no trend toward decreased CBC testing over the decade-long period of the study, and there were only “modest” decreases in hepatic enzyme and lipid monitoring. They called for an awareness campaign on the part of professional societies, and consideration for “more specific guideline recommendations” that may ease the testing burden on the adolescent and young adult population receiving isotretinoin.

The study was funded in part by the National Institutes of Health, and Dr. Barbieri receives partial salary support from Pfizer through a grant to the University of Pennsylvania. He has received support for unrelated work from Eli Lilly and Novartis. The other authors reported no conflicts of interest.

koakes@mdedge.com

SOURCE: Barbieri J et al. J Am Acad Dermatol. 2020 Jan;82(1):72-9.

Abnormalities in lipids, liver enzymes, and blood counts were rare, and serious abnormalities virtually nonexistent among individuals taking isotretinoin for moderate to severe acne who received laboratory testing.

In a review of 1,863 patients receiving isotretinoin, there were no cases of grade 4 abnormalities of lipids, liver enzymes, or complete blood count (CBC). Further, fewer than 1% of patients had grade 2-3 laboratory abnormalities, and no patients had cholesterol or CBC abnormalities of grade 3 or higher.

The retrospective cohort study used an electronic database to identify patients who were prescribed isotretinoin for acne from 2007 to 2017, with inclusion criteria structured to “increase the likelihood of capturing a complete course of isotretinoin therapy,” wrote John Barbieri, MD, and coauthors. The database allowed the investigators to group lab values into baseline testing, and testing by month of therapy for individual deidentified patient records.

Dr. Barbieri, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, and coinvestigators found that over half of all patients had baseline triglyceride, total cholesterol, AST, ALT, and platelet and white blood cell count levels.

Though the number of patients who had any of these levels checked in a given month of treatment declined over time, as did the total number of patients still on isotretinoin therapy, monthly AST and ALT monitoring occurred in 37.6%-58.5% of patients. Monthly triglyceride monitoring was conducted in between 39.6% and 61.4% of participants, and CBCs were obtained in 26.8%-37.4% of participants.

In terms of the abnormalities that were seen, grade 1 triglyceride elevations of 150-300 mg/dL were present in about 13% of patients at baseline, rising to 39% of participants who were still receiving isotretinoin at month 6. However, grade 2 elevations of up to 500 mg/dL were seen in 1.4% of patients at baseline and 2.4%-5.6% of patients during subsequent months.

Grade 1 liver enzyme abnormalities of less than three times the upper limit of normal values were seen at baseline in under 4% of patients, and in no more than 6.7% of patients through the course of treatment.

Leukopenia of between 3 x 10³/mcL and the lower limit of normal occurred in 4.1% of baseline tests and in 6.6%-10.1% of tests in subsequent months. Grade 1 thrombocytopenia (values between 75 x 10³/mcL and the lower limit of normal) occurred in 1.9% of baseline tests and no more than 2.9% of tests in the following months.

The results, wrote Dr. Barbieri and coauthors, affirm that most patients fare well on isotretinoin, and frequent laboratory testing is likely to be low-yield. Even using relatively low Medicare reimbursement rates for these tests yielded an estimated $134 in per-patient charges for the studied population. If baseline lipid and liver functions were followed only by repeat testing when peak isotretinoin dose was reached, charges would drop to about $87 per patient. Using the iPLEDGE database figures, this would save $17.4 million in monitoring costs annually, they wrote.

They also calculated that the monitoring regimen they observed puts the cost of detecting one single grade 3 hepatic enzyme elevation at $6,000; one grade 3 triglyceride elevation would cost $7,750.

Of the patients, 49% were female, the median age was 18.2 years, and the median duration of isotretinoin therapy was under 5 months (148 days). Nearly 90% of patients were white and non-Hispanic; 2.5% were black.

The data used for the analysis did not give the investigators access to clinician notes, but they did observe that, even when abnormal test values were seen, isotretinoin prescribing continued. This, they added, pointed toward reassuring clinical scenarios, even in cases of abnormal lab values.

“These findings are consistent with prior studies and suggest that extensive laboratory monitoring observed in this population may be of low value,” concluded Dr. Barbieri and colleagues. “In addition, changes to lipid levels observed in this study typically occurred during the first 2-3 months of therapy before stabilizing, which is consistent with findings in prior studies.”

The investigators noted that, despite mounting evidence of isotretinoin’s safety, there was no trend toward decreased CBC testing over the decade-long period of the study, and there were only “modest” decreases in hepatic enzyme and lipid monitoring. They called for an awareness campaign on the part of professional societies, and consideration for “more specific guideline recommendations” that may ease the testing burden on the adolescent and young adult population receiving isotretinoin.

The study was funded in part by the National Institutes of Health, and Dr. Barbieri receives partial salary support from Pfizer through a grant to the University of Pennsylvania. He has received support for unrelated work from Eli Lilly and Novartis. The other authors reported no conflicts of interest.

koakes@mdedge.com

SOURCE: Barbieri J et al. J Am Acad Dermatol. 2020 Jan;82(1):72-9.

Gastroenterology

November 2019

Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Albéniz E et al. 2019 Nov;157(5):1213-21.e4. doi. 10.1053/j.gastro.2019.07.037.

Tumor seeding during colonoscopy as a possible cause for metachronous colorectal cancer. Backes Y et al. 2019 Nov;157(5):1222-32.e4. doi. 10.1053/j.gastro.2019.07.062.

December 2019

How to “DEAL” with disruptive physician behavior. Junga Z et al. 2019 Dec;157(6):1469-72. doi. 10.1053/j.gastro.2019.10.021.

Effect of sex, age, and positivity threshold on fecal immunochemical test accuracy: A systematic review and meta-analysis. Selby K et al. 2019 Dec;(6):1494-505. doi. 10.1053/j.gastro.2019.08.023.

January 2020

How to approach burnout among gastroenterology fellows. DeCross AJ 2020 Jan;158(1):32-5. doi. 10.1053/j.gastro.2019.11.032.

Efficacy and safety of peppermint oil in a randomized, double-blind trial of patients with irritable bowel syndrome. Weerts ZZRM et al. 2020 Jan;158(1):123-36. doi. 10.1053/j.gastro.2019.08.026.

Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Shung DL et al. 2020 Jan;158(1):160-7. doi. 10.1053/j.gastro.2019.09.009.

Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding. Niikura R et al. 2020 Jan;158(1):168-75.e6. doi. 10.1053/j.gastro.2019.09.010.

Clinical Gastroenterology and Hepatology

November 2019

Medical professional liability in gastroenterology: Understanding the claims landscape and proposed mechanisms for reform. Adams MA and John I. Allen. 2019 Nov;17(12):2392-6.e1. doi. 10.1016/j.cgh.2019.07.002.

Optimizing use of nonalcoholic fatty liver disease fibrosis score, Fibrosis-4 score, and liver stiffness measurement to identify patients with advanced fibrosis. Chan W-K et al. 2019 Nov;17(12):2570-80.e37. doi. 10.1016/j.cgh.2019.03.006.

December 2019

Clinical and molecular features of post-colonoscopy colorectal cancers. Samadder NJ et al. 2019 Dec;17(12):2731-9.e2. doi. 10.1016/j.cgh.2019.02.040.

Neurologic deficits in patients with newly diagnosed celiac disease are frequent and linked with autoimmunity to transglutaminase 6. Hadjivassiliou M et al. 2019 Dec;17(12):2678-86.e2. doi. 10.1016/j.cgh.2019.03.014.

Increased risk of death in first year after liver transplantation among patients with nonalcoholic steatohepatitis vs liver disease of other etiologies. Nagai S et al. 2019 Dec;17(12):2759-68.e5. doi. 10.1016/j.cgh.2019.04.033.

January 2020

Incorporating high value care into gastroenterology fellowship training. Shah BJ and Janice H. Jou. 2020 Jan;18(1):11-3. doi. 10.1016/j.cgh.2019.10.040.

Association of obesity with colonic diverticulosis in women. Peery AF et al. 2020 Jan;18(1):107-14.e1. doi. 10.1016/j.cgh.2019.04.058.

Endocuff vision reduces inspection time without decreasing lesion detection: A clinical randomized trial. Rex DK et al. 2020 Jan;18(1):158-62.e1 doi. 10.1016/j.cgh.2019.01.015.

Gastroenterology

November 2019

Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Albéniz E et al. 2019 Nov;157(5):1213-21.e4. doi. 10.1053/j.gastro.2019.07.037.

Tumor seeding during colonoscopy as a possible cause for metachronous colorectal cancer. Backes Y et al. 2019 Nov;157(5):1222-32.e4. doi. 10.1053/j.gastro.2019.07.062.

December 2019

How to “DEAL” with disruptive physician behavior. Junga Z et al. 2019 Dec;157(6):1469-72. doi. 10.1053/j.gastro.2019.10.021.

Effect of sex, age, and positivity threshold on fecal immunochemical test accuracy: A systematic review and meta-analysis. Selby K et al. 2019 Dec;(6):1494-505. doi. 10.1053/j.gastro.2019.08.023.

January 2020

How to approach burnout among gastroenterology fellows. DeCross AJ 2020 Jan;158(1):32-5. doi. 10.1053/j.gastro.2019.11.032.

Efficacy and safety of peppermint oil in a randomized, double-blind trial of patients with irritable bowel syndrome. Weerts ZZRM et al. 2020 Jan;158(1):123-36. doi. 10.1053/j.gastro.2019.08.026.

Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Shung DL et al. 2020 Jan;158(1):160-7. doi. 10.1053/j.gastro.2019.09.009.

Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding. Niikura R et al. 2020 Jan;158(1):168-75.e6. doi. 10.1053/j.gastro.2019.09.010.

Clinical Gastroenterology and Hepatology

November 2019

Medical professional liability in gastroenterology: Understanding the claims landscape and proposed mechanisms for reform. Adams MA and John I. Allen. 2019 Nov;17(12):2392-6.e1. doi. 10.1016/j.cgh.2019.07.002.

Optimizing use of nonalcoholic fatty liver disease fibrosis score, Fibrosis-4 score, and liver stiffness measurement to identify patients with advanced fibrosis. Chan W-K et al. 2019 Nov;17(12):2570-80.e37. doi. 10.1016/j.cgh.2019.03.006.

December 2019

Clinical and molecular features of post-colonoscopy colorectal cancers. Samadder NJ et al. 2019 Dec;17(12):2731-9.e2. doi. 10.1016/j.cgh.2019.02.040.

Neurologic deficits in patients with newly diagnosed celiac disease are frequent and linked with autoimmunity to transglutaminase 6. Hadjivassiliou M et al. 2019 Dec;17(12):2678-86.e2. doi. 10.1016/j.cgh.2019.03.014.

Increased risk of death in first year after liver transplantation among patients with nonalcoholic steatohepatitis vs liver disease of other etiologies. Nagai S et al. 2019 Dec;17(12):2759-68.e5. doi. 10.1016/j.cgh.2019.04.033.

January 2020

Incorporating high value care into gastroenterology fellowship training. Shah BJ and Janice H. Jou. 2020 Jan;18(1):11-3. doi. 10.1016/j.cgh.2019.10.040.

Association of obesity with colonic diverticulosis in women. Peery AF et al. 2020 Jan;18(1):107-14.e1. doi. 10.1016/j.cgh.2019.04.058.

Endocuff vision reduces inspection time without decreasing lesion detection: A clinical randomized trial. Rex DK et al. 2020 Jan;18(1):158-62.e1 doi. 10.1016/j.cgh.2019.01.015.

Gastroenterology

November 2019

Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Albéniz E et al. 2019 Nov;157(5):1213-21.e4. doi. 10.1053/j.gastro.2019.07.037.

Tumor seeding during colonoscopy as a possible cause for metachronous colorectal cancer. Backes Y et al. 2019 Nov;157(5):1222-32.e4. doi. 10.1053/j.gastro.2019.07.062.

December 2019

How to “DEAL” with disruptive physician behavior. Junga Z et al. 2019 Dec;157(6):1469-72. doi. 10.1053/j.gastro.2019.10.021.

Effect of sex, age, and positivity threshold on fecal immunochemical test accuracy: A systematic review and meta-analysis. Selby K et al. 2019 Dec;(6):1494-505. doi. 10.1053/j.gastro.2019.08.023.

January 2020

How to approach burnout among gastroenterology fellows. DeCross AJ 2020 Jan;158(1):32-5. doi. 10.1053/j.gastro.2019.11.032.

Efficacy and safety of peppermint oil in a randomized, double-blind trial of patients with irritable bowel syndrome. Weerts ZZRM et al. 2020 Jan;158(1):123-36. doi. 10.1053/j.gastro.2019.08.026.

Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Shung DL et al. 2020 Jan;158(1):160-7. doi. 10.1053/j.gastro.2019.09.009.

Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding. Niikura R et al. 2020 Jan;158(1):168-75.e6. doi. 10.1053/j.gastro.2019.09.010.

Clinical Gastroenterology and Hepatology

November 2019

Medical professional liability in gastroenterology: Understanding the claims landscape and proposed mechanisms for reform. Adams MA and John I. Allen. 2019 Nov;17(12):2392-6.e1. doi. 10.1016/j.cgh.2019.07.002.

Optimizing use of nonalcoholic fatty liver disease fibrosis score, Fibrosis-4 score, and liver stiffness measurement to identify patients with advanced fibrosis. Chan W-K et al. 2019 Nov;17(12):2570-80.e37. doi. 10.1016/j.cgh.2019.03.006.

December 2019

Clinical and molecular features of post-colonoscopy colorectal cancers. Samadder NJ et al. 2019 Dec;17(12):2731-9.e2. doi. 10.1016/j.cgh.2019.02.040.

Neurologic deficits in patients with newly diagnosed celiac disease are frequent and linked with autoimmunity to transglutaminase 6. Hadjivassiliou M et al. 2019 Dec;17(12):2678-86.e2. doi. 10.1016/j.cgh.2019.03.014.

Increased risk of death in first year after liver transplantation among patients with nonalcoholic steatohepatitis vs liver disease of other etiologies. Nagai S et al. 2019 Dec;17(12):2759-68.e5. doi. 10.1016/j.cgh.2019.04.033.

January 2020

Incorporating high value care into gastroenterology fellowship training. Shah BJ and Janice H. Jou. 2020 Jan;18(1):11-3. doi. 10.1016/j.cgh.2019.10.040.

Association of obesity with colonic diverticulosis in women. Peery AF et al. 2020 Jan;18(1):107-14.e1. doi. 10.1016/j.cgh.2019.04.058.

Endocuff vision reduces inspection time without decreasing lesion detection: A clinical randomized trial. Rex DK et al. 2020 Jan;18(1):158-62.e1 doi. 10.1016/j.cgh.2019.01.015.

The rash was consistent with nonblanching purpura. Two punch biopsies were performed for hematoxylin and eosin stain and direct immunofluorescence, which were consistent with IgA mediated small vessel vasculitis, or Henoch-Schoenlein purpura.

IgA small vessel vasculitis commonly occurs in children after a transient viral illness or as an allergic reaction to a medication. Nonblanching purpura occurs because small vessels have been cracked open by neutrophils and lymphocytes and leaked blood cells outside of the vascular circulation. Pressure fails to move these cells downstream, and thus, the skin does not blanch.

Joint pain is common, as is a self-resolving IgA mediated nephropathy. Approximately 1% to 3% of children will progress to end stage renal disease. IgA vasculitis also occurs in adults, with a higher portion developing nephropathy. In adults, lesions that present on the abdomen are suspected to correspond with gravity dependency and the total burden of IgA, leading to a higher risk for nephropathy.

The differential diagnosis of purpura is broad, but includes leukocytoclastic vasculitis, antineutrophil cytoplasmic antibodies-associated vasculitis, capillaritis, and disseminated intravascular coagulation.

The patient in this case was given topical triamcinolone 0.1% ointment to treat the rash. She returned 3 weeks later and her blood pressure was 160/105 mm Hg and she had protein and blood in her urine. The FP recommended a renal biopsy, which confirmed severe IgA nephropathy and end stage renal failure. She was given systemic steroids and ultimately received a renal transplant. Her outcome was atypical and unfortunate. Usually IgA vasculitis is benign and self-resolves with rest. Even when nephropathy is present, it typically resolves over weeks to months.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

The rash was consistent with nonblanching purpura. Two punch biopsies were performed for hematoxylin and eosin stain and direct immunofluorescence, which were consistent with IgA mediated small vessel vasculitis, or Henoch-Schoenlein purpura.

IgA small vessel vasculitis commonly occurs in children after a transient viral illness or as an allergic reaction to a medication. Nonblanching purpura occurs because small vessels have been cracked open by neutrophils and lymphocytes and leaked blood cells outside of the vascular circulation. Pressure fails to move these cells downstream, and thus, the skin does not blanch.

Joint pain is common, as is a self-resolving IgA mediated nephropathy. Approximately 1% to 3% of children will progress to end stage renal disease. IgA vasculitis also occurs in adults, with a higher portion developing nephropathy. In adults, lesions that present on the abdomen are suspected to correspond with gravity dependency and the total burden of IgA, leading to a higher risk for nephropathy.

The differential diagnosis of purpura is broad, but includes leukocytoclastic vasculitis, antineutrophil cytoplasmic antibodies-associated vasculitis, capillaritis, and disseminated intravascular coagulation.

The patient in this case was given topical triamcinolone 0.1% ointment to treat the rash. She returned 3 weeks later and her blood pressure was 160/105 mm Hg and she had protein and blood in her urine. The FP recommended a renal biopsy, which confirmed severe IgA nephropathy and end stage renal failure. She was given systemic steroids and ultimately received a renal transplant. Her outcome was atypical and unfortunate. Usually IgA vasculitis is benign and self-resolves with rest. Even when nephropathy is present, it typically resolves over weeks to months.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

The rash was consistent with nonblanching purpura. Two punch biopsies were performed for hematoxylin and eosin stain and direct immunofluorescence, which were consistent with IgA mediated small vessel vasculitis, or Henoch-Schoenlein purpura.

IgA small vessel vasculitis commonly occurs in children after a transient viral illness or as an allergic reaction to a medication. Nonblanching purpura occurs because small vessels have been cracked open by neutrophils and lymphocytes and leaked blood cells outside of the vascular circulation. Pressure fails to move these cells downstream, and thus, the skin does not blanch.

Joint pain is common, as is a self-resolving IgA mediated nephropathy. Approximately 1% to 3% of children will progress to end stage renal disease. IgA vasculitis also occurs in adults, with a higher portion developing nephropathy. In adults, lesions that present on the abdomen are suspected to correspond with gravity dependency and the total burden of IgA, leading to a higher risk for nephropathy.

The differential diagnosis of purpura is broad, but includes leukocytoclastic vasculitis, antineutrophil cytoplasmic antibodies-associated vasculitis, capillaritis, and disseminated intravascular coagulation.

The patient in this case was given topical triamcinolone 0.1% ointment to treat the rash. She returned 3 weeks later and her blood pressure was 160/105 mm Hg and she had protein and blood in her urine. The FP recommended a renal biopsy, which confirmed severe IgA nephropathy and end stage renal failure. She was given systemic steroids and ultimately received a renal transplant. Her outcome was atypical and unfortunate. Usually IgA vasculitis is benign and self-resolves with rest. Even when nephropathy is present, it typically resolves over weeks to months.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.